Every finding on record at Diversicare of Ripley

Based on staff interviews, record review, Payroll-Based Journal (PBJ) staffing data report review, and facility policy review, the facility failed to accurately submit staffing data into the PBJ system, in accordance with CMS (Centers for Medicare and Medicaid Services) reporting requirements, for one (1) of four (4) quarters reviewed (Fourth Quarter 2025, July 1 - September 30, 2025). Findings Include:Review of the facility policy titled Payroll Based Journal Entry Submission, unrevised, revealed under Policy: CMS (Centers for Medicare and Medicaid Services) regulations for Payroll Based Journal (PBJ) entries submission are adhered to.Record review of the PBJ Staffing Data Report revealed the facility submitted excessively low weekend staffing for the fourth quarter (July - September 2025).An interview with the Workforce Manager Coordinator (WMC) on 2/10/26 at 11:05 AM revealed she was responsible for scheduling the certified nurse aides (CNAs). She explained that the facility had CNAs who transported dialysis residents on Saturdays and, after returning to the facility, worked on the floor helping to give baths, answer call lights, pass meal trays, and feed residents. The WMC stated those hours were not captured during the 4th quarter due to an inability to change the role from van driver to CNA in the payroll system. She confirmed the PBJ would not have been accurate for the 4th quarter of 2025.An interview with the Administrator on 2/10/26 at 11:42 AM revealed the PBJ was submitted through the corporate office. He stated the Director of Nursing, Assistant Director of Nursing, and the Discharge Care Coordinator were salaried employees, and during the 4th quarter, the facility was unable to make changes to the payroll system to capture direct care hours worked on the weekends. He stated that during that time the Discharge Care Coordinator was working many weekends as the RN supervisor. He confirmed he was aware the PBJ was not accurate for that quarter.

Based on observation, resident and staff interviews, record review, staffing schedule review, and Payroll Based Journal (PBJ) staffing data report review, the facility failed to provide sufficient nursing staff to meet the needs of residents for six (6) of 119 residents and five (5) of 77 occupied rooms in the facility. This resulted in delayed call light response times, delayed toileting and incontinence care, and delayed assistance with activities of daily living for multiple residents, placing residents at risk for unmet care needs, skin breakdown, falls, and decreased quality of life. Resident #28, Resident #75, Resident #94, Resident #103, Resident #116, and Resident #122.Findings include:The facility provided a statement on letterhead, signed by the administrator which read, It is the practice of [Proper name of the facility]to assure that adequate staffing is maintained to provide the necessary care and services for each resident. Staffing expectations are based on resident acuity and needs and may fluctuate based on the center population as identified in the facility assessment .Record review of the PBJ Staffing Data Report revealed the facility triggered for excessively low weekend staffing for the fourth quarter (July 1 - September 30, 2025). Record review of the Center Assessment Tool dated 6/18/25, revealed the facility identified a need for 13-15 licensed nursing staff providing direct care daily and 25-35 nurse aides on average over a 24-hour period. Review of the posted Daily Nurse Staffing Form dated 2/8/26 revealed a resident census of 123 and the following: Day Shift: 1 Registered Nurse, 5 Licensed Practical Nurses, and 9 Certified Nurse AidesEvening Shift: 1 Registered Nurse, 5 Licensed Practical Nurses, and 7 Certified Nurse AidesNight Shift: 1 Registered Nurse, 2 Licensed Practical Nurses and 5 Certified Nurse Aides Further review of the Daily Nurse Staffing Form revealed the facility scheduled a total number of 21 nurse aides over a 24-hour period, which did not meet the facility's assessed need of 25-35 nurse aides, as identified in the Center Assessment Tool dated 6/18/25.An observation and interview on 2/8/26 at 2:40 PM with Resident #103 revealed she was an obese female and dependent on staff for her Activities of Daily Living needs. She stated that sometimes she remained wet for up to two hours before the aides changed her and stated, I have wet through my brief, gown, and bed pad before. Resident #103 revealed that they needed more aides to work on the halls and answer call lights. She explained that when she pushed her call light, it takes them sometimes two hours to come in and see what she needed and voiced sometimes there was only one CNA working an entire hall. She also revealed that she had to wait over an hour for her call light to be answered on average two to three times a week, and more commonly on the 3PM to 11PM shift. During initial tour on 2/8/2026 at 3:26 PM, Resident #28 stated that staffing was noticeably short on weekends and sometimes at night. He explained that on Wednesday night he woke up at 2:30 AM and had soiled his brief. He stated he pressed the call light and had to wait 55 minutes for someone to come and change him. He stated that he did report it to the nurse on duty.An interview on 2/8/26 at 3:30 PM with Resident #75 revealed that it took a long time to get someone to answer the call light. She explained that she did not like to get up into the wheelchair because staff would just leave her sitting in her room and would not answer the call light when she wanted to lie down. Further interview with a family member in the room revealed the call light sounded on average for 30-45 minutes and he frequently had to go get someone to answer the light. During initial tour on 2/8/26 at 3:43 PM, Resident #116 stated that weekend staffing was always short. He further stated that they had to wait longer than usual for help or to receive care. He stated that the staff would apologize for the excessive wait, stating we are working short. An observation of Resident #94's room on 2/8/26 at 4:26 PM revealed call light had sounded for approximately 12 minutes. A Certified Nurse Aide (CNA) observed passing ice and a nurse giving medications on the hall but neither responded. Upon entry to the room the resident stated she needed to be changed and was wet. Further interview revealed she had waited up to an hour before to be changed and guessed they (the facility) did not have enough help. An interview with Resident #122 on 2/8/26 at 5:30 PM revealed call light response time was a big concern. She stated some of the staff come and tell her, It's going to be awhile and others just let her wait without knowing. Resident #94 stated she had waited up to an hour to be changed and revealed the incontinence briefs cannot hold up long when it was wet. An observation on A hall on 2/8/26 at 5:40 PM revealed a nurse seated at the nurses' station and another standing at the medication cart while multiple call lights were audibly sounding. Call lights were observed sounding from rooms A2, A5, A6, A9, and A12 with no staff response for approximately 15-20 minutes. During an observation and interview with Licensed Practical Nurse (LPN) #1 on 2/8/26 at 6:03 PM she confirmed multiple resident call lights were sounding and that she did not stop medication pass to address the residents' needs. She stated, Everyone is responsible for answering the call lights. LPNs #1 revealed she was unsure how many aides were assigned to A hall and since her shift began, she had only seen one aide working. She revealed that when call lights go unanswered the residents get delayed care and they might decide to get up by themselves and fall. An observation and interview with Certified Nurse Aide (CNA) #7 on 2/8/26 at 6:07 PM confirmed she was working A hall and was aware of multiple call lights sounding stating I've seen them. She revealed that she was in a room and was unsure where the other aide was that had the split section. She confirmed call lights should be answered in a timely manner stating, Anything could happen to them (the resident). An interview with CNA #5 on 2/9/26 at 12:15 PM confirmed that she worked day shift and weekends. She revealed today she had the split section of A hall and revealed it was difficult to keep track of the call lights with two halls. CNA #5 confirmed that the residents had complained about the slow call light response time and revealed it was hard to stop caring for one resident to answer another call light. CNA #5 revealed she had 16 residents to care for today, but the total changed depending on what hall they were working. She revealed call ins were the issue on the weekends, and the facility tried to find replacements, but nobody wants to work on the weekends. An interview with CNA #4 on 2/9/26 at 12:20 PM revealed she worked day shift and weekends. She revealed call ins were the issue on the weekends and stated they (the aides) had worked with one aide to an entire hall before. She stated when that happens the medication cart nurse will come help them when they finish passing medications. An interview with CNA #6 on 2/10/26 at 10:25 AM revealed they were always short staff on the weekends due to call ins. She stated they have worked one aide to an entire hall before which would mean they were responsible for 28-30 residents. She explained they were responsible for getting the residents up, bathing, dressing, changing, toileting, turning, answering call lights, passing trays and assisting the residents with meals. She revealed the nurses do help when they can, but it can be overwhelming to know you have eight (8) hours to get the job done. An interview with the Workforce Manager Coordinator (WMC) on 2/10/26 at 11:05 AM revealed she was responsible for scheduling the aides and the Director of Nursing scheduled the nurses. She explained that she used a template provided by corporate to determine staffing numbers based on the census and by considering the acuity of the residents. The WMC revealed she scheduled enough staff for the weekends and call ins were the problem. She explained they have on call nurses that take call from Friday until Monday and were responsible for calling around to find staff when someone called in. During an interview on 2/10/26 at 11:42 AM, the Administrator (ADM) stated he was aware the facility had dropped below the expected staffing hours per patient day (PPD) on several days. He stated the facility was actively attempting to recruit staff and was offering bonuses and shift differentials to employees. The Administrator acknowledged call light response time was a concern and stated his expectation was that any staff member could answer a resident call light. He further acknowledged this had resulted in delays in care and unmet care needs for the residents.On 2/10/26 at 2:50 PM, during an interview with CNA #3, she stated the facility has had issues in the past with CNA call-ins on the weekends. She reported that staff have been asked to work double shifts to cover staffing shortages. CNA #3 further stated that a significant issue was that nurses do not assist with call lights. She explained that staff may be in a resident room providing care while a call light was sounding, and when they exit the room, a nurse may be sitting at the nurse's station who could have answered the call light. CNA #3 stated that care would go much better if staff worked together as a team and believed residents would be happier if call lights were answered timely. Record review of the admission Record revealed the facility admitted Resident #28 on 11/20/25 with medical diagnosis that included Unspecified Sequelae of Cerebral Infarction. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/25 revealed under section C, a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #28 was moderately cognitively impaired. Record review of the admission Record revealed the facility admitted Resident #75 on 2/7/25 with medical diagnosis that included Pancytopenia. Record review of the MDS with an ARD of 12/22/25 revealed under section C, a BIMS score of 9, indicating Resident #75 was moderately cognitively impaired. Record review of the admission Record revealed the facility admitted Resident #94 on 9/11/23 with medical diagnosis that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side. Record review of the MDS with an ARD of 12/5/25 revealed under section C, BIMS score of 15, indicating Resident #94 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #103 on 6/3/24 with medical diagnosis that included Chronic Venous Hypertension with Ulcer of Right Lower Extremity. Record review of the MDS with an ARD of 12/4/25 revealed under section C, BIMS score of 15, indicating Resident #103 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #116 on 5/24/25 with medical diagnosis that included Alcoholic Cirrhosis of Liver without Ascites. Record review of the MDS with an ARD of 1/2/26 revealed under section C, BIMS score of 14, indicating Resident #116 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #122 on 11/11/24 with medical diagnosis that included Chronic Obstructive Pulmonary Disease. Record review of the MDS with an ARD of 2/2/26 revealed under section C, BIMS score of 14, indicating Resident #122 was cognitively intact.

Based on record review, staff interview, and facility policy review, the facility failed to ensure concerns voiced during Resident Council meetings were addressed and resolved to residents' satisfaction in accordance with the requirements. Specifically, the facility failed to effectively respond to and resolve ongoing food-related concerns, including meals served cold and meats described as too tough to chew, which were repeatedly documented in Resident Council meeting minutes from August 2025 through December 2025, placing residents at risk for continued dissatisfaction for five (5) of six (6) months reviewed.Findings include:Review of facility policy titled, Customer Concern (Grievance) Policy with revised date: October 2024, revealed, Purpose: Support each customer's (patient's/responsible party's/family's) right to voice concerns (grievances) and to ensure after receiving a concern, the center actively seeks a resolution and keeps the customer appropriately apprised of its progress toward resolution.Customer concerns will have a prompt response.A Resident Council meeting was held in dining room on 2/10/2026 at 11:00 AM. A total of nine (9) residents were in attendance. Seven (7) of the nine (9) residents present expressed concerns regarding the food, stating the meals are often cold and certain meats are too tough to chew. Residents stated these concerns have been ongoing for several months. Record review of Resident Council Minutes dated 8/13/2025 at 2:00 PM revealed documented concerns including pork chops described as tough; breakfast items inconsistent with the posted menu; food reported as cold and lacking seasoning; fish described as not as good as previously served; and residents not being served a complete breakfast. Documentation under Old Business reflected pork chops described as too tough or undercooked and incomplete breakfast service, with the issue noted as not resolved to residents' satisfaction. Under New Business, similar concerns were documented, with 10 to 12 residents sharing concerns regarding tough pork chops, menu inconsistencies, cold food, and food quality.Record review of Customer Concern/Grievance Communication Form dated 8/13/2025, revealed .Residents voiced in meeting that.Fish is not as good as it used to be.Food is cold when received and don't have seasoning on it.Pork chop is still too tough to eat and enjoy.Record review of Resident Council Minutes dated 9/10/2025 at 2:00 PM revealed Old Business concerns of tough pork chops, cold food, and fish quality were documented as not resolved to residents' satisfaction. New Business documented ongoing concerns, with nine (9) to twelve (12) residents reporting tough pork chops, cold food, overcooked fish, melted ice cream, and cold soup items at the time of service.Record review of Customer Concern/Grievance Communication Form dated 9/10/2025, revealed, .Pork Chop is still too tough. Food is often cold. Fish is thin and fried too hard. Ice cream is always melted when received. Soup additives on trays are ice (fridge) cold.Record review of Resident Council Minutes dated 10/8/2025 at 2:00 PM revealed New Business concerns that meal trays were frequently delivered late, resulting in residents missing scheduled activities or allowing food to sit before consumption. Ten (10) residents shared concerns regarding tough pork chops, cold hall trays upon receipt, and melted ice cream.Record review of Customer Concern/Grievance Communication Form dated 10/8/2025, revealed, .Pork Chop still too tough, can't chew. Hall food trays are still cold sometimes when received. Ice cream is still melted when received.Record review of Resident Council Minutes dated 11/12/2025 at 2:00 PM revealed Old Business concerns regarding melted ice cream were documented as not resolved. New Business documented concerns including fried chicken described as overly hard, meals reported as cold upon receipt, and ice cream described as soft or melted.Record review of Customer Concern/Grievance Communication Form dated 11/12/2025, revealed, .Ice cream still soft and melted.Record review of Resident Council Minutes dated 12/29/2025 at 11:00 AM revealed documentation that ice cream consistency had improved; however, Old Business reflected fried chicken described as too hard and meals described as cold remained unresolved. New Business documented six (6) to eleven (11) residents reporting concerns of hard fried chicken, cold food at the time of service, and pork chops described as hard and not tender.Record review of Customer Concern/Grievance Communication Form dated 12/29/2025, revealed .Residents stated that their food when received is often cold or not at a desired temp to enjoy.During an interview on 2/10/2026 at 4:00 PM, the Administrator stated he was aware of the ongoing food-related complaints and that a new Dietary Manager had been hired and started approximately one week prior. He stated she had previously worked for the facility and food service was something that they were working to improve but confirmed that the previous resident grievances were unresolved. Record review of the admission Record indicated that the facility admitted Resident #9 on 11/7/2022 with a medical diagnosis that included Cellulitis of Right Finger, End Stage Renal Disease, and Type 2 Diabetes Mellitus without Complications. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/25 revealed under section C, a Brief Interview for Mental Status BIMS summary score of 14 which indicated Resident #9 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #19 on 5/20/2022 with a medical diagnosis that included Paraplegia, Incomplete and Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. A record review of the MDS with an ARD of 11/17/25 revealed under section C, a BIMS summary score of 15 which indicated Resident #19 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #37 on 12/2/2025 with a medical diagnosis that included Other Displaced Fracture of Upper End of Left Humerus, Subsequent Encounter for Fracture with Routine Healing, Incomplete and Type 2 Diabetes Mellitus without Complications. A record review of the MDS with an ARD of 12/9/25 revealed under section C, a BIMS summary score of 15 which indicated Resident #37 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #49 on 2/10/2025 with a medical diagnosis that included Acute on Chronic Diastolic (Congestive) Heart Failure and Type 2 Diabetes Mellitus without Complications. A record review of the MDS with an ARD of 11/13/25 revealed under section C, a BIMS summary score of 9 which indicated Resident #49 had moderately impaired cognition.Record review of the admission Record indicated that the facility admitted Resident #64 on 8/10/2024 with a medical diagnosis that included Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. A record review of the MDS with an ARD of 11/5/25 revealed under section C, a BIMS summary score of 15 which indicated Resident #64 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #94 on 9/11/2023 with a medical diagnosis that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side. A record review of the MDS with an ARD of 12/5/25 revealed under section C, a BIMS summary score of 15 which indicated Resident #94 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #100 on 2/5/2019 with a medical diagnosis that included Other Specified Arthritis, Multiple Sites. A record review of the MDS with an ARD of 11/28/25 revealed under section C, a BIMS summary score of 15 which indicated Resident #100 was cognitively intact.

Based on observation, staff interview, and facility policy review, the facility failed to ensure medication carts were secured to prevent unauthorized access for two (2) of five (5) medication carts observed (A Wing and E Wing). Findings include: Review of the facility policy titled, (Proper Name) PharMedCo, Inc. Policies and Procedures, revised 04/22, states, It is the responsibility of the facility to keep the medication cart locked and secure at all times when not in use . During an observation on 2/08/26 at 2:43 PM, the medication cart on E Wing was observed unlocked and unattended. Licensed Practical Nurse (LPN) #2 stated she walked down the hall to administer a medication and forgot to lock the cart. She stated the cart should always be secured when she leaves it. During an observation on 2/08/26 at 3:55 PM, the medication cart on A Wing was observed unlocked and unattended. LPN #1 stated she walked down the hall and forgot to lock the medication cart. She stated the cart should always be secured when not in use. On 2/09/26 at 2:45 PM, an interview was conducted with the Director of Nursing (DON), who stated medication carts should never be left unlocked. She stated staff are aware carts must remain locked when not in use and she planned to provide education regarding proper medication storage.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident received the necessary treatment and services to promote healing of a pressure wound for one (1) of two (2) pressure wounds reviewed. Resident #120Findings Include:Review of the facility policy titled Clean Dressing Change, unrevised, revealed under Guideline: It is the policy of this center to provide wound care in a manner to decrease the potential for infection and/or cross contamination. Physician's orders will specify the type of dressing and frequency of changes.Record review of Resident #120's wound measurements dated 2/4/26 revealed a Stage 3 pressure ulcer/injury to the sacrum measuring 1.41 centimeters (cm) in length, 1.24 centimeters (cm) in width, and 0.2 centimeters (cm) in depth.An observation of Resident #120's sacral wound care with Registered Nurse (RN) #1 on 2/9/26 at 2:20 PM revealed the resident did not have a dressing intact on the wound, and the resident was wearing an incontinence brief that was saturated with urine, with the wetness indicator line turned blue.Record review of Resident #120's Treatment Administration Record revealed an order dated 9/5/25: Cleanse unstageable wound to sacrum with NS (normal saline) or wound cleanser, pat dry, skin prep periwound, apply calcium alginate Ag (silver) to wound bed, and cover with foam dressing every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday) for wound care. Also revealed an order, Cleanse unstageable wound to sacrum with NS (normal saline) or wound cleanser, pat dry, skin prep periwound, apply calcium alginate Ag (silver) to wound bed, and cover with foam dressing every 8 (eight) hours as needed if soiled or dislodged, with no indication the dressing was replaced when this occurred for the month of February.An interview with Resident #120 on 2/9/26 at 2:31 PM revealed she had a bowel movement on Saturday night, and when staff changed her brief, they decided it would be best to remove the dressing because it was soiled. She explained that she often went without dressing when it became soiled and stated staff did not usually replace it.An interview with Registered Nurse (RN) #1 on 2/9/26 at 2:34 PM confirmed Resident #120's wound did not have a dressing. She revealed the resident had a physician order to replace the dressing if it became soiled or dislodged. RN #1 stated that if a dressing was not intact, it could allow stool and urine to enter the wound and become infected. She also stated urine could cause the wound edges to become macerated and deteriorate the wound.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/25 revealed under Section M that Resident #120 had an unhealed pressure ulcer documented as unstageable due to the wound bed being covered in slough and/or eschar. Also revealed under Section H, the resident was always incontinent of urine and bowel.An interview with the Director of Nursing on 2/9/25 at 2:41 PM revealed that her expectations were for staff caring for Resident #120 to notify the nurse when the wound dressing came off or was soiled to ensure the wound received consistent treatment and healed without complications.Record review of the admission Record revealed the facility admitted Resident #120 on 1/13/25 with a medical diagnosis including other complications of amputation stump and irritable bowel syndrome.Record review of the MDS with an ARD of 12/12/25 revealed under Section C a Brief Interview for Mental Status (BIMS) summary score of 13, indicating Resident #120 was cognitively intact.

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to implement the comprehensive care plan for one (1) of 21 residents sampled. (Resident #111)Findings Include:Review of facility policy titled Care Plans with effective date: October 2021, revealed, Policy .Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change.Record review of Resident #111's Care Plan Report revised 12/10/25 revealed a Self-Care Deficit related to Mobility impairment, ROM (range of motion) limitations, Self-care impairment, related to spastic cerebral palsy, peripheral neuropathy, and spina bifida. Under intervention, Personal Hygiene provide substantial/maximum assistance. On 2/09/2026 at 8:20 AM, during an interview and observation, Resident #111 stated he doesn't get shaved all the time when he is supposed to. They do it when they take a notion to do it. Resident #111 has facial hair approximately one (1) inch on his cheeks, above his upper lip, and on his chin. The resident stated, I can't tell you when the last time it was done.On 2/09/2026 at 12:15 PM during an interview and observation Certified Nurse Aide (CNA) #1 confirmed that his facial hair was long and that it had been a while since he had been shaved. The resident stated, Well, if y'all don't care how I look, then I guess I don't care either. An observation on 2/09/2026 at 3:05 PM, Resident #111 remains unshaven, and no change in appearance from the previous observation.An observation on 2/10/2026 at 9:40 AM, Resident #111 remains unshaven, and no change in appearance from the previous day. During an interview on 2/10/2026 at 10:35 AM, CNA #2 revealed today is Resident #111's bath day and that is when he also gets shaved. She confirmed his facial hair was long and stated, I really don't know when he was last shaved. On 2/10/2026 at 12:00 PM, during an interview the Assistant Director of Nursing Services (ADNS) stated that the resident is to be shaved during his baths, which is a part of his personal hygiene. She revealed if he was not shaved, then his plan of care related to his personal hygiene was not being followed. During an interview on 2/10/2026 at 3:00 PM, the Minimum Data Set (MDS) Coordinator stated that the purpose of the care plan is to inform staff of the individualized care each resident requires. She confirmed they do not have a specific care plan for shaving; it is under personal hygiene, and staff know it is part of bathing and hygiene. She revealed if Resident #111 was not shaved, then his plan of care was not being followed, and it should have been. Record review of the admission Record revealed Resident #111 was admitted to the facility on [DATE] with diagnoses that included Spina Bifida, Psoriasis, and Need for assistance with personal care.Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/02/2025 revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident #111 has moderate cognitive impairment.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident who required assistance received activities of daily living (ADL) care, including grooming and personal hygiene services such as shaving, in accordance with the resident's assessed needs, for one (1) of 21 residents. (Resident #111) Findings Include:Review of facility policy titled ADLs (Activities of Daily Living), with an effective date of August 2021, revealed the facility policy is to ensure activities of daily living are provided in accordance with accepted standards of practice, the resident's care plan, and reasonable accommodation of the resident's choices and preferences. The policy further identified hygiene activities of daily living to include bathing, dressing, grooming, and oral care. During an interview and observation on 2/09/2026 at 8:20 AM, Resident #111 stated he doesn't get shaved all the time when he is supposed to. They do it when they take a notion to do it. Resident #111 has facial hair approximately one (1) inch on his cheeks, above his upper lip, and on his chin. The resident stated, I can't tell you when the last time it was done. During an interview and observation on 2/09/2026 at 12:15 PM, Certified Nurse Aide (CNA) #1 revealed the resident usually gets shaved when he gets his bath which is on Tuesday, Thursday and Saturday. CNA #1 revealed that sometimes when he gets his bath and doesn't have a whole lot of facial hair growth we will wait until his next bath day to shave him. She confirmed that his facial hair was long and that it had been a while since he had been shaved. The resident stated, Well, if y'all don't care how I look, then I guess I don't care either. An observation on 2/09/2026 at 3:05 PM, revealed Resident #111 remains unshaved, and no change in appearance from the previous observation. An observation on 2/10/2026 at 9:40 AM, revealed Resident #111 remains unshaved, and no change in appearance from the previous day. During an interview on 2/10/2026 at 10:35 AM, CNA #2 revealed today is Resident #111's bath day and that is when he also gets shaved. She confirmed his facial hair was long and stated, I really don't know when he was last shaved. During an interview on 2/10/2026 at 10:58 AM, the Director of Nursing Services (DNS) revealed it is our expectation that all residents are adequately groomed, including being shaved and presentable. During an interview on 2/10/2026 at 11:40 AM, CNA #3 stated, I have worked with Resident #111 in the past, and I know he likes to be shaved. During an interview on 2/10/2026 at 12:00 PM, the Assistant Director of Nursing Services (ADNS) stated that the resident is to be shaved during his baths, which is a part of his personal hygiene that the facility is to honor. Record review of the admission Record revealed Resident #111 was admitted to the facility on [DATE] with diagnoses that included Spina Bifida, Psoriasis, and Need for assistance with personal care. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/02/2025 revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicates Resident #111 has moderate cognitive impairment.

Based on observations, resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident was provided with the required adaptive equipment during meals for one (1) of four (4) residents reviewed for dining. Resident #33.Findings Include: Review of the facility policy titled Assistive Devices revealed under, Policy statement: Assistive devices/utensils will be provided as identified in the individualized plan of care to maintain or improve a resident's/patient's ability to eat or drink independently.An interview with Resident #33 on 2/8/26 at 4:10 PM revealed the resident required a divided plate to feed himself independently. The resident stated he did not always receive the divided plate with meals and further stated that when the divided plate was not provided, he was unable to feed himself using utensils.An observation of Resident #33's breakfast meal on 2/9/26 at 8:24 AM revealed the resident received oatmeal, a sausage patty, and a piece of toast served on a regular plate.Record review of Resident #33's breakfast tray card revealed the resident was to receive a divided plate with meals.An observation and interview with Licensed Practical Nurse (LPN) #3 on 2/9/26 at 8:28 AM revealed that if a divided plate was listed on the meal ticket, it should be provided with the meal. LPN #3 confirmed Resident #33 did not have a divided plate and stated the resident required it to eat independently.An interview with the Administrator on 2/10/26 at 2:44 PM revealed the facility was out of divided plates and had to borrow some from another facility.An interview with the Dietary Manager on 2/10/26 at 2:50 PM revealed dietary staff were responsible for checking the tray line to ensure adaptive equipment was provided.Record review of the admission Record revealed the facility admitted Resident #33 on 7/30/24 with a medical diagnosis including Friedreich Ataxia.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/25 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #33 was cognitively intact.

Based on observation, interview, record review and facility policy review the facility failed to utilize enhanced barrier precautions while providing care for two (2) of five (5) care areas observed. Resident #5 and Resident #120. Findings Include: Review of the undated facility Infection Control Guide revealed that EBP refers to the expanded use of PPE (Personal Protective Equipment) and refers to the use of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's (Multidrug-Resistant Organism) to staff hands and clothing Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO's. The use of gowns and gloves for high-contact residents is indicated when Contact Precautions do not otherwise apply, for nursing home residents with wounds/or indwelling medical devices An interview on 02/09/26 at 2:35 PM with Registered Nurse (RN) #1, revealed that Resident #5 had a Percutaneous Endoscopic Gastrostomy (PEG) tube that was used to administer hydration flushes and used for enteral feedings if he didn't eat a certain amount of his meals. She revealed that his PEG tube site care was ordered to be completed every day. An observation on 02/09/26 at 2:45 PM with RN #1 revealed that she performed Resident #5's PEG tube site care and failed to utilize Enhanced Barrier Precautions (EBP). She donned gloves but did not wear a gown while providing the care. An interview on 02/10/26 at 2:10 PM with RN #1 revealed that she had been trained on Enhanced Barrier and that the purpose was to protect the resident from germs or bacteria she might be carrying. She also confirmed that she did not wear a gown while providing PEG tube care with Resident #5 and stated she forgot to put one on. During an interview on 02/10/26 at 2:20 PM with Infection Preventionist, she revealed that she expected the staff to utilize EBP while providing wound care and while providing care to residents with indwelling devices. She revealed that the purpose of utilizing Enhanced Barrier Precautions, was to protect the resident by preventing the staff from passing germs or bacteria to the resident which might cause infection. Record review of Resident #5's admission Record revealed the most recent admission date of 10/27/25 with diagnoses that included Anoxic Brain Damage and Dysphagia. Record review of Resident #5's Treatment Administration Record revealed an order dated 10/27/25 to Cleanse peg tube insertion site with NS (normal saline)/dermal wound cleanser and apply drainage sponge every day shift . RN #1 signed that she completed the task on 02/09/26. Resident #120 Record review of Resident #120's wound measurements dated 2/4/26 revealed a Stage 3 pressure ulcer/injury to the sacrum measuring 1.41 centimeters (cm) in length, 1.24 centimeters (cm) in width, and 0.2 centimeters (cm) in depth. Record review of Resident #120's Treatment Administration Record revealed an order dated 9/5/25: Cleanse unstageable wound to sacrum with NS (normal saline) or wound cleanser, pat dry, skin prep peri wound, apply calcium alginate Ag (silver) to wound bed, and cover with foam dressing every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday) for wound care. On 2/9/26 at 2:20 PM, during an observation of Resident #120's sacral wound care with Registered Nurse (RN) #1, the nurse performed treatment to the wound without application of a gown for Enhanced Barrier Precautions (EBP). An interview with Registered Nurse #1 on 2/10/26 at 2:02 PM confirmed she did not wear a gown for Resident #120's wound care. She stated the purpose of the precautions was to protect the resident from infections and explained that she had been trained on the precautions but forgot to apply the gown. An interview with the Director of Nursing on 2/10/26 at 2:24 PM confirmed her expectations were for the staff to practice Enhanced Barrier Precautions for the residents with chronic wounds to prevent the spread of infection. Record review of the admission Record revealed the facility admitted Resident #120 on 1/13/25 with a medical diagnosis including other Complications of Amputation Stump. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/25 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 13, indicating Resident #120 was cognitively intact.

Based on observations and interviews the facility failed to ensure sufficient staffing in the dietary department to meet the nutritional needs of residents for eight (8) of 12 sampled residents (Resident #2, Resident #3, Resident 4, Resident #5, Resident #6, Resident #7, Resident #9, Resident #10.) Specifically, the facility did not employ adequate dietary staff to prepare and serve meals in a timely manner, resulting in residents receiving cold meals and prolonged delays during meal service. Findings include: Review of the facility policy titled Food: Quality and Palatability with a revision date of 2/2023 revealed under, Policy Statement: 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 temperature. Initial observation on 01/21/25 at 8:15 PM revealed one (1) employee in the kitchen preparing food for 122 resident census. On 1/21/25 at 9:15 AM, an interview with the Regional Dietary Manager (RDM) #1 revealed that the kitchen staffing continued to be the biggest concern for the dietary department. He stated that he has been at this facility for two months and has never seen a building so hard to find dietary staff that will work. He explained that the kitchen staff continued to work with short staff and that for the last two weeks he has been in the kitchen preparing meals. He revealed that the other day they had an employee get sick in the dietary department and had to call an ambulance for her and that the Administrator went to a local restaurant and bought breakfast for the residents because they did not have anyone to prepare the meal that morning. The RDM revealed just this morning he had a staff member to walk out and quit despite being aware of the staff shortage and offering him a bonus to stay. On 1/21/25 at 9:20 AM, an interview with Resident #4 revealed the food continued to be a big concern for the residents. She stated, It's horrible. The resident explained that she ate grilled cheese and soup every day because what was served from the menu, she could not eat, and it was always cold. On 1/21/25 at 9:28 AM, an interview with Resident #3 revealed her only concern with the facility was the food. She stated, It's not fit to eat and it's not good. She stated the food was not properly cooked and that the vegetables were mushy, and the meat was tough. On 1/21/25 at 9:33 AM, an interview with Resident #5 revealed the food was no better. She stated, The food is slop, and our food choices are limited. She explained that last night at dinner she received chicken strips that were overcooked and were too tough to chew and that she just ate the fruit off her tray. She revealed the dietary department was always late getting the meal trays out and the food was always cold. She stated, they don't have any help in there. On 1/21/25 at 9:52 AM, during an interview with Resident #2 the resident voiced his food had been cold every meal. He stated, I'm not talking about lukewarm; I'm talking about cold like it's been in the refrigerator. He revealed he wished the facility could do something to fix the problem. On 1/21/25, an observation revealed, between 8:30 AM-9:00 AM and again at 11:35 AM-12:15 PM, the breakfast and lunch trays were placed on uncovered tray racks and then were later retrieved from the dining room by the aides then distributed to the residents in their rooms. On 1/21/25 at 11:35 AM, an interview with the Administrator (ADM) revealed the kitchen was in transition and the current RDM was leaving, and a new person was starting. He revealed he was not involved in the decision about the change and verbalized it was a corporate decision and that he was not happy about it because they have had so many issues with staff not being available to work in the dietary department as it is currently. The ADM revealed he would like to keep the same consistent staff in the kitchen to carry out food services. On 1/21/25 at 12:50 PM, an observation and interview with Resident #9 revealed he was sitting in his chair in his room. The resident voiced his lunch tray was just brought in to him and stated, The food here is lousy. He revealed last night for dinner he received a Swiss steak fried so hard it was not eatable, which was often the case with a lot of the meats served. He explained the dietary department did not know how to cook the foods properly without overcooking them. Resident #9 revealed cold food had been an issue for a while and stated, The food is never warm. An observation of the lunch meal provided revealed pulled pork loin, mashed potatoes, and Brussel sprouts and it was observed that the resident could not cut the meat with his utensils. On 1/21/25 at 1:02 PM, an observation and interview with Resident #6 revealed, she was sitting on the side of the bed eating her lunch meal. The resident stated, The food is horrible, and it's horrid to chew. She stated, When you all were here last, the kitchen put on a show and the food was good, but when you all left, it went back to the same old thing. Resident #6 revealed they had been served Chef Boyardee out of a can a couple of times and stated, I wouldn't serve that to my kids, but they serve it to us. An observation revealed the resident was eating a piece of cut-up bologna and not eating her lunch meal because the pork meat was too tough to chew. On 1/22/25 at 1:11 PM, an observation and interview with Resident #7 revealed she motioned for the Survey Agent (SA) to enter her room. The resident was observed eating her lunch meal and stated, It's cold. She picked up her fork and began pushing around the meat and stated, That's so tough, I can't chew it. An observation of the lunch meal revealed she received pork loin, au gratin potatoes, Brussel sprouts, corn bread and a cookie. She stated, They need some help in the kitchen. On 1/21/25 at 1:21 PM, an observation and interview with Resident #10 revealed he came to the facility last Friday and he had not had a warm meal since he came to the facility and stated, It's cold every day. The lunch meal was sitting untouched on the bedside table. The meal consisted of pork loin, au gratin potatoes, Brussel sprouts, and cornbread. On 1/21/25 at 2:35 PM, during an interview with Registered Nurse (RN) #1 revealed, the biggest complaint she gets is about the food. She explained we try to do what we can to make sure the residents have snacks and stuff, so they do not get hungry. RN #1 revealed the food had been an issue for a while and the dietary staff have struggled to find help. On 1/21/25 at 3:05 PM, an interview and observation with the RDM #1 confirmed the current dietary manager was stepping down to become the cook and acknowledged there was a lot of transition in the dietary department along with staffing concerns. On 01/21/25 at 3:11 PM in an interview RDM #2 confirmed that this was her second day on the job as the new replacement for RDM #1. She revealed one of the things she had noticed about the kitchen was they did not have a steamer. She revealed her experience had shown that anytime a kitchen did not have a steamer, the vegetables such as broccoli tend to get softer and softer until mushy. revealed she observed the meal tray line at lunch and the temperatures were adequate upon leaving the kitchen. She revealed after the tray carts leave the kitchen, they have no control over how quickly the trays were distributed and explained that could be how the food was becoming cold. She confirmed uncovered tray racks were used to distribute the food on the halls and revealed without insulated boxes, it would be impossible to keep the food warm. She confirmed that she was aware of the ongoing concerns with RDM #1 not being able to find staff that will work in the dietary department. Record review of the Admission Record revealed the facility admitted Resident #2 on 5/30/24 with a medical diagnosis that included Malignant neoplasm of stomach. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/24 revealed under, section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #2 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #3 on 4/01/24 with a medical diagnosis that included Irritable Bowel Syndrome. Record review of the MDS with an ARD of 1/10/25 revealed under, section C, a BIMS summary score of 15, which indicated Resident #3 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #4 on 11/01/22 with medical diagnoses that included Chronic Obstructive Pulmonary Disease and Dysphasia. Record review of the MDS with an ARD of 11/11/24 revealed under, section C, a BIMS summary score of 14, which indicated Resident #4 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #5 on 6/06/24 with medical diagnoses that included Chronic Obstructive Pulmonary Disease and Dysphasia. Record review of the MDS with an ARD of 12/13/24 revealed under, section C, a BIMS summary score of 15, which indicated Resident #5 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #6 on 3/05/24 with a medical diagnosis that included Cerebral Ischemia. Record review of the MDS with an ARD of 11/29/24 revealed under section C, a BIMS summary score of 13, which indicated Resident #6 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #7 on 2/05/19 with medical diagnoses that included Parkinson's Disease and Dysphasia. Record review of the MDS with an ARD of 12/16/24 revealed under section C, a BIMS summary score of 15, which indicated Resident #7 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #9 on 9/13/18 with a medical diagnosis that included Type 2 Diabetes Mellitus. Record review of the MDS with an ARD of 11/12/24 revealed under section C, a BIMS summary score of 15, which indicated Resident #9 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #10 on 1/16/25 with a medical diagnosis that included Acute Chronic Diastolic Heart Failure. Record review of the Admission BIMS dated 1/17/25 revealed Resident #10 was cognitively intact.

Based on observation, resident and staff interviews, and facility policy review, the facility failed to ensure the food was palatable and had an appetizing appearance for eight (8) of twelve sampled residents. Resident #2, Resident #3, Resident 4, Resident #5, Resident #6, Resident #7, Resident #9, and Resident #10 Findings Include: Review of the facility policy titled Food: Quality and Palatability with a revision date of 2/2023 revealed under, Policy Statement: 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 temperature. An interview with the Regional Dietary Manager (RDM) #1 on 1/21/25 at 9:15 AM revealed the kitchen staffing continued to be the biggest concern for the dietary department. He explained this area was the hardest to staff and they continued to work short in the dietary department. The RDM revealed just this morning he had a staff member to walk out despite him being aware of the staff shortage and offering him a bonus to stay. An interview with Resident #4 on 1/21/25 at 9:20 AM revealed that the food continued to be a big concern with the residents. She stated, It's horrible. The resident explained that she ate grilled cheese and soup every day because what was served from the menu, she could not eat. An interview with Resident #3 on 1/21/25 at 9:28 AM revealed her only concern with the facility was the food. She revealed the food was not good and stated, It's not fit to eat. Resident #3 explained the food was not properly cooked and revealed that sometimes the food was not done, and sometimes it was overcooked so hard she could not eat it. She further explained the vegetables were almost always mushy, and the meat was tough. The resident voiced she never asked for an alternate meal because the food always came out the same way, which was not good. An interview with Resident #5 on 1/21/25 at 9:33 AM revealed the food was no better. The resident stated, The food is slop, and our food choices are limited. She explained that last night at dinner she received chicken strips that were overcooked and were too tough to chew. She revealed that she ate the fruit off her tray and then ate left over cold pizza that she had in her refrigerator. Furthermore, she revealed the dietary department was always late getting the meal trays out and the food was always cold. An interview with Resident #2 on 1/21/25 at 9:52 AM revealed his food had been cold every meal. He stated, I'm not talking about lukewarm; I'm talking about cold like it's been in the refrigerator. Resident #2 explained that most of the time, he could not eat the food, but he had family and friends that would often bring in food for him. He revealed he wished the facility could do something to fix the problem. On 1/21/25, an observation revealed, between 8:30 AM-9:00 AM and again at 11:35 AM-12:15 PM, the breakfast and lunch trays were placed on uncovered tray racks and retrieved from the dining room by the aides then distributed to the residents on the halls. An interview with the Administrator (ADM) on 1/21/25 at 11:35 AM revealed the kitchen was in transition and the current RDM was leaving and a new person starting. He revealed he was not involved in the decision for the change and verbalized it was a corporate decision. The ADM revealed he would like to keep the same consistent staff in the kitchen to carry out food services. The ADM confirmed he was aware of concerns in the dietary department and had worked to fix the issues. He stated, There's always room for improvement. He explained that he had spoken to dietary regarding ensuring the meal tray carts were pushed out to the floor and notifying the nurse if an aide was not in the dining room when the carts were ready. An observation and interview with Resident #9 on 1/21/25 at 12:50 PM revealed he was sitting in his chair in his room. The resident voiced his lunch tray was just brought in and stated, The food here is lousy. He revealed last night for dinner he received a Swiss steak fried so hard it was not eatable, which was often the case with a lot of the meats served. He explained the dietary department did not know how to cook the foods properly without overcooking them. Resident #9 revealed cold food had been an issue for a while and stated, The food is never warm. An observation of the lunch meal provided revealed pulled pork loin, mashed potatoes, and brussel sprouts and it was observed that the resident could not cut the meat with his utensils. An observation and interview with Resident #6 on 1/21/25 at 1:02 PM revealed, she was sitting on the side of the bed eating her lunch meal. The resident stated, The food is horrible, and it's horrid to chew. She stated, When you all were here last, the kitchen put on a show and the food was good, but when you all left, it went back to the same old thing. Resident #6 revealed they had been served Chef Boyardee out of a can a couple of times and stated, I wouldn't serve that to my kids, but they serve it to us. An observation revealed the resident was eating a piece of cut up bologna and not eating her lunch meal because the pork meat was too tough to chew. An observation and interview with Resident #7 on 1/22/25 at 1:11 PM revealed, she was motioning with her hand for the Survey Agent (SA) to enter her room. The resident was observed eating her lunch meal and stated, It's cold. She picked up her fork and began pushing around the meat and stated, That's so tough, I can't chew it. An observation of the lunch meal revealed she received pork loin, au gratin potatoes, brussel sprouts, corn bread and a cookie. An observation and interview with Resident #10 on 1/21/25 at 1:21 PM revealed, he was sitting on the edge of his bed. He revealed he came to the facility last Friday and he had not had a warm meal since he came to the facility and stated, It's cold every day. The lunch meal was sitting on the bedside table and the meal was untouched. The meal consisted of pork loin, au gratin potatoes, brussel sprouts, and cornbread. An interview with Registered Nurse (RN) #1 on 1/21/25 at 2:35 PM revealed she did the Minimum Data Set (MDS) assessments. She confirmed that when she goes into the resident rooms to complete interviews, the biggest complaint she gets is about the food. She explained we try to do what we can to make sure the residents have snacks and stuff, so they do not get hungry. RN #1 revealed the food had been an issue for a while. An interview and observation with the RDM on 1/21/25 at 3:05 PM confirmed the meals provided to the residents should be attractive, taste good and warm when they receive it and he confirmed that the meat served today was tough and the meal was cold because it sits uncovered until the staff can serve it to the residents. He confirmed the palatability of the food had been an ongoing issue for the facility. He revealed the current dietary manager was stepping down to become the cook and acknowledged there was a lot of transition in the dietary department along with staffing concerns. In an interview with on 01/21/25 at 3:11 PM RDM #2 confirmed that this was her second day on the job as the new replacement RDM. She revealed one of the things she had noticed about the kitchen was they did not have a steamer. She revealed her experience had shown that anytime a kitchen did not have a steamer, the vegetables such as broccoli tend to get softer and softer until mushy. revealed she observed the meal tray line at lunch and the temperatures were adequate upon leaving the kitchen. She revealed after the tray carts leave the kitchen, they have no control over how quickly the trays were distributed and explained that could be how the food was becoming cold. She confirmed uncovered tray racks were used to distribute the food on the halls and revealed without insulated boxes, it would be impossible to keep the food warm. Record review of the Admission Record revealed the facility admitted Resident #2 on 5/30/24 with a medical diagnosis that included Malignant neoplasm of stomach. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/24 revealed under, section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #2 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #3 on 4/01/24 with a medical diagnosis that included Irritable Bowel Syndrome. Record review of the MDS with an ARD of 1/10/25 revealed under, section C, a BIMS summary score of 15, which indicated Resident #3 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #4 on 11/01/22 with medical diagnoses that included Chronic Obstructive Pulmonary Disease and Dysphasia. Record review of the MDS with an ARD of 11/11/24 revealed under, section C, a BIMS summary score of 14, which indicated Resident #4 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #5 on 6/06/24 with medical diagnoses that included Chronic Obstructive Pulmonary Disease and Dysphasia. Record review of the MDS with an ARD of 12/13/24 revealed under, section C, a BIMS summary score of 15, which indicated Resident #5 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #6 on 3/05/24 with a medical diagnosis that included Cerebral Ischemia. Record review of the MDS with an ARD of 11/29/24 revealed under section C, a BIMS summary score of 13, which indicated Resident #6 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #7 on 2/05/19 with medical diagnoses that included Parkinson's Disease and Dysphasia. Record review of the MDS with an ARD of 12/16/24 revealed under section C, a BIMS summary score of 15, which indicated Resident #7 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #9 on 9/13/18 with a medical diagnosis that included Type 2 Diabetes Mellitus. Record review of the MDS with an ARD of 11/12/24 revealed under section C, a BIMS summary score of 15, which indicated Resident #9 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #10 on 1/16/25 with a medical diagnosis that included Acute Chronic Diastolic Heart Failure. Record review of the Admission BIMS dated 1/17/25 revealed Resident #10 was cognitively intact.

Based on observation, staff interview, and facility policy review, the facility failed to prevent the possibility of the spread of foodborne illness as evidenced by thawing meat at room temperature and using unsafe food handling practices for food preparation for one (1) of two (2) kitchen tours. Findings include: Record review of the facility policy titled, Food: Preparation with a revision date of 9/2017 revealed under, Procedures: . 2. Dining Services will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination . 5. The Cook(s) thaws frozen items that requires defrosting prior to preparation using one of the following methods: Thawing in the refrigerator, in a drip-proof container, and in a manner that prevents cross-contamination; . Completely submerging the item under cold water (at a temperature of 70 [degrees] F [Fahrenheit] or below) that is running fast enough to agitate and float off loose particles . During the initial kitchen tour, on 12/15/24 at 3:10 PM, an observation of the two (2)-compartment sink revealed, five (5) packs of kielbasa sausages that were placed in the sink to thaw at room temperature with no running water. Dietary Staff #1 confirmed that meat should not be left out to thaw at room temperature and should have been placed in the cooler to prevent the potential for bacteria growth during the thawing process. Further observation revealed, a brown box placed on the kitchen floor that contained raw chicken skin inside the box and resting on the outer edges. Dietary Staff #1 confirmed the box contained raw chicken skin that had been removed during preparation of the chicken for the upcoming dinner meal. Dietary Staff #1 picked up the box to remove it and the box dripped a pink tinged watery drainage onto the floor and onto the drainboard of the 2-compartment sink. An interview with Dietary Staff #1 revealed the chicken skin should have been disposed of in the garbage during the preparation of the chicken. She revealed the raw chicken skin and drainage could contaminate surfaces and spread salmonella and potentially make someone sick. An interview with the Regional Dietary Manager on 12/18/24 at 8:10 AM confirmed that frozen meat should be thawed under running water or placed in a bin and into a cooler to thaw. He revealed the purpose was to prevent the growth of bacteria on the meat. He confirmed that raw chicken skin should be disposed of in the trash to prevent the possibility of contamination. The Regional Dietary Manager confirmed unsafe food handling practices could make someone sick.

Based on staff interviews, record review, and facility policy review, the facility failed to submit accurate data into the Payroll Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. Fiscal Year Quater 2024 (July 1-September 30) Findings include: Record review of the facility policy titled, Payroll Based Journal Entry Submission, dated 2022, revealed, CMS (Centers for Medicare and Medicaid Services) regulations for Payroll Based Journal (PBJ) entries submission are adhered to. The policy also revealed, Procedure: 1. Collaboration with Human Resources and Payroll must occur to capture payroll hours for clinical team in centers and submission. 2. CMS allows manual input data or through the use of automatic reports generated by time-tracking or payroll software. If necessary, you may use both types of submissions for your facility. 7. Hours that each team member works each day must be submitted. Per CMS training hours and corporate team member hours may be included if the team member is providing direct care or performing direct care duties. On 12/16/24 at 2:00PM, an interview with the Workforce Management Coordinator confirmed that the facility did not accurately report to PBJ. She stated that there were salary employees that worked the weekends sometimes and their work hours had to be put in manually instead of by the time clock. She revealed that she thinks the numbers entered into PBJ were not accurate. During an interview on 12/16/24 at 2:30 PM, the Human Resource Coordinator confirmed she was responsible for submitting the information for any staff schedule changes into the computer system. She stated this was generally done on Monday or Tuesday after each weekend, and if the report was sent out prior to that, then it was not accurate since it did not reflect all of the staff that worked during the weekend. An interview with the Administrator on 12/18/24 at 8:20 AM confirmed that he felt this was an inaccurate submission concern for PBJ showing they were having low weekend staffing. He stated he pulled the salary employees' time and validation report, and it was noted that these employees were not entered manually into the computer system timely. He stated the PBJ information was submitted to the corporate staff on Monday morning and if the weekend changes were not entered at that time, the information submitted was inaccurate. He confirmed the facility was responsible for submitting PBJ information accurately to reflect the staffing in the facility and the facility failed to do this. Record review of the PBJ for the fourth quarter of 2024 revealed the facility triggered for low weekend staffing. Record review of the facility's staffing validation computer printout revealed the additional staff that worked had not been entered. Verification by the State Agency was conducted through documentation that those staff members were in the facility and performing resident care.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement a care plan for Activities of Daily Living) (ADL) care plan (Resident #8, #58, and #104) and for respiratory care (Resident #73) for (4) four of twenty-four care plans reviewed. Findings Include: Review of the facility policy titled, Care Area Assessment (CAA) Process and Care Planning, dated October 2024, revealed, under The RAI (Resident Assessment Instrument) and Care Planning: the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives, and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident#8 A record review of Resident #8's care plan titled; Self-care deficit related to mobility impairment . His deficits make it hard for him to perform his ADLs without assistance . Interventions: Nail, hair, and oral care daily and as needed. Date initiated 10/25/23. On 12/15/24 at 4:00 PM, an observation and interview revealed Resident #8's fingernails to be 1/2 inch long, jagged in appearance, with a thick brown substance under the nail beds, his facial hair/beard was unkept. Resident #8 stated that he would love his nails cut, and his beard trimmed, but he can't get anyone to do it. In an interview with the Minimum Data Set (MDS) nurse on 12/17/24 at 10:50 AM, she revealed the purpose of the care plan is to identify the needs of each resident for the staff to know how specifically to care for each resident. She then stated if staff did not trim and clean Resident #8's beard /facial hair or clean and trim his nails per the care plan interventions, staff did not follow the care plan. Record review of the Admission Record revealed the facility admitted Resident #8 on 8/24/19 with medical diagnosis that included Need for Assistance with Personal Care and Contracture, Left Hand. Record review of Resident #8's Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/16/24 revealed on a Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. 45598 Resident #58 Record review of Resident #58's Care Plan revealed that he had self-care deficit related to mobility impairment with interventions that included nail, hair, and oral care daily and as needed. On 12/15/24 at 3:42 PM an observation revealed Resident #58's fingernails on his right hand had a brown substance underneath them. On 12/16/24 at 2:15 PM, observation revealed Resident #58 lying in bed with no change in the resident's fingernails. On 12/16/24 at 2:25 PM, an observation in Resident #58's room and an interview with Certified Nursing Assistant (CNA) #5 confirmed that Resident #58 had dirty fingernails with gunk underneath the fingernails on his right hand. An interview on 12/17/24 at 3:20 PM with the MDS Coordinator revealed that nail care was included in Resident #58's Care Plan to be completed daily and as needed and since his nails were observed to be dirty, the care plan was not followed. Record review of Resident #58's Admission Record revealed the facility admitted the resident on 07/18/22 with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction. Record review of Resident #58's MDS with an ARD of 11/08/24 under Section C a BIMS Score of 04 which indicated that he had Severe Cognitive Deficits. Resident #104 On 12/15/24 at 4:00 PM, an interview with Resident #104 revealed that she hadn't had a shower since Wednesday night, 12/11/24. She stated, I sure need one. She revealed that they were so busy, they did not give her a shower last night, 12/14/24, and that she had missed one other bath last week. She stated, The aide never came in to offer me a shower. Record review of Resident #104's Care Plan revealed that she had a self-care deficit and had interventions in place that included to assist with bathing as needed and nail, hair, and oral care daily and as needed. On 12/16/24 at 2:10 PM, an observation and interview with Resident #104 revealed her hair was greasy with a mild odor observed while standing next to the resident. She stated, I'm fat, I sweat underneath my boobs and if I don't get proper care, I smell. Resident #104 also revealed that it had been several days since she had her hair washed and her head had started itching. During an interview with CNA #5 on 12/16/24 at 2:17 PM, she confirmed that Resident #104's hair was greasy and needed to be washed. On 12/17/24 at 9:00 AM, an interview with the MDS Coordinator confirmed that Resident #104's Care Plan included interventions to assist with bathing as needed and to complete nail, hair, and oral care daily and as needed. She confirmed that since Resident #104 did not receive her scheduled shower and hair care, her care plan was not followed. Record review of Resident #104's Admission Record revealed an admitted [DATE] and that she had diagnoses that included Difficulty in Walking, Need for Assistance with Personal Care, and Type 2 Diabetes Mellitus. Record review of Resident #104's MDS with ARD of 12/11/24 under Section C revealed a BIMS Score of 15 which indicated that she was cognitively intact. 46013 Resident #73 A record review of the Care plan revealed Resident #73 has an alteration in Respiratory Status due to Asthma, Chronic Obstructive Pulmonary Disease, and Sleep Apnea with interventions initiated on 11/18/2024 that included Change oxygen tubing and humidifier bottle weekly. An observation on 12/15/24 at 3:55 PM, revealed Resident #73's oxygen concentrator with an undated, empty humidifier water bottle. The oxygen tubing connected to the humidifier water bottle was dated 11/29. An observation on 12/16/24 at 12:39 PM, revealed no change in the oxygen tubing. During an interview and observation on 12/16/24 at 2:10 PM, Licensed Practical Nurse (LPN) #1 confirmed that the oxygen tubing was dated 11/29 and revealed that it is important for the tubing to be changed as ordered to prevent the possibility of infections. In an interview on 12/16/24 at 2:30 PM, the Director of Nurses (DON) confirmed that Resident #73's care plan was not followed since the oxygen tubing and the water bottle were not changed as the physician had ordered. In an interview on 12/17/24 at 02:35 PM, the MDS Coordinator revealed that the care plan is developed so that the staff knows the individual needs of the residents. She revealed that the plan of care is patient-centered, and if the oxygen tubing and humidifier bottles were not changed out weekly, then the plan of care was not being followed as it should have been. A record review of Resident #73's Admission Record revealed the facility admitted the resident on 11/11/2024 with medical diagnoses that included Acute Respiratory Failure with Hypoxia, Unspecified Asthma, and Chronic Obstructive Pulmonary Disease. Record review of the MDS with an ARD of 11/19/24, revealed Resident #73 had a BIMS score of 15, which indicated the resident is cognitively intact.

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to provide needed services for residents who were unable to carry out their Activities of Daily Living (ADL's) for three (3) of 23 sampled residents. (Resident #8, Resident # 58, and Resident #104) This was cited as a pattern due to a previous citation with the last Annual Recertification Survey 8/31/23. Findings Include: (Cross-reference F725) Review of the facility policy titled, ADL's (Activities of Daily Living) with effective date of August 2021 revealed Policy: Ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences. Resident #8 An observation and interview on 12/15/24 at 4:00 PM revealed Resident #8's fingernails to be one-half (1/2) inch long past the tip of the fingers, jagged in appearance, with a thick brown substance under the nail beds, his facial hair/beard was unkempt. He stated that he would love his nails cut, and his beard trimmed, but he can't get anyone to do it. In an interview with Certified Nurse Assistant (CNA) #4 on 12/16/24 at 2:10 PM, confirmed Resident #8 's nails were long and jagged with a thick brown substance underneath. She stated that they appeared to have not been trimmed and cleaned in a while. She also confirmed his beard and facial hair was unkempt, long, and needed to be shaved. In an interview with Licensed Practical Nurse (LPN) #2 on 12/16/24 at 3:21 PM, she revealed that concerns from residents not having their dirty jagged nails cut included scratching themselves possibly leading to a skin infection from the dirty nails. She then revealed that not shaving a resident could be irritating to the resident. In an interview with the Director of Nursing (DON) on 12/17/24 at 9:48 AM, she revealed she was unable to find any documentation of recent refusals of ADL care for Resident #8 and confirmed the resident should have been shaved and nail care provided. Record review of the Admission Record revealed the facility admitted Resident #8 on 8/24/19 with a diagnosis that included Need for Assistance with Personal Care and Contracture, Left Hand. Record review of Resident #8's Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/16/24 revealed a Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. 45598 Resident #58 An observation on 12/15/24 at 3:42 PM, revealed Resident #58's fingernails on his right hand had a brown substance underneath them. An observation on 12/16/24 at 2:15 PM, revealed Resident #58 continued to have a brown substance underneath his fingernails on his right hand. An observation in Resident #58's room and an interview on 12/16/24 at 2:25 PM with CNA #5, revealed that ADL included nail care. She confirmed that Resident #58's fingernails were dirty with gunk underneath them on his right hand. CNA #5 revealed that dirty fingernails could cause issues like spreading germs, sickness or infection. She revealed that it was their (CNA's) responsibility to clean out from under resident fingernails during their bath or shower and as needed. She revealed that Resident #58 is a two-person assist with ADLs. Record review of Resident #58's Admission Record revealed the facility admitted the resident on 07/18/22 and that he had diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction, Aphasia, and Chronic Obstructive Pulmonary Disease. Record review of Resident #58's MDS with an ARD of 11/08/24 under Section C revealed a BIMS Score of 04 which indicated that the resident had severe cognitive deficits. Resident #104 An interview on 12/15/24 at 4:00 PM, with Resident #104 revealed that she hadn't had a shower since Wednesday night, 12/11/24 and stated, I sure need one. She revealed that they were so busy, they did not give her a shower last night, 12/14/24. She stated, The aide never came in to offer me a shower. An observation and interview with Resident #104 on 12/16/24 at 2:10 PM, revealed her sitting up in her wheelchair in her room with her hair pulled up on her head appearing greasy with a mild odor observed while standing next to the resident. She stated, I'm fat, I sweat underneath my boobs and if I don't get proper care, I smell. Resident #104 also revealed that it had been several days since she had her hair washed and her head had started itching. An interview with CNA #5 on 12/16/24 at 2:17 PM, CNA #5 confirmed that Resident #104's hair was greasy and that it had not been washed in a few days. She revealed that Resident #104 was scheduled to get her showers on the 3PM-11AM shifts on Tuesdays, Thursdays, and Saturdays and that Resident #104 reported to her this morning that she missed her shower on Saturday night. She also revealed that Resident #104 should have had a shower, and her hair washed on her scheduled days to make sure she was clean and to prevent body odor. An observation and interview with the Assistant Director of Nursing (ADON) on 12/17/24 at 8:30 AM, confirmed that Resident #104 and all residents should receive their scheduled showers and that residents' hair should be washed during that time. She confirmed that Resident #104's hair was oily and that she should have received her shower as scheduled on Saturday night. Resident #104 reported to the ADON that she had not had a shower since Wednesday night, 12/11/24. She revealed that on Saturday night, the aide never came in to get her for her shower. Record review of Resident #104's Admission Record revealed the facility admitted the resident on 06/03/24 and that she had diagnoses that included Difficulty in Walking, Need for Assistance with Personal Care, and Type 2 Diabetes Mellitus. Record review of Resident #104's MDS with an ARD of 12/11/24 under Section C revealed a BIMS Score of 15 which indicated that she was cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide dignity to residents, as evidenced by leaving indwelling urinary catheter bags and tubing uncovered for three (3) of eleven residents with a catheter reviewed. Resident #58, #99 and #103. Findings include: A review of the facility policy, Rights of Nursing Facility Residents dated May 1, 2012, revealed By law, every nursing facility resident has the right .To be treated with dignity, respect, courtesy and consideration . Resident #58 An observation on 12/15/24 at 3:43 PM, revealed Resident #58 lying in his bed in his room. A urinary catheter bag containing 100 milliliters of yellow urine was hanging on his bed and visible from the hall with no privacy bag in place. An interview on 12/16/24 at 2:30 PM, with Certified Nursing Assistant (CNA) #5, confirmed that Resident #58's catheter bag was hanging on his bed and there was no privacy bag. She revealed that the catheter bags were supposed to be placed inside a privacy bag. CNA #5 confirmed that not having a privacy bag was a dignity issue. An interview on 12/17/24 at 8:45 AM, with the Assistant Director of Nursing (ADON) confirmed that Resident #58's urinary catheter bag should have been in a privacy bag out of sight. She confirmed that it was a dignity issue for a resident not to be provided with a privacy bag for a urinary catheter. Record review of Resident #58's Admission Record revealed the facility admitted the resident on 07/18/22 and that he had diagnoses that included Obstructive and Reflux Uropathy. Record review of Resident #58's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/08/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 04 which indicated that the resident had severe cognitive deficits. Resident #99 An observation on 12/15/24 at 3:20 PM, revealed Resident #99 sitting in his room with a urinary catheter bag containing 300 milliliters of urine hanging on his wheelchair visible from the hall with no privacy bag in place. He revealed that sometimes they placed the catheter bag in a black satchel to keep it covered but most of the time they did not. He revealed that it made him feel bad when he went out of his room to see people when his catheter bag was exposed for everyone to see, and he would rather it be covered. An observation on 12/15/24 at 5:25 PM, revealed Resident #99 sitting in his wheelchair. The urinary catheter bag was hanging on the right side of the wheelchair with amber colored urine visible from the hallway. There was no privacy bag in place. An interview on 12/16/24 at 8:15 AM, with CNA #6, confirmed that Resident #99's catheter bag was hooked to his wheelchair this morning and was not in a privacy bag. She revealed that they were supposed to always keep the urinary catheter bags covered and she agreed that this was a dignity issue. An interview on 12/17/24 at 8:40 AM, with the ADON confirmed that resident's urinary catheter bags should always be placed in a privacy bag and out of sight to promote the residents dignity. Record review of Resident #99's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Obstructive and Reflux Uropathy and Retention of Urine. Record review of Resident #99's MDS with an ARD of 09/20/24 under Section C revealed a BIMS score of 11 which indicated that the resident had moderate cognitive deficits. 46013 Resident #103 An observation on 12/15/24 at 5:30 PM, and again on 12/16/24 at 9:30 AM, revealed Resident #103 lying in bed with a urinary catheter bag and tubing exposed with approximately 100 cc (cubic centimeters) of a brown substance in the catheter bag and no privacy covering. The catheter bag and tubing were exposed and visible to anyone entering the room. An interview and observation on 12/16/24 at 12:30 PM, Resident #103 revealed he has stomach cancer, and his tubing connects to his stomach. He stated, I don't even know what kind of stuff is in that bag, but it sure looks nasty. He revealed he doesn't like that people can see what's in the bag because it's kind of disgusting. During an observation and interview on 12/16/24 at 2:25 PM, Licensed Practical Nurse (LPN) #1 revealed all catheter bags are to always be in a privacy bag. She confirmed that the uncovered catheter bag was a dignity issue for the resident and revealed it should have a privacy covering over the tubing and bag. An interview on 12/16/24 at 3:00 PM, with the Director of Nurses (DON) confirmed Resident #103's dignity was not honored by leaving his catheter bag exposed. She revealed all catheter bags are supposed to have a covering over them. A record review of Resident #103's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Stomach, Obstructive and Reflux Uropathy, and Acquired Absence of Other Specified Parts of Digestive Tract. Record review of the MDS with an ARD of 12/5/24, under Section C revealed a BIMS score of 15 which indicated that the resident was cognitively intact.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure that oxygen tubing and an oxygen concentrator humidifier water bottle was changed as ordered for one (1) of eight (8) residents with oxygen observed. Resident #73 Findings include: Review of the facility policy titled, Oxygen Guideline updated 8/1/2024 revealed, Policy .Medical oxygen is classified by the food and drug Administration as a drug and therefore it is provided in accordance with a health care provider's order and in accordance with acceptable standards of practice. Procedure: Oxygen with humidification will be provided in accordance to a physician's order . Record review of Resident #73's Order Summary Report revealed an order dated 12/6/24 to change oxygen tubing and humidifier bottle weekly. Cleanse any external filters one time a day every Friday. On 12/15/24 at 3:55 PM, Resident #73's oxygen concentrator was observed with an undated, empty humidifier water bottle. The oxygen tubing connected to the humidifier water bottle was dated 11/29. An observation on 12/16/24 at 12:39 PM, revealed the oxygen tubing connected to the humidifier water bottle remained dated 11/29. During an interview and observation on 12/16/24 at 2:10 PM, Licensed Practical Nurse (LPN) #1 revealed that the nightshift nurses are to change out the oxygen tubing and water humidification bottles weekly. She confirmed that the oxygen tubing was dated 11/29 and revealed that it is important for the tubing to be changed as ordered to possibly prevent any infections. In an interview on 12/16/24 at 2:30 PM, the Director of Nurses (DON) revealed that the nurses on Friday nights are responsible for changing the oxygen tubing and water humidification bottles. She revealed she put a new water bottle on this morning when she noticed the humidifier bottle had no water and was unsure why the oxygen tubing and water bottle had not been changed since 11/29. She confirmed the facility failed to follow the physician's order by not changing out the oxygen tubing and water humidifier bottle as ordered. She revealed it's important for the tubing and humidification bottle to be changed weekly to prevent infection. A record review of Resident #73's Admission Record revealed she was admitted to the facility on [DATE] with medical diagnoses that included Acute Respiratory Failure with Hypoxia, Unspecified Asthma, and Chronic Obstructive Pulmonary Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/24 revealed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide sufficient nursing staff to meet the resident's activities of daily living (ADL) needs for for three (3) of five (5) residents reviewed for ADLs. (Resident # 8, #55 and #104) Findings included: Cross-reference with F677 Record review of facility policy titled, Staffing, revealed, It is the practice of (proper name of facility) to assure that adequate staffing is maintained to provide the necessary care and services for each resident. Resident #8 During an observation and interview on 12/15/24 at 4:00 PM revealed Resident #8's fingernails were 1/2 inch long, jagged in appearance, with a thick brown substance under the nails, facial hair/beard were unkempt. During the interview, Resident #8 stated that he would love to have his nails cut and his beard trimmed but cannot get anyone to do it. During an interview on 12/16/24 at 2:10 PM, Certified Nurse Assistant (CNA) #4 revealed that when she arrived at work, she observed that Resident #8's nails were long and jagged with a thick brown substance under them and appeared to have not been trimmed and cleaned in a while. She also confirmed his beard, and facial hair were long and unkempt and needed to be shaved. She revealed she felt that staffing was a big issue with residents not getting the care they needed, due to staff calling in, this lead to the staff working short-staffed all the time. Review of the Admission Record revealed the facility admitted Resident #8 on 8/24/19 with a diagnosis of Need for Assistance with Personal Care and Contracture, Left Hand. Record review of Resident #8's Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/16/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #58 During an observation on 12/15/24 at 3:42 PM, it was revealed that Resident #58 was lying in bed and his fingernails on his right hand were noted to have a brown substance underneath them. During an observation on 12/16/24 at 2:15 PM revealed Resident #58 lying in bed. He continued to have a brown substance underneath the fingernails on his right hand. On 12/16/24 at 2:25 PM, in an observation of Resident #58 nails with CNA #5, she confirmed that Resident #58 had long fingernails and had gunk underneath the fingernails on his right hand. She revealed that it was the CNAs responsibility to clean the resident's fingernails during their bath or shower and as needed. An interview on 12/17/24 at 8:40 AM, with CNA # 1, she confirmed that they run low on staffing due to people calling in and being absent. Record review of Resident #58's Admission Record revealed an admitted [DATE] and that he had diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction, Aphasia, and Chronic Obstructive Pulmonary Disease. Record review of Resident #58's MDS with an ARD of 11/08/24 under Section C revealed a BIMS Score of 04, which indicated that he had severe cognitive deficits. Resident #104 In an interview on 12/15/24 at 4:00 PM with Resident #104, she revealed that the staff were so busy, they did not give her a shower last night, and they never came in to offer her a bath. She stated that she missed her bath last night because they did not have time and had missed a couple of baths, including this past Tuesday night. She revealed that her scheduled bath times were Tuesday, Thursday, and Saturday on night shifts. She revealed that on Tuesday night, the CNA said it was too late by the time they got to her and gave an excuse that they really didn't have time. During an observation and interview with Resident #104 on 12/16/24 at 2:10 PM, revealed her sitting up in her wheelchair in her room. The resident's hair appeared greasy and was pulled up into a ponytail. A mild odor was noted while standing next to the resident. Resident #104 revealed that it had been so long since she had had her hair washed, her head had started itching. CNA #5 confirmed during an interview on 12/16/24 at 2:17 PM, that Resident #104 hair was greasy when she brushed it for her that morning and it should have been washed on her scheduled bath days, but it was not. Record review of Resident #104's Admission Record revealed the resident was admitted to the facility on [DATE] and that she had diagnoses that included Difficulty in Walking, Need for Assistance with Personal Care, and Type 2 Diabetes Mellitus. Record review of Resident #104's MDS with an ARD of 12/11/24 revealed under Section C a BIMS Score of 15 which indicated the resident was cognitively intact. During an interview on 12/18/24 at 9:33 AM, the Director of Nursing (DON) confirmed that the facility did have a staffing concern regarding aides. She stated they may have 10 or 15 aides on the schedule and five (5) may call in and not show up for their shift. She revealed the scheduler will get on the phone and start trying to get aides to come in and work, and at times, the aides that are already at the facility will work a double shift. She revealed the facility gave incentives and bonuses to try to get the staff to work and if they could not get any aides to come in, the nurses on the floor would help. She confirmed that this had been an ongoing issue, especially on the 3 PM-11 PM shift. Record reviews of a list provided by the facility revealed there were 46 residents that required two people to assist with care.

Based on observation, resident and staff interview, and record review the facility failed to ensure medications were stored appropriately and not left in the resident's room for one (1) of 23 sampled residents. Resident #68 Findings include: A review of the statement on facility letterhead, signed by the Administrator and dated 12/20/24, revealed, (Proper Name) does not have a specific policy for medication storage. The center utilizes the medication administration competencies that refers to returning medications back to medication cart as well as standards of practice. An observation and interview on 12/16/24 at 9:35 AM revealed Resident #68 had two (2) inhalers lying on his bedside table. The inhalers were labeled 1. Spiriva Respimat Inhalation Aerosol Solution 2.5 MCG/ACT(micrograms/actuation) and 2. Symbicort Inhalation Aerosol 80-4.5 MCG/ACT. A nebulizer machine was observed on the bedside table with two (2) unopened Ipratropium-Albuterol Inhalation Solution 0.5-2.5 packages. Resident #68 stated those are my emergency inhalers. During an observation and interview on 12/16/24 at 2:00 PM, Licensed Practical Nurse (LPN) #1 confirmed that the medications were left unattended on the bedside table and should have been locked in the medication cart. She revealed that the medicines are supposed to be given as the physician ordered, and with the inhalers being in the resident's room then they don't know if she is using them or how much she is taking. During an interview on 12/16/24 at 2:25 PM, the Director of Nurses (DON) confirmed that medications should not be left at the bedside unattended but should always be kept locked up in the medication cart. Otherwise, a wandering resident could enter a resident's room and take the medicines. A record review of Resident #68's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Chronic Respiratory Failure, Pulmonary Fibrosis, and Atelectasis. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #68 was cognitively intact.

Based on observation, resident and staff interviews, and facility policy review, the facility failed to provide a resident with alternative food items (Resident #59) and failed to honor a resident's food preferences (Resident #83) for two (2) of nine (9) residents sampled for dining services. Findings include: A review of the facility policy titled, Dining and Food Preferences, revealed , revised 9/2017 revealed Policy Statement: Individual dining, food and beverage preferences are identified for all residents .Procedures: 7. The individual tray assembly ticket will identify all food items appropriate for the resident based on diet order, and preferences . 8. Upon meal service, any resident with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value . 9. The alternate meal and/or beverage will be provided in a timely manner . Resident # 59 An interview with Resident #59 on 12/16/24 at 5:00 PM, she revealed that she was unhappy with the food, stating that if she does not like something it does not help to ask for something else because you won't get it. She stated that the dietary staff tell her they have to wait until all residents in the facility have been served to make sure they have enough food. An observation of the evening meal for Resident #59 on 12/15/24 at 5:45 PM, revealed the resident to have a ground turkey patty, green beans, cornbread dressing, a wet roll, and iced tea. Resident #59 asked Certified Nurse Assistant (CNA) #2 if she would ask the kitchen for another helping of the cornbread dressing because that is all she liked on the tray. CNA # 2 returned from the kitchen and stated the Dietary Manager told her she could not give her anymore dressing until all the meal trays were made for all the residents. In an interview with CNA #2 on 12/15/24 at 5:55 PM, she revealed this is a problem every day and when we ask for an alternative, or something different, the dietary staff state they cannot do that, or they don't have the food items. In an interview with the Dietary Manager (DM) on 12/16/24 at 12:10 PM, she revealed she was trained that all residents had to be served before giving any resident any other food to ensure they don't run out of food. In an interview with the District Dietary Manager on 12/18/24 at 8:10 AM, stated there was no reason someone should be told to wait until everybody else is served because they always have plenty of food and alternates they can provide the residents with. An interview with CNA #3 on 12/16/24 at 3:00 PM revealed that if a resident does not like what they get from the kitchen the dietary staff will not give them any extra servings or alternates because they say they may run out of food. Review of the Admission Record revealed the facility admitted Resident #59 on 11/1/22. Record review of Resident #59's Section C of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. 45598 Resident #83 An observation and interview on 12/16/24 at 8:27 AM revealed Resident #83 was sitting up in her bed eating breakfast. She had oatmeal, eggs, toast, and two slices of bacon on her plate. She stated that she could not eat the bacon because she did not have bottom dentures to chew it. She revealed that she had told nurses, aides, and the Dietary Manager but they continued to put bacon on her plate. She stated, They won't fix it. She admitted that she had told the Dietary Manager several times and she was supposed to change it in the computer then stated, You can't get anything done around here. An observation of the meal ticket on the resident's tray indicated that she preferred bacon in place of sausage. An interview on 12/17/24 at 8:50 AM with the Dietary Manager (DM) confirmed that Resident #83 had talked to her about her preference for sausage instead of bacon and she had changed it in the computer. The DM revealed that they had completed a food preference interview with Resident #83 on 09/16/24 and Resident #83 had voiced that she wanted no bacon and that she preferred sausage. She revealed that the meal ticket continued to print off as a preference for bacon instead of sausage, so it had to be a glitch in the computer system. The DM confirmed that Resident #83 had told her that she continued to receive bacon instead of sausage on her plate. She also confirmed that she had not followed up with Resident #83 like she should have to make sure it was resolved. The Dietary Manager revealed that the residents should be able to make their own food choices and receive what they requested. Record review of Resident #83's Food Preference Interview form dated 09/16/24 revealed under Dining Preferences that she preferred no bacon!!! for breakfast. She also had marked an x beside bacon under food dislikes. Record review of Resident #83's Meal Ticket dated for Monday, 12/16/24 revealed that she prefers bacon in place of sausage. Record review of Resident #83's Admission Record revealed an admitted [DATE]. Record review of Resident #83's MDS with ARD of 09/12/24 under Section C revealed a BIMS Score of 15 which indicated that she was cognitively intact.

Based on observation, resident and staff interview, record review, and facility policy review the facility failed to ensure the safety of a dependent resident during a lift transfer by using the wrong lift sling resulting in a strap on the sling breaking. Resident #1 fell to the floor and sustained fractures as a result of the fall for one (1) of three (3) residents reviewed for falls. Resident #1 Based on implementation of corrective actions completed on 8/30/24 prior to the State Agency (SA) entrance on 9/11/24, it was determined to be Past Non-Compliance (PNC). Findings Included: Review of the facility policy, Lift 4 Care - Safe 4 All dated May 2024, revealed under guideline, 7. In order to maintain patient's and residents' safety, patients and residents should be lifted or transferred by the lift and sling which is deemed appropriate after the lift evaluation is completed. There should be no interchanging of lifts and slings . Record review of the Investigation of Resident #1's fall revealed that on 08/21/24 at 2:00 PM, Resident #1 had a fall with injury in her room. The incident was reported to Resident #1's representative, her daughter. Resident #1 experienced a witnessed fall with two witnesses, Certified Nursing Assistant (CNA) #1 and CNA #2. Interviews with CNA #2 revealed the fall occurred during an active staff transfer from bed to wheelchair for Resident #1 to attend activities. CNA #2 revealed that during the transfer, Resident #1's right shoulder strap disconnected from the sling which caused immediate fall to floor with resident landing on right side. Staff did witness Resident #1 hitting her head with complaints expressed from resident of right shoulder and left hip pain. CNA #1 revealed through investigative interview that while transferring Resident #1 from bed to chair, resident was up in the lift, the lift was guided to the middle of the room, before the wheelchair could be placed under her, the upper right strap broke and the resident fell to the floor, landing on her right side. Record review of the Emergency Department (ED) notes dated 08/21/24-08/22/24 revealed, the right lower extremity is shortened, externally rotated and tender to movement. Left hip x-ray and computed tomography scan (CT) revealed a comminuted mildly displaced left intertrochanteric femur fracture deformity. Resident #1 was transferred from the local ED to a hospital for surgical repair of the fracture. On 09/11/24 at 8:55 AM, an observation and interview with Resident #1, revealed her lying in her bariatric bed in her room. She had bruising to her right upper arm and shoulder and a healing surgical site to her left leg. Resident #1 was morbidly obese. Resident #1 revealed that she had a bad fall last month. She revealed that there were two aides in the room to transfer her out of bed into the wheelchair using a lift. She revealed that they lifted her up off her bed, pushed the lift towards the wheelchair and as soon as she was out of reach of her bed, the strap on the sling broke and she fell to the floor. Resident #1 revealed that she fell face down on the floor, she heard a loud pop and stated, It hurt so bad. She revealed that the nurses and nurse practitioner came immediately to her room, checked her out, called the ambulance and she went to the hospital. She confirmed that she had to have surgery and that her staples were removed yesterday and stated that she was still in pain, but it was much better. On 09/11/24 at 9:05 AM, an interview with Licensed Practical Nurse (LPN) #2, revealed that she worked the day of Resident #1's fall but was not in the room when it happened. LPN #2 revealed that she heard a scream for help from down the hall and that when she entered Resident #1's room, she found her lying with her head on the floor at the foot of her roommate's bed and Resident #1 was positioned on her right side. LPN #2 noticed that her left leg was shorter than her right leg and that she was screaming for help and complaining of pain. LPN #2 revealed that the nurse practitioner came immediately into her room, checked her out, and they called for an ambulance. LPN #2 revealed that Resident #1 complained of pain to her right arm, right shoulder and left leg. LPN #2 revealed that Resident #1 went out to the hospital, had surgery and was back at the facility about a week later and stated that this was very traumatic for her. On 09/11/24 at 9:22 AM, an interview with Administrator (ADM), revealed that on 08/21/24, the staff came and got him when Resident #1 fell from the sling. He revealed that the strap on the sling broke while Resident #1 was in it during a transfer from her bed to her wheelchair and she fell to the floor. ADM revealed that he reported this to the lift manufacturer, they inspected the lift and found nothing wrong with it. ADM revealed that the laundry staff inspected the slings every time they go to laundry and if they looked ragged out they discarded them. He clarified that ragged out meant that the material on the sling was worn thin, tattered or torn or if the straps were in disrepair. ADM confirmed that they used the green sling with Resident #1, and that the Certified Nursing Assistants (CNAs) did not use the bariatric sling which was safe up to 750 pounds. ADM revealed that Resident #1 was sent to the hospital and was found that she had a fractured hip and fractured femur. ADM revealed that they started an immediate investigation and reported the witnessed fall. He revealed that this was an unfortunate accident, and he hated it for the resident. On 09/11/24 at 9:35 AM, an interview with Family Nurse Practitioner (FNP), revealed that she was in the facility working on the day that Resident #1 fell from the lift, on 08/21/24. She stated that the staff came and got her when it happened, and she went and immediately assessed the resident. FNP revealed that Resident #1 was stunned, and she complained of left leg and hip pain. FNP revealed that she observed that her left leg was externally rotated and was shorter than her right leg. She revealed that the ambulance arrived within a couple of minutes, they gave her some pain medication and transported her to the hospital. On 09/11/24 at 10:00 AM, an interview with Director of Clinical Education (DCE), revealed that each specific sling had weight ranges to go by and that the blue sling was for bariatric residents up to 750 pounds. She revealed that the green sling shouldn't have been used with Resident #1, the CNAs should have used the blue sling. DCE revealed that the slings were inspected as they came through the laundry department, but she had educated the CNAs to inspect them prior to use as well to prevent other incidents. On 09/11/24 at 12:15 PM, an interview with Assistant Director of Nursing (ADON), revealed on 08/21/24, that CNA #1 and CNA #2 were transferring Resident #1 using a lift and one of the straps on the sling broke and she fell to the floor. ADON verified that the guidelines on the proper lift sling use on the Lift Assessments for Resident #1 revealed that the green sling was a size large, and its weight ranges were 175 - 300 pounds and the blue sling was an extra-large and it's weight ranges were 275 - 500 pounds. ADON confirmed that the blue sling was care planned to be used with Resident #1 and the green sling should not have been used. On 09/11/24 at 1:40 PM, an interview with CNA #1, revealed that on 08/21/24, she and CNA #2 had gotten Resident #1 in the sling and raised her up to get her into the wheelchair. She confirmed that when they raised her up over the bed and moved the lift towards the chair, the right shoulder strap on the sling snapped and Resident #1 fell to the floor and landed on her right shoulder and was in pain. CNA #1 revealed that they used the green sling because that's the one they had always used. She stated, We went along with everyone else. CNA #1 revealed that they realized that she was supposed to be in the extra-large blue sling because of her weight but they didn't know this until after the fact. She revealed that they were supposed to look it up in the Kiosk to find out which sling to use. She stated, We felt terrible about it. CNA #1 revealed that Resident #1 had always been in a green sling and she did what everyone else was doing. She revealed that they should have gone to the Kiosk and looked up what sling was on her care plan to use. She said, This really upset me because I have always tried to do the right thing and be diligent with these residents. On 09/11/24 at 2:35 PM, a phone interview with CNA #2, revealed that on 08/21/24, she and CNA #1 were getting Resident #1 up for an activity, that they got her ready, positioned her in the green sling and moved the lift off of the bed to move towards her wheelchair. She revealed that as soon as they cleared the bed with her, the strap snapped, and she fell to the floor. CNA #2 revealed that the green sling was always used with Resident #1. She confirmed that they should have used the blue sling that was care planned, they just followed suit and did what everyone else was doing. CNA #2 revealed that the Kardex told them which sling to use and what care was needed to be done for each resident. She stated, I will definitely look at the Kardex from now on. Record review of Resident #1's Lift Transfer Evaluation dated 05/28/24 revealed that a total lift was required, and the sling size marked to use was the extra-large blue sling which had weight ranges of 275 pounds (lbs.) - 500 lbs. Total Lift Required section was documented, Focus: I have a physical functioning deficit with transfers and require assistance of .Intervention: Hoyer Total Lift XLarge (Blue) Sling Record review also revealed that the Large green sling weight ranges were 175 lbs. - 300 lbs. Record review of Resident #1's Weight Summary revealed that she weighed 376.3 pounds on 08/08/24. Record review of Resident #1's Progress Note dated 08/21/24 completed by Family Nurse Practitioner, revealed, complains of left hip and leg pain. Hit back of head on wheel of roommate's bed. Near Syncope after fall, difficulty breathing immediately following fall, 02 (oxygen) applied via mask. LLE (left lower extremity) with external rotation and LLE shortened compared to RLE (right lower extremity). Record review of Resident #1's Admission Record revealed an admitted [DATE] and diagnoses that included Morbid (Severe) Obesity and Need for Assistance with Personal Care. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/08/24 under Section C revealed a Brief Interview for Mental Status Score of 15 which indicated that she was cognitively intact. Record review revealed the following measures were taken and plans put in place to correct the deficient practice prior to the State Agency's (SA) entrance into the facility on [DATE]: Resident #1 was assessed by Nurse Practitioner immediately after the fall and was sent out to the emergency roiagnom on [DATE]. Lift was inspected on 08/22/24 following the incident with no identified concerns by Maintenance. The lift and sling involved in the accident were removed from the floor by Administrator and remained out of service immediately on 08/21/24. All lifts and slings were assessed by the for any disrepair on 08/21/24 by Administrator and four yellow slings, one blue sling and one green sling were removed due to being worn, and in ill repair. New replacements were ordered on 08/26/24. New lift slings arrived on 08/29/24, they were numbered, dated, and put in service. The Kardex was reviewed for all residents for appropriate lift and sling use on 08/22/24 by the DCE. CNA #1 and CNA #2 were educated on proper lift and sling use and return demonstration was completed on 08/21/24 by the DCE. Checkoffs were completed by the DCE with all staff which were initiated on 08/21/24 and continue throughout all shifts until everyone completed. New Lift Transfer assessments were completed by the ADON on all current residents and care plans were updated on 08/22/24. Therapy referrals were made as needed by the ADON on 08/22/24 for anyone who required a lift and lift sling. Care Plans and Kardex updated as needed on 08/22/24 by the ADON. Team huddles with lift/transfer education completed 08/21/24 - 08/22/24 by the DCE. State Agency, Ombudsman, and Attorney General (AG's) office notified on 08/22/24 by Director of Nursing. In-Service on Lift/Transfer Program and Transfer Belts, Abuse/Neglect/Exploitation, and Elder Justice Program were completed by the DCE for all staff members with 100% compliance on 08/21/24 - 08/23/24. Topics included: Performance of lift usage, inspecting the sling prior to use, laundering slings and where to find them, and on the Kardex - only using care planned sling colors. In-Services initiated on 08/23/24 with Housekeeping and Laundry Manager on sling inspection and guidelines by the DCE. Hoyer Lift Policy and Procedures were reviewed with CNA #1 and CNA #2 and all other staff beginning on 08/21/24-08/22/24 by the DCE. Audits on all Lift Assessments were completed on 08/21/24 and are on-going by the ADON. Quality Assurance and Performance Improvement (QAPI) meeting was held on 08/30/24 and all required staff members were in attendance. Plan to continue the weekly audits and bring results to the monthly QAPI meetings for three (3) months.

Based on observation, interview, record review, and facility policy review the facility failed to ensure that a comprehensive care plan was implemented for a dependent resident who was transferred via a mechanical lift using the wrong size sling which resulted in the sling breaking and causing the resident to sustain a fall with fracture for one (1) of three (3) residents reviewed. Resident #1. Based on implementation of corrective actions completed on 8/30/24 prior to the State Agency (SA) entrance on 9/11/24, it was determined to be Past Non-Compliance (PNC). Findings Included: Review of the facility policy, MDS (Minimum Data Set) and Care Plans with effective date of August 2019, revealed that care plans and MDS will be developed and maintained per RAI (Resident Assessment Instrument) Guidelines. Record review of Resident #1's Care Plan initiated on 07/17/24 revealed that she had a physical functioning deficit with interventions that included to use a total lift with blue sling. On 09/11/24 at 8:55 AM, an observation and interview with Resident #1, revealed that she had a bad fall last month. She confirmed that on the day of the fall, there were two aides in the room to transfer her out of bed into the wheelchair using a lift. She revealed that they lifted her up off her bed, pushed the lift towards the wheelchair and as soon as she was out of reach of her bed, the strap on the sling broke and she fell to the floor. On 09/11/24 at 9:22 AM, an interview with Administrator (ADM) revealed that on 08/21/24, the staff came to his office and reported that Resident #1 fell from the lift sling to the floor. He revealed that the right shoulder strap on the sling broke while Resident #1 was in it during a transfer from her bed to her wheelchair. ADM revealed that the Certified Nursing Assistants (CNA) used the green sling with Resident #1 and confirmed that the CNAs did not use the bariatric sling which was safe up to 750 pounds. On 09/11/24 at 1:40 PM, an interview with CNA #1, revealed that on 08/21/24, she and CNA #2 had gotten Resident #1 in the sling, raised her up to get her in the wheelchair. She revealed that when they raised her up over the bed and moved the lift towards the chair, the right shoulder strap on the sling snapped and Resident #1 fell to the floor and landed on her right shoulder. CNA #1 revealed that they used the green lift sling because that's the one they had always used with her. She stated, We went along with everyone else. CNA #1 revealed that they realized that she was supposed to be in the extra large blue lift sling because of her weight but they didn't know this until after the fall. She revealed that they were supposed to look in the Kiosk to find out which sling to use. She stated, We felt terrible about it. CNA revealed that Resident #1 had always been in a green sling and they (CNAs) did what everyone else was doing. She revealed that they should have gone to the Kiosk and seen what sling was on her care plan to use. She said, This really upset me because I have always tried to do the right thing and I was just not aware that her care plan stated something different. On 09/11/24 at 2:35 PM, a phone interview with CNA #2, revealed that on 08/21/24, she and CNA #1 were getting Resident #1 up for an activity. She revealed that they got her ready, positioned her in the green sling and moved the lift off of the bed to move towards her wheelchair. She revealed that as soon as they cleared the bed with her, the right shoulder strap on the green sling snapped and Resident #1 fell to the floor. CNA #2 revealed that they always used the green sling with Resident #1 like everyone else did but said they should have used the extra-large blue sling that was care planned. CNA #2 revealed that they should have looked it up in their computer system before they grabbed the green sling because the type of sling to use was care planned. She revealed that the care plan also included what care needed to be done for each resident. She stated, I will definitely look at the Kardex from now on. On 09/11/24 at 3:15 PM, an interview with MDS Coordinator, revealed that the purpose of the care plan was to set up what individualized care was needed for each resident, so the staff knew how to provide for them. She revealed that the care plans were specific to each resident and should be followed by all staff members. MDS Coordinator confirmed that Resident #1's care plan related to the hoyer lift was not followed when the CNAs used the green sling instead of the blue sling that was care planned and it resulted in a fall with injury. Record review of Resident #1's Lift Transfer Evaluation dated 05/28/24 revealed that a total lift was required and the sling size marked to use was the extra large blue sling which had weight ranges of 275 lbs - 500 lbs Under Total Lift Required section of the Lift Transfer Evaluation was documented, Focus: I have a physical functioning deficit with transfers and require assistance of Intervention: Hoyer Total Lift XLarge (Blue) Sling Record review of the Lift Transfer Evaluation also revealed that the Large green sling weight ranges were 175 lbs - 300 lbs. Record review of Resident #1's Weight Summary revealed that she weighed 376.3 pounds on 08/08/24. Record review of Resident #1's Admission Record revealed an admitted [DATE] and had diagnoses that included Morbid (Severe) Obesity, Type 2 Diabetes Mellitus, and Need for Assistance with Personal Care. Record review of Resident #1's MDS with Assessment Reference Date (ARD) of 09/08/24 under Section C revealed a Brief Interview for Mental Status Score of 15 which indicated that she was cognitively intact. Record review revealed the following measures were taken and plans put in place to correct the deficient practice prior to the State Agency's (SA) entrance into the facility on [DATE]: Resident #1 was assessed by Nurse Practitioner immediately after the fall and was sent out to the emergency roiagnom on [DATE]. Lift was inspected on 08/22/24 following the incident with no identified concerns by Maintenance. The lift and sling involved in the accident were removed from the floor by Administrator and remained out of service immediately on 08/21/24. All lifts and slings were assessed by the for any disrepair on 08/21/24 by Administrator and four yellow slings, one blue sling and one green sling were removed due to being worn, and in ill repair. New replacements were ordered on 08/26/24. New lift slings arrived on 08/29/24, they were numbered, dated, and put in service. The Kardex was reviewed for all residents for appropriate lift and sling use on 08/22/24 by the Director of Clinical Education (DCE). CNA #1 and CNA #2 were educated on proper lift and sling use and return demonstration was completed on 08/21/24 by the DCE. Checkoffs were completed by the DCE with all staff which were initiated on 08/21/24 and continue throughout all shifts until everyone completed. New Lift Transfer assessments were completed by the ADON on all current residents and care plans were updated on 08/22/24. Therapy referrals were made as needed by the ADON on 08/22/24 for anyone who required a lift and lift sling. Care Plans and Kardex updated as needed on 08/22/24 by the ADON. Team huddles with lift/transfer education completed 08/21/24 - 08/22/24 by the DCE. State Agency, Ombudsman, and Attorney General (AG's) office notified on 08/22/24 by Director of Nursing. In-Service on Lift/Transfer Program and Transfer Belts, Abuse/Neglect/Exploitation, and Elder Justice Program were completed by the DCE for all staff members with 100% compliance on 08/21/24 - 08/23/24. Topics included: Performance of lift usage, inspecting the sling prior to use, laundering slings and where to find them, and on the Kardex - only using care planned sling colors. In-Services initiated on 08/23/24 with Housekeeping and Laundry Manager on sling inspection and guidelines by the DCE. Hoyer Lift Policy and Procedures were reviewed with CNA #1 and CNA #2 and all other staff beginning on 08/21/24-08/22/24 by the DCE. Audits on all Lift Assessments were completed on 08/21/24 and are on-going by the ADON. Quality Assurance and Performance Improvement (QAPI) meeting was held on 08/30/24 and all required staff members were in attendance. Plan to continue the weekly audits and bring results to the monthly QAPI meetings for three (3) months.

Based on interviews, record review and facility policy review the facility failed to protect the resident's right to be free from neglect as evidenced by failure of the staff to communicate and put measures in place to prevent the second elopement of Resident #1 who left the faciity on [DATE] unnoticed and unsupervised. Resident #1 was one (1) of three (3) residents reviewed. Resident #1 was allowed to exit the facility on 01/07/24 unnoticed and unsupervised at an unknown time and was discovered to be missing from the facility at approximately 8:10 PM. On 01/07/24 at approximately 8:00 PM, the police department received a 911 call from an unknown bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. A local Police Officer was dispatched and found Resident #1 walking in the middle of the street approximately 1850 feet from the facility and she had no shoes and no coat on. The Police Officer assisted Resident #1 into the backseat of his car and took her to the facility where he discovered that the facility staff were looking for her. Resident #1 was last observed in the facility at 7:55 PM, a Code 10 (elopement) was called at 8:10 PM, and Resident #1 was returned to the facility at 8:25 PM. A head-to-toe assessment was completed immediately upon her return to the facility. Resident #1 was a wandering risk and had previously exited the facility on 12/14/23 and once again eloped from the facility without staff knowledge on 1/7/24. The facility's failure to provide supervision to prevent an elopement for Resident #1 who was actively exit seeking and diagnosed with Alzheimer's and Dementia allowed her to leave the facility unnoticed and unsupervised until she was picked up by a local Police Officer in the middle of the street about 1850 feet away from the facility. The elopement placed Resident #1 and other residents who were at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ), and Substandard Quality of Care (SQC) which began on 01/07/24 when Res #1 eloped from the facility unsupervised. The SA notified the facility's Administrator (ADM) of the IJ and SQC on 01/11/24 at 3:19 PM, and provided IJ templates to the ADM. The facility submitted an acceptable Removal Plan on 1/12/24, in which they alleged all corrective actions to remove the IJ were completed on 1/12/24, and the IJ removed on 1/13/24. The SA validated the Removal Plan on 1/22/24 and determined the IJ was removed on 1/13/24, prior to exit. Therefore, the scope and severity for 42 CFR (s): 483.12 (a) (1) - Free from Abuse and Neglect (F600), was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Record review of the facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy with effective date of January 2019 revealed Purpose: To prohibit and prevent . neglect .Definitions: .Neglect: Failure of the center, its team members or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Record review of Facility Investigation Template completed by Administrator documented the following: On 1/7/2024 at 8:10 pm a code 10 was called as resident was unable to be located. Staff completed a room to room audit to ensure all residents were safe and accounted for. At 8:25 pm resident was escorted back into center by Police Department officer. Investigation Summary: Review of the center's maintenance camera revealed the resident exited the center out an unlocked door in the rear of the center . Record review of Progress Notes Type: Behavior Charting, completed by Licensed Practical Nurse (LPN) #2, dated 01/01/2024 at 18:48 (6:48 PM) revealed Resident constantly trying to get out of building, she got into the kitchen and was headed out the back door before a staff member caught her. We are ensuring that she stays on this side of building however its hard to watch her 24/7. An additional entry by LPN #2 at 18:58 (6:58 PM) revealed DON (Director of Nursing) notified, ensured that kitchen doors were locked. Record review of Progress Note dated 01/04/2024 and signed by the Family Nurse Practitioner (FNP) on 01/05/2024 revealed .Chief Complaint/Reason for this Visit - Facility requested visit for not sleeping at night and wandering throughout the night .HPI (History of Present Illness) relating to this visit DNS (Director of Nursing Services Proper Name) reported that resident has insomnia during the night and wanders aimlessly throughout facility at night with exit seeking behaviors. Staff report resident wanders during day time hours but wandering increases late in the afternoon and continues through night time hours with exit seeking behavior increasing during night time hours as well .Cognitive Status: Forgetful, Dementia, Confused . On 01/09/24 at 8:45 PM, during an interview with LPN #1, revealed that she was working the night of 01/07/24 when Resident #1 left the facility without staff knowledge. LPN #1 stated that she had last seen Resident #1 that night around 7:50 PM walking down B-Hall. She revealed that Resident #1's cognitive status is not good due to dementia. She stated they could hold her hand and easily redirect her back to her room. LPN #1 revealed that Resident #1 had been seen exit seeking a lot lately and stated, They think she may have exited the kitchen. On 01/09/24 at 9:05 PM, an interview with the Administrator (ADM) revealed that Resident #1 had gotten out of the building again on 01/07/24 on the night shift. He revealed that according to interviews and statements taken by staff, Resident #1 was last seen around 7:55 PM and that there was about 20 to 25 minutes that Resident #1 was unaccounted for that night. The ADM revealed that he thought she left through the kitchen door this time. He revealed that the staff had been doing hourly checks since the last elopement incident on 12/14/23 and that this happened between the scheduled hourly visual checks. The ADM revealed that a Code 10 (elopement of a resident) was called around 8:10 PM. Resident #1 was last seen around 7:55 PM and was returned to the facility by a police officer around 8:25 PM or 8:30 PM. The ADM revealed that Maintenance came in that night and checked all of the windows and doors, checked all of the door alarms and wander guard bracelets and everything worked properly. The ADM revealed that the only way possible for her to get out was through the kitchen door. He revealed that the two doors that led from the dining room into the kitchen had locks on them from the inside of the kitchen and staff had to push the lock in and turn it for them to lock properly. He stated he wasn't aware that Resident #1 had gone back into the kitchen earlier that evening until he read the statements provided by the staff during the investigation of the elopement. The ADM indicated that this resident wanders a lot and according to what he was told, Resident #1 was last seen in the dining room around 7:25 PM on 01/07/2024. The ADM revealed that Resident #1 was placed on one on one (1:1) supervision after the incident until the new kitchen door locks were installed on 01/08/24 at 1:00 PM. He stated, The only thing we really changed were the kitchen doorknobs and put a pin lock on the doors so that everyone who entered had to have the code. On 01/09/24 at 10:05 PM, an interview with Certified Nursing Assistant (CNA) #1, revealed that she was working on the night of 01/07/24 when Resident #1 got out of the facility. She revealed that Resident #1 liked to wander at night and sometimes she would walk to the end of the hall, jiggle the door to see if it would open. CNA #1 revealed that it was hard to keep up with Resident #1 most of the time because she was constantly on the move. CNA #1 revealed that on 01/07/24 at around 7:35 PM, a kitchen staff member brought Resident #1 to her on the C/D hall and told her that Resident #1 had gotten into the kitchen again. CNA #1 revealed that she brought Resident #1 to the CNA she was assigned to for the night, and he took care of her. CNA #1 revealed that a little after 8 PM, Resident #1's CNA asked her if she had seen Resident #1. CNA #1 revealed that they looked down halls, resident rooms, and outside. CNA #1 revealed that a few minutes later, the police brought Resident #1 back to the facility. CNA #1 stated, I have no idea how she got out. On 01/10/24 at 10:10 AM, an interview with the Administrator (ADM) revealed that all windows and doors were checked by Maintenance, and everything worked properly. He stated there was still 20 minutes that Resident #1 was unaccounted for the night of 01/07/24. The ADM agreed that a lot could have happened to her in 20 minutes and stated, I'm just glad she was safe, it could have been really bad. On 01/10/24 at 10:20 AM, a phone interview with the Director of Nursing (DON), revealed that on Sunday night 01/07/24, the Administrator called and told her about Resident #1 getting out of the building again. She revealed that she was off, but came on to the facility. The DON revealed that Maintenance came in and checked all the doors, and she was confident that the kitchen door was the only door Resident #1 could have gotten out of. The DON revealed that Resident #1 had walked into the kitchen a couple of times that she knew of prior to this night because staff had mentioned it to her. The DON stated, This had happened during the day while we were there. The DON stated that she wasn't aware that Resident #1 had been brought out of the kitchen earlier the night of 01/07/24 until she arrived on that Sunday night around 9:00 PM. On 01/10/24 at 10:45 AM, an interview with Dietary Aide #1, revealed that she was working on the evening of 01/07/24 during the time that Resident #1 got out of the building. She revealed that at approximately 7:30 PM or a little after, she was bent down washing dishes in the washroom next to the kitchen door when she heard something. Dietary Aide #1 revealed that she saw that Resident #1 had come into the kitchen, had walked past her and was standing over by the stove and was walking towards the exit door which led to the outside of the building. Dietary Aide #1 revealed that she was in the kitchen by herself when this happened because Dietary Aide #2 had taken the trash out. Dietary Aide #1 revealed that she took Resident #1 by the hand and led her out of the kitchen and took her to CNA #1 who was working on the hall. Dietary Aide #1 revealed that about 30 minutes later, she came out of the kitchen to see that a CODE 10 was called and found out that Resident #1 was missing. This Dietary Aide #1 revealed that she was familiar with Resident #1 and that the resident walked constantly and was seen frequently at doors looking out. On 01/10/24 at 11:00 AM, an interview LPN #2 revealed that Resident #1 usually slept during the day until late afternoon or supper time and then walked the floors. LPN #2 stated, She stays busy, just does her thing. She also stated, We try to work together with the CNAs and do the best we can to keep our eyes on her but it's hard with her constantly on the move. She revealed that when Resident #1 walked the halls, she would push on the doors, then turn around and walk off if the doors wouldn't open. She revealed that Resident #1 was not combative and was easily redirected; but would often return to what she was doing. LPN #2 stated, Everyone knows that as soon as you redirect her, she goes right back. LPN #2 revealed that Resident #1 had dementia but said she was Smarter than you think, it's like she's watching and waiting. On 01/10/24 at 11:20 AM, an interview with the Administrator revealed that there were two older video cameras on the Maintenance Shop out behind the facility. He revealed that the cameras were 50 feet from the facility pointing back towards the back of the Nursing Home where the kitchen exit door was. The Administrator revealed that they played back the video camera footage, and it revealed Resident #1 exiting the kitchen door to the outside. The ADM stated, We do have evidence of her exiting the building and I know for sure that she went out the side kitchen door, not out the Emergency Exit door in the dining room. The ADM revealed that it was dietary not keeping the doors from the dining room into the kitchen locked properly that caused Resident #1 to get out. The ADM revealed that Maintenance had come in and changed the door locks on the doors which led from the dining room into the kitchen and had put in keypads that required a code to enter. The ADM stated, Now they don't have a choice but to keep the doors locked. The ADM revealed that he did not realize Resident #1 had gotten into the kitchen earlier the day of 01/07/24 until he was reading statements. The ADM revealed that the kitchen doors would lock but staff were not keeping them locked and stated, I do know that I've been on them about keeping the kitchen doors locked. On 01/10/24 at 11:55 AM, an interview with Dietary Aide #2, revealed that she was working on 01/07/24 in the kitchen. She revealed that she was outside taking the trash out and when she returned, was told by Dietary Aide #1, that Resident #1 had walked into the kitchen and was headed towards the exit door over by the stove. Dietary Aide #2 revealed that she got snacks together and when she passed out the snacks around 7:30 PM to A/B hall, she saw Resident #1 exiting a resident's room on that hall. She revealed that after 8:00 PM, a CODE 10 was called, and everyone went to look for her. Dietary Aide #2 revealed that Resident #1 came into the kitchen pretty often, but most of the time she just opened the door and closed it back without coming in. Dietary Aide #2 revealed that if Resident #1 opened the door to the kitchen, the staff would find a nurse or CNA to get her out of the kitchen. Dietary Aide #2 stated, If we didn't, she would just come right back. She revealed that Resident #1 had come into the kitchen a couple times while she had been at work but couldn't recall the dates. Dietary Aide #2 revealed that they always made sure the kitchen doors were locked before they left at night-time. She revealed that one door they had to manually lock when they were in the kitchen. Dietary Aide #2 revealed that Resident #1 must have gone into the kitchen while she (Dietary Aide #2) was passing out snacks and while Dietary Aide #1 was washing dishes for them not to have seen her. On 01/10/24 at 12:10 PM, a phone interview with the Police Officer who found the resident, revealed that on 01/07/24 around 8:00 PM, the Police Department had received a 911 call from a bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. The Officer revealed that he drove to the area and found that Resident #1 was walking in the middle of the street behind the Emergency Department at the local County Hospital which was a pretty good way from the nursing home. The Officer revealed that the resident had a shirt, jogging pants, and socks on. The Officer stated that Resident #1 was not wearing a coat or shoes. He stated that he stopped her, and the resident seemed to be confused. He asked her where she was going, and she told him to the nursing home. He revealed that she was hard to understand but Resident #1 told him she was going back to Proper Name of Facility. The officer revealed that he helped her into his car and drove her back to the facility. The Officer revealed that he released her to to LPN #3. Record review of the City of (Proper name of City) Police Department Incident Report revealed .Narrative .I was informed by (Proper Name) LPN #3 that this was not the first time that this has happened, that one of the doors in the building was not locked and does not have an alarm on it This incident report was completed by the Police Officer on 01/07/24. On 01/10/24 at 4:25 PM, a phone interview with LPN #3 revealed that she was working on 01/07/24, the night that Resident #1 got out of the facility. LPN #3 revealed that she had seen Resident #1 several times walking all around on A/B hall and E/F hall and staff members kept bringing her back to her room. LPN #3 revealed that Resident #1 was last seen just outside her room a little before 8:00 PM. She revealed that about 8:10 PM, she asked the CNA who was assigned to Resident #1 to go see if she was in her room and he found that she was not. LPN #3 revealed that she called a Code 10 and immediately started looking for her. She revealed that they looked on all halls, in all rooms and outside the building. LPN #3 revealed that she went to the front door about 8:25 PM and saw a police car drive up and then saw that he had Resident #1 in the back seat. She revealed that the police officer brought her to the door and stated, I believe I have someone who belongs to y'all and the officer released Resident #1 to them. LPN #3 revealed that Resident #1 had a pair of sweatpants on with a cuff at the bottom, had a long-sleeved shirt on, some gripper socks and had no coat or shoes on. She revealed that they immediately got her inside, checked her vital signs and did a head-to-toe assessment and there were no injuries noted. On 01/11/24 at 11:05 AM, an interview with LPN #2 revealed that on 01/01/24, Resident #1 had walked into the kitchen and was found to be on the left side of the stove walking towards the exit door when she was approached by a dietary aide and redirected back to the C/D hall. LPN #2 revealed that the kitchen doors should have been locked so that residents couldn't enter, and this situation should have been reinforced and monitored better so as to help prevent the elopement. She revealed that the door that goes to the outside of the building from the kitchen was unlocked. LPN #2 revealed that on 01/01/24 after supper, the staff members were in the kitchen pulling trays getting ready to wash dishes when one of the staff members in the kitchen saw Resident #1 heading straight for the exit door. LPN #2 revealed that she reported this to the DON who told her to make sure the kitchen doors were locked and to put a progress note (behavior) in about the incident and to make sure to cover herself in case the resident was to get out of the building again. LPN#2 revealed that this was the first and only time that this had happened on her shift that she was aware of. She revealed that Resident #1 seemed to have her days and nights mixed up and that her wandering seemed to be worse later in the evening. LPN #2 agreed that had this incident been addressed and taken care of back the first of the month when it happened and was reported to the DON it might have prevented Resident #1 from getting out of the facility on 01/07/2024. On 01/11/24 at 11:30 AM, an interview with Minimum Data Set (MDS) Coordinator, revealed that they had been having Quality Assurance and Performance Improvement (QAPI) Meetings every month with the Medical Director present. The MDS Coordinator revealed that Quality Assurance Performance Improvement (QAPI) was a functional tool that forced everyone to look at [NAME] if something had happened and a good way to follow up. She stated, It's a continual thing. The MDS Coordinator revealed that she was not aware of the wandering incident where Resident #1 was found inside the kitchen heading out the exit door on 01/01/2024. She revealed that this was not brought up in stand up or in QAPI meeting but then she had missed some. The MDS Coordinator stated, I didn't know about this incident and I should have. I must have missed some of this. The MDS Coordinator agreed that the facility neglected to handle this incident and it should have been reported, discussed, and taken care of. She revealed that it should have been care planned, interviews should have been completed, and they should have made sure that the incident was noted, and things were in place. The MDS Coordinator agreed that if the incident with Resident #1 had been taken care of on 01/01/24, it could have prevented the elopement incident on 01/07/24 which put the resident at risk of harm. The MDS Coordinator stated, Apparently we dropped the ball on this one. On 01/11/24 at 12:20 PM, an interview with the ADM revealed that he was not aware of the incident with Resident #1 walking into the kitchen and heading out the exit door which occurred on 01/01/24. He stated, I had no idea, no one told me that. The ADM revealed, I was told that the kitchen staff was not keeping the doors to the kitchen locked and we educated them on how to properly lock the doors. The ADM revealed that when this was brought to his attention, he was thinking more about safety with knives, hot steam tables, and infection control issues, not elopement concerns. He revealed that he wasn't sure why this wasn't brought up in their morning meetings and that if it had happened, they should have addressed it, corrected the situation then, and had measures in place. He stated, I was not aware and should have been notified. On 01/11/24 at 12:35 PM, a phone interview with the Director of Nursing Services (DON), revealed that she was made aware after she arrived at the facility on the night of 01/07/24, that Resident #1 had gone into the kitchen earlier in the evening prior to the elopement. The DON revealed that they always tried to keep an eye on Resident #1 and the staff had to bring her back to her room constantly. She revealed that the kitchen staff had been in-serviced on keeping the kitchen doors locked 24/7 with no exceptions. The DON revealed that she checked the kitchen doors when she was there, always making sure the doors to the kitchen were locked. The DON revealed that Resident #1 wandered all the time, and worse in the evenings. She revealed that the staff were constantly having to redirect her. She also revealed that when she walked the floors, someone was usually with Resident #1. The DON was asked what she knew about Resident #1 getting into the kitchen on 01/01/24 prior to the elopement on 01/07/24, she stated, LPN #2 didn't tell me until after the fact, but confirmed it was prior to the elopement on 01/07/24. The DON revealed that LPN #2 had called her and reported to her by phone because she was off work. She had told LPN #2 to chart a behavior note on Resident #1 in the computer. The DON revealed that she was off on 01/01/24, 01/02/24, and 01/03/24, and was not at work to bring it up and had not thought about it. The DON agreed that she should have reported this to other staff members even though she was off. She agreed the elopement on 01/07/24 might have been prevented had this been taken care of on 01/01/24. The DON confirmed that each morning at stand up meeting that a 24 hour report should be run to discuss any concerns from the last 24 hours in the facility and this was not done. On 01/11/24 at 1:00 PM, an interview with the ADM revealed that his goal was that Resident #1 and all one hundred twenty-one residents be kept safe. He revealed that he was ultimately responsible for everyone in the facility and his goal was to fix the problem and move on. The ADM revealed that after looking at video coverage, he knew how Resident #1 got out, he fixed the problem, and everything was secured. He revealed that he did not know about what happened on 01/01/24 and could not fix what he did not know because he was never made aware of it. Record review of the (Name of Local City) weather revealed on 01/07/24 at the time of the elopement that the temperature was 39 degrees Fahrenheit with clear skies. Record review of Resident #1's Admission Record revealed the facility admitted Resident #1 on 04/14/2017. Her current diagnoses include Alzheimer's Disease, Need for Assistance with Personal Care, Dementia with unspecified severity with other behavioral disturbance, and Unspecified Psychosis not due to a substance or known physiological condition. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/2023 revealed under Section C0100 that a Brief Interview for Mental Status (BIMS) should not be conducted because the resident is rarely/never understood. C1000, Cognitive Skills for Daily Decision Making, revealed Resident #1's cognitive status was severely impaired. Section P0200 revealed a Wander/elopement alarm was used daily. Record review of Resident #1's Elopement Risk Assessment completed on 01/07/24 revealed that resident had a history of wandering or elopement. The facility implemented the following Removal Plan: On 1/7/2024 at approximately 8:10 pm the facility called a code 10 that Resident #1 was not found in her room, staff searched the entire building and upon going to look for resident outside an Officer with the local police department was pulling into facility parking lot with resident, resident was assisted back into the facility by nurse and Certified Nursing Assistant (CNA). The nursing staff last saw the resident at approximately 8:00 pm in the dining room and returned to facility at 8:25 pm on 1/7/2024. On January 11 at 3:19 PM the facility was verbally notified that Immediate Jeopardy (IJ) was identified for Federal tag 600 -Abuse, Federal tag 656- Care Plans, Federal tag 689- Failure to Prevent Accidents and Hazards, Federal tag 867 - QAPI (Quality Assurance Performance Improvement). The facility received IJ templates on January 11, 2024, at 3:19 PM. Immediate Corrective Actions for Resident #1: At 8:30 pm on 1/7/2024 the Executive Director and Director of Nursing (DON) begin official investigation of Resident #1 Elopement and determined the resident exited out of the door going through the kitchen. At 8:30 pm on 1/7/2024 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. Upon return to facility Resident # 1 was ambulating independently, awake, alert with usual state of cognition. Resident was examined by Licensed Practical Nurse (LPN) with no injuries noted. Resident was immediately taken to room and vitals and head to toe assessment obtained. Resident was smiling and had no complaints of pain noted. No signs of injury noted, no bruising, scratches, cuts, or bleeding noted blood pressure 135/72, pulse 75, respirations 18, temperature 96.8, blood oxygen saturation 92%. Resident changed b/p. 135/72, p. 75, r. 18, t. 96.8, sa02 92%. Resident changed for bed and CNA in room doing one on one care. Director of Nursing (DON) was notified at 8:27 pm. Upon her return to the center on 1/7/2024, the resident was examined by the staff nurse and noted to have no negative findings. She was placed on 1:1 supervision until 1 PM on 1/8/2024 after the door locks were replaced in the kitchen. After that she was placed on every 15-minute checks to assure her safety. The kitchen doors were monitored until locks were replaced at 1:00pm 1/8/2024. This close supervision continues as of 1/11/2024. Resident #1 will be placed on 15-minute checks until exit-seeking behavior ceases. On 1/7/2024 at 8:55 pm Medical Director (MD), Physician's Assistant (PA) and Nurse Practitioner (NP) was notified of Resident Elopement from facility. On 1/7/2024 maintenance staff arrived at 9:30 pm to assess all facility exit doors, doors were checked for proper functioning by maintenance staff. All doors and wander guard systems were functioning properly. On 1/7/2024 at 9:00 pm all residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. On 1/7/2024 at 9:00 pm, Director of Nursing (DON) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. On 1/7/2024 at 10:00 pm in-services was initiated by Director of Nursing (DON) to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 1/8/2024 with no staff allowed to work until in-service completed. At 10:00 pm on 1/7/2024 Director of Nursing (DON) attempted to notify Resident # 1 Responsible Representative (RR) of the resident elopement from facility with no answer message left for RR to return call. RR returned call at 8:08 AM on 1/8/2024 and was notified of incident. On 1/8/2024, the Administrator and the Director of Nursing (DON) immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 1/8/2024 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing via phone, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing (ADON), Infection Preventionist and Minimum Data Set Nurse (MDS) to discuss Resident #1's exit seeking behavior and all safeguards put in place to ensure safety of all residents. QA identified modification to resident #1's plan of care to include the addition of melatonin and snack at bedtime and involvement in daytime activities. At 2:46 pm on 1/8/2024, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. On 1/8/2024 at 11:30 pm maintenance staff initiated an Elopement Alarm Drill with all employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. On 1/8/2024, the maintenance assistant replaced the lock on the exterior door leaving the kitchen to avoid unsupervised residents leaving the center. On 1/8/2024, the Maintenance supervisor replaced the locks going into the kitchen with automatic door locks to assure that the kitchen doors will lock when they shut and to assure that unsupervised residents are not allowed into the kitchen. On 1/11/24, the psych nurse practitioner conducted a Telehealth visit to determine if medications needed to be adjusted. The nurse practitioner indicated she was pleasant and did not pose a risk to herself and others. On 1/11/2024, the Director of Clinical Education initiated education related to the importance of providing adequate supervision to resident to avoid accidents to including securing unsafe areas in the center. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. On 1/11/2024, the MDS Nurse conducted medical record reviews of all residents to identify which residents were interviewable verses those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interviewable. On 1/11/2024, The Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence of abuse or neglect. Assessments of these resident revealed no such evidence of abuse or neglect. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 1/11/24. On 1/11/2024, the Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced abuse or neglect. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 1/11/2024. On 1/11/2024, the Senior Director of Clinical Operations provided training for the Administrator, Director of Nursing (DON), the Assistant Director of Nursing (ADON) regarding abuse and neglect identification, protection, investigation. This action was completed on 1/1 [TRUNCATED]

Based on interviews, record review and facility policy review the facility failed to monitor and implement a Quality Assurance (QA) program that prevented an elopement for Resident #1 who had previously eloped from the facility on 12/14/23 and continued to seek an exit from the building for one (1) of three (3) residents reviewed. Resident #1. Resident #1 was allowed to exit the facility on 01/07/24 unnoticed and unsupervised at an unknown time and was discovered to be missing from the facility at approximately 8:10 PM. On 01/07/24 at approximately 8:00 PM, the police department received a 911 call from an unknown bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. A local Police Officer was dispatched and found Resident #1 walking in the middle of the street approximately 1850 feet from the facility and she had no shoes and no coat on. The Police Officer assisted Resident #1 into the backseat of his car and took her to the facility where he discovered that the facility staff were looking for her. Resident #1 was last observed in the facility at 7:55 PM, a Code 10 (elopement) was called at 8:10 PM, and Resident #1 was returned to the facility at 8:25 PM. Resident #1 was a wandering risk and had previously exited the facility on 12/14/23 and once again eloped from the facility without staff knowledge on 1/7/24. The facility's failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) program. Resident #1 was allowed to leave the facility unnoticed and unsupervised until she was picked up by a local Police Officer in the middle of the street about 1850 feet away from the facility. The elopement placed Resident #1 and other residents who were at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) which began on 01/07/24 when Res #1 eloped from the facility unsupervised. The SA notified the facility's Administrator (ADM) of the IJ on 01/11/24 at 3:19 PM, and provided IJ templates to the ADM. The facility submitted an acceptable Removal Plan on 1/12/24, in which they alleged all corrective actions to remove the IJ were completed on 1/12/24, and the IJ removed on 1/13/24. The SA validated the Removal Plan on 1/22/24 and determined the IJ was removed on 1/13/24, prior to exit. Therefore, the scope and severity 42 CFR (s): 483.75(d)(1)- QAPI/QAA Improvement Activities (F867) was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Record review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) dated February 2017 revealed Purpose: QAPI is a data driven, proactive approach to improving the quality of life, care and services in our centers. The activities of QAPI involve team members at all levels of the organization to identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor the effectiveness of our interventions. QAPI is consistent with our Service Standard: We continually strive to improve personal and company performance. In an interview with the Administrator on 01/09/24 at 9:05 PM, revealed that Resident #1 had gotten out of the building again on 01/07/24 on night shift. He stated, The only thing we really changed were the kitchen doorknobs and put a pin lock on the doors so that everyone who entered had to have the code. He revealed that the QAPI team along with the Medical Director were all notified at 8:55 PM on 01/07/24 and they had a QAPI meeting on Monday morning, 01/08/24. In an interview with the Minimum Data Set (MDS) Coordinator on 01/11/24 at 11:30 AM, revealed that they had been having Quality Assurance and Performance Improvement (QAPI) Meetings every month with the Medical Director present and that they had an Emergency QAPI Meeting on 01/08/24 after Resident #1 eloped. The MDS Coordinator revealed that QAPI was a functional tool that forced everyone to look at [NAME] if something had happened and a good way to follow up. She stated, It's a continual thing. The MDS Coordinator revealed that they looked at alert notes, falls, active infection, all skilled residents, admissions, discharges, nursing concerns, therapy, acute problems, and really, anything going on. The MDS Coordinator revealed that she was not aware of the wandering incident where Resident #1 was found inside the kitchen heading out the exit door on 01/01/2024. She revealed that this was not brought up in stand up or in QAPI meeting but then she had missed some. The MDS Coordinator stated, I didn't know about this incident and should have. I must have missed some of this. The MDS Coordinator agreed that this incident should have been reported, discussed, and taken care of. She revealed that it should have been care planned, interviews should have been completed, and they should have made sure that the incident was noted, and things were in place. The MDS Coordinator agreed that if the incident with Resident #1 had been taken care of on 01/01/24, it could have prevented the elopement incident on 01/07/24 which put the resident at risk of harm. The MDS Coordinator stated, Apparently we dropped the ball on this one. In a phone interview with the Director of Nursing Services (DON), on 01/11/24 at 12:35 PM, the DON was asked why at the QA meetings or the stand up meetings that the resident attempting to leave the facility prior through the unlocked door in the kitchen had not been talked about or addressed and she stated that she was off work on 01/01/24-01/03/24. She stated that when the LPN called her she just told the nurse to document the behavior in the nurse's notes and stated I wasn't at work to bring it up and had not thought about it anymore. The DON agreed that she should have reported this and agreed that the elopement on 01/07/24 might have been prevented had this been taken care of on 01/01/24 and discussed in the stand up meetings or the QA meetings. Record review of Progress Notes created and completed by LPN #2 revealed the following on 01/01/2024: At 18:48 Resident constantly trying to get out of building, she got into the kitchen and was headed out the back door before a staff member caught her. We are ensuring that she stays on this side of building however its hard to watch her 24/7. At 18:58 was documented, DON (Director of Nursing) notified, ensured that kitchen doors were locked. Progress notes were documented as Behavior Charting. In an interview with the Assistant Director of Nursing Service (ADON) on 01/10/24 at 5:30 PM, the ADON agreed that the facility failed to ensure that an effective monitoring system was in place throughout the facility to prevent the resident from getting out of the facility again. The ADON confirmed that they should be monitoring this resident more closely and talking about her in the meetings because she has eloped from the facility prior. In an interview with ADM on 01/11/24 at 12:20 PM, revealed that he was not aware of the incident with Resident #1 walking into the kitchen and heading out the exit door which occurred on 01/01/24. He stated, I had no idea, no one told me that. He revealed that he wasn't sure why this wasn't brought up in their morning meetings and that if it had happened, they should have addressed it, corrected the situation then, and had measures in place. He stated, I was not aware and should have been notified. The facility implemented the following Removal Plan: On 1/7/2024 at approximately 8:10 pm the facility called a code 10 that Resident #1 was not found in her room, staff searched the entire building and upon going to look for resident outside an Officer with the local police department was pulling into facility parking lot with resident, resident was assisted back into the facility by nurse and Certified Nursing Assistant (CNA). The nursing staff last saw the resident at approximately 8:00 pm in the dining room and returned to facility at 8:25 pm on 1/7/2024. On January 11 at 3:19 PM the facility was verbally notified that Immediate Jeopardy (IJ) was identified for Federal tag 600 -Abuse, Federal tag 656- Care Plans, Federal tag 689- Failure to Prevent Accidents and Hazards, Federal tag 867 - QAPI (Quality Assurance Performance Improvement). The facility received IJ templates on January 11, 2024, at 3:19 PM. Immediate Actions: At 8:30 pm on 1/7/2024 the Executive Director and Director of Nursing (DON) begin official investigation of Resident #1 Elopement and determined the resident exited out of the door going through the kitchen. At 8:30 pm on 1/7/2024 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. Upon return to facility Resident # 1 was ambulating independently, awake, alert with usual state of cognition. Resident was examined by Licensed Practical Nurse (LPN) with no injuries noted. Resident was immediately taken to room and vitals and head to toe assessment obtained. Resident was smiling and had no complaints of pain noted. No signs of injury noted, no bruising, scratches, cuts, or bleeding noted blood pressure 135/72, pulse 75, respirations 18, temperature 96.8, blood oxygen saturation 92%. Resident changed b/p. 135/72, p. 75, r. 18, t. 96.8, sa02 92%. Resident changed for bed and CNA in room doing one on one care. Director of Nursing (DON) was notified at 8:27 pm. Upon her return to the center on 1/7/2024, the resident was examined by the staff nurse and noted to have no negative findings. She was placed on 1:1 supervision until 1 PM on 1/8/2024 after the door locks were replaced in the kitchen. After that she was placed on every 15-minute checks to assure her safety. The kitchen doors were monitored until locks were replaced at 1:00pm 1/8/2024. This close supervision continues as of 1/11/2024. Resident #1 will be placed on 15-minute checks until exit-seeking behavior ceases. On 1/7/2024 at 8:55 pm Medical Director (MD), Physician's Assistant (PA) and Nurse Practitioner (NP) was notified of Resident Elopement from facility. On 1/7/2024 maintenance staff arrived at 9:30 pm to assess all facility exit doors, doors were checked for proper functioning by maintenance staff. All doors and wander guard systems were functioning properly. On 1/7/2024 at 9:00 pm all residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. On 1/7/2024 at 9:00 pm, Director of Nursing (DON) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. On 1/7/2024 at 10:00 pm in-services was initiated by Director of Nursing (DON) to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 1/8/2024 with no staff allowed to work until in-service completed. At 10:00 pm on 1/7/2024 Director of Nursing (DON) attempted to notify Resident # 1 Responsible Representative (RR) of the resident elopement from facility with no answer message left for RR to return call. RR returned call at 8:08 AM on 1/8/2024 and was notified of incident. On 1/8/2024, the Administrator and the Director of Nursing (DON) immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 1/8/2024 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing via phone, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing (ADON), Infection Preventionist and Minimum Data Set Nurse (MDS) to discuss Resident #1's exit seeking behavior and all safeguards put in place to ensure safety of all residents. QA identified modification to resident #1's plan of care to include the addition of Elation and snack at bedtime and involvement in daytime activities. At 2:46 pm on 1/8/2024, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. On 1/8/2024 at 11:30 pm maintenance staff initiated an Elopement Alarm Drill with all employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. On 1/8/2024, the maintenance assistant replaced the lock on the exterior door leaving the kitchen to avoid unsupervised residents leaving the center. On 1/8/2024, the Maintenance supervisor replaced the locks going into the kitchen with automatic door locks to assure that the kitchen doors will lock when they shut and to assure that unsupervised residents are not allowed into the kitchen. On 1/11/24, the psych nurse practitioner conducted a Telehealth visit to determine if medications needed to be adjusted. The nurse practitioner indicated she was pleasant and did not pose a risk to herself and others. On 1/11/2024, the Director of Clinical Education initiated education related to the importance of providing adequate supervision to resident to avoid accidents to including securing unsafe areas in the center. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. On 1/11/2024, the MDS Nurse conducted medical record reviews of all residents to identify which residents were interviewable verses those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interviewable. On 1/11/2024, The Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or neglect. Assessments of these resident revealed no such evidence of abuse or neglect. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 1/11/24. On 1/11/2024, the Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager and interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced abuse or neglect. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 1/11/2024. On 1/11/2024, the Senior Director of Clinical Operations provided training for the Administrator, Director of Nursing (DON) the Assistant Director of Nursing (ADON) regarding abuse and neglect identification, protection, investigation. This action was completed on 1/11/2024. On 1/8/2024, the Director of Clinical Education initiated training on abuse and neglect to include identification of abuse and neglect, protections of residents, investigation, and reporting requirements. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. On 1/12/24, the Senior [NAME] President of Operations provided education to the Administrator regarding the expectation of following the facility Quality Assurance Policy and Procedure in having ADHOC meetings as needed when new concerns are identified to immediately discuss, and determine immediate action needed to correct/address the identified area of concern to prevent safety issues related to elopement and then to continue monthly meetings to review effectiveness of plans and adjust plans as needed to ensure sustained compliance. The Administrator educated the Quality Assurance Committee Members on 1/12/24. The Director of Nursing (DON) will be educated prior to next scheduled shift by the Administrator. Education initiated on 1/12/24 by the Director Clinical Education with all staff regarding the expectations to immediately report any identified deficient practice to the Administrator or Director of Nursing (DON) so that the deficient practice or new concern can be addressed through the facility Quality Assurance Performance Improvement Committee by initiation of a plan of correction to include education, systemic changes, and auditing to ensure correction and sustained compliance. Education included review of the Quality Assurance and Performance Improvement Policy. Staff that did not receive education on 1/12/24 will be educated prior to working next scheduled shift. An adhoc QAPI meeting addressing the finding was initiated and completed 1/12/24 with the attendance of the Administrator, Nurse Practitioner (NP), Human Resources Coordinator, Director of Rehab, Registered MDS Coordinator, Director of Clinical Education (Infection Preventionist), Director of Nursing via phone, Maintenance Director, Dietary Manager, Activity Director, and Health Information Manager and Medical Director via phone. All corrective actions were completed by 1/12/2024 and the facility alleges removal of the Immediate Jeopardy (IJ) 1/13/2024. The State Agency (SA) validated the facility's Removal Plan on 01/22/24. The SA validated through interviews and record review that at 8:30 pm on 1/7/2024 the Executive Director and Director of Nursing (DON) begin official investigation of Resident #1 Elopement and determined the resident exited out of the door going through the kitchen. The SA validated through interviews and record review that at 8:30 pm on 1/7/2024 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. The SA validated through interviews and record review that upon return to facility Resident # 1 was ambulating independently, awake, alert with usual state of cognition. Resident was examined by Licensed Practical Nurse (LPN) with no injuries noted. Resident was immediately taken to room and vitals and head to toe assessment obtained. Resident was smiling and had no complaints of pain noted. No signs of injury noted, no bruising, scratches, cuts, or bleeding noted blood pressure 135/72, pulse 75, respirations 18, temperature 96.8, blood oxygen saturation 92%. Resident changed b/p. 135/72, p. 75, r. 18, t. 96.8, sa02 92%. Resident changed for bed and CNA in room doing one on one care. Director of Nursing (DON) was notified at 8:27 pm. The SA validated through interviews and record review that upon her return to the center on 1/7/2024, the resident was examined by the staff nurse and noted to have no negative findings. She was placed on 1:1 supervision until 1 PM on 1/8/2024 after the door locks were replaced in the kitchen. After that she was placed on every 15-minute checks to assure her safety. The kitchen doors were monitored until locks were replaced at 1:00pm 1/8/2024. This close supervision continues as of 1/11/2024. Resident #1 will be placed on 15-minute checks until exit-seeking behavior ceases. The SA validated through interviews and record review that on 1/7/2024 at 8:55 pm Medical Director (MD), Physician's Assistant (PA) and Nurse Practitioner (NP) was notified of Resident Elopement from facility. The SA validated through interviews and record review that on 1/7/2024 maintenance staff arrived at 9:30 pm to assess all facility exit doors, doors were checked for proper functioning by maintenance staff. All doors and wander guard systems were functioning properly. The SA validated through interviews and record review that on 1/7/2024 at 9:00 pm all residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. The SA validated through interviews and record review that on 1/7/2024 at 9:00 pm, Director of Nursing (DON) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. The SA validated through interviews and record review that on 1/7/2024 at 10:00 pm in-services was initiated by Director of Nursing (DON) to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 1/8/2024 with no staff allowed to work until in-service completed. The SA validated through interviews and record review that at 10:00 pm on 1/7/2024 Director of Nursing (DON) attempted to notify Resident # 1 Responsible Representative (RR) of the resident elopement from facility with no answer message left for RR to return call. RR returned call at 8:08 AM on 1/8/2024 and was notified of incident. The SA validated through interviews and record review that on 1/8/2024, the Administrator and the Director of Nursing (DON) immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. The SA validated through interviews and record review that on 1/8/2024 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing via phone, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing (ADON), Infection Preventionist and Minimum Data Set Nurse (MDS) to discuss Resident #1's exit seeking behavior and all safeguards put in place to ensure safety of all residents. QA identified modification to resident #1's plan of care to include the addition of Elation and snack at bedtime and involvement in daytime activities. The SA validated through interviews and record review that at 2:46 pm on 1/8/2024, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. The SA validated through interviews and record review that on 1/8/2024 at 11:30 pm maintenance staff initiated an Elopement Alarm Drill with all employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. The SA validated through interviews and record review that on 1/8/2024, the maintenance assistant replaced the lock on the exterior door leaving the kitchen to avoid unsupervised residents leaving the center. The SA validated through observation, interviews and record review that on 1/8/2024, the Maintenance supervisor replaced the locks going into the kitchen with automatic door locks to assure that the kitchen doors will lock when they shut and to assure that unsupervised residents are not allowed into the kitchen. The SA validated through interviews and record review that on 1/11/24, the psych nurse practitioner conducted a Telehealth visit to determine if medications needed to be adjusted. The nurse practitioner indicated she was pleasant and did not pose a risk to herself and others. The SA validated through interviews and record review that on 1/11/2024, the Director of Clinical Education initiated education related to the importance of providing adequate supervision to resident to avoid accidents to including securing unsafe areas in the center. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. The SA validated through interviews and record review that on 1/11/2024, the MDS Nurse conducted medical record reviews of all residents to identify which residents were interviewable versus those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed versus those that were considered non interviewable. The SA validated through interviews and record review that on 1/11/2024, The Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or neglect. Assessments of these resident revealed no such evidence of abuse or neglect. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 1/11/24. The SA validated through interviews and record review that on 1/11/2024, the Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager and interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced abuse or neglect. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 1/11/2024. The SA validated through interviews and record review that on 1/11/2024, the Senior Director of Clinical Operations provided training for the Administrator, Director of Nursing (DON) the Assistant Director of Nursing (ADON) regarding abuse and neglect identification, protection, investigation. This action was completed on 1/11/2024. The SA validated through interviews and record review that on 1/8/2024, the Director of Clinical Education initiated training on abuse and neglect to include identification of abuse and neglect, protections of residents, investigation, and reporting requirements. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. The SA validated through interviews and record review that on 1/12/24, the Senior [NAME] President of Operations provided education to the Administrator regarding the expectation of following the facility Quality Assurance Policy and Procedure in having ADHOC meetings as needed when new concerns are identified to immediately discuss, and determine immediate action needed to correct/address the identified area of concern to prevent safety issues related to elopement and then to continue monthly meetings to review effectiveness of plans and adjust plans as needed to ensure sustained compliance. The Administrator educated the Quality Assurance Committee Members on 1/12/24. The Director of Nursing (DON) will be educated prior to next scheduled shift by the Administrator. The SA validated through interview and record review that Director of Nursing had been educated prior to her return to work. The SA validated through interviews and record review that education was initiated on 1/12/24 by the Director Clinical Education with all staff regarding the expectations to immediately report any identified deficient practice to the Administrator or Director of Nursing (DON) so that the deficient practice or new concern can be addressed through the facility Quality Assurance Performance Improvement Committee by initiation of a plan of correction to include education, systemic changes, and auditing to ensure correction and sustained compliance. Education included review of the Quality Assurance and Performance Improvement Policy. Staff that did not receive education on 1/12/24 will be educated prior to working next scheduled shift. The SA validated through interviews and record review that an adhoc QAPI meeting addressing the finding was initiated and completed 1/12/24 with the attendance of the Administrator, Nurse Practitioner (NP), Human Resources Coordinator, Director of Rehab, Registered MDS Coordinator, Director of Clinical Education (Infection Preventionist), Director of Nursing via phone, Maintenance Director, Dietary Manager, Activity Director, and Health Information Manager and Medical Director via phone. The SA validated through observation, interview, and record review that the facility removed the Immediate Jeopardy (IJ) on 01/12/24 and alleged compliance on 01/13/24.

Based on interviews, record review and facility policy review the facility failed to supervise and prevent the elopement of Resident #1 who left the faciity on [DATE] for the second time unnoticed and unsupervised. Resident #1 was one (1) of three (3) residents reviewed. Resident #1 was allowed to exit the facility on 01/07/24 unnoticed and unsupervised at an unknown time and was discovered to be missing from the facility at approximately 8:10 PM. On 01/07/24 at approximately 8:00 PM, the police department received a 911 call from an unknown bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. A local Police Officer was dispatched and found Resident #1 walking in the middle of the street approximately 1850 feet from the facility and she had no shoes and no coat on. The Police Officer assisted Resident #1 into the backseat of his car and took her to the facility where he discovered that the facility staff were looking for her. Resident #1 was last observed in the facility at 7:55 PM, a Code 10 (elopement) was called at 8:10 PM, and Resident #1 was returned to the facility at 8:25 PM. A head-to-toe assessment was completed immediately upon her return to the facility. Resident #1 was a wandering risk and had previously exited the facility on 12/14/23 and once again eloped from the facility without staff knowledge on 1/7/24. The facility's failure to provide supervision to prevent the second elopement for Resident #1 who was diagnosed with Alzheimer's and Dementia placed Resident #1 and other residents who were at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ), and Substandard Quality of Care (SQC) which began on 01/07/24 when Res #1 eloped from the facility unsupervised. The SA notified the facility's Administrator (ADM) of the IJ and SQC on 01/11/24 at 3:19 PM, and provided IJ templates to the ADM. The facility submitted an acceptable Removal Plan on 1/12/24, in which they alleged all corrective actions to remove the IJ were completed on 1/12/24, and the IJ removed on 1/13/24. The SA validated the Removal Plan on 1/22/24 and determined the IJ was removed on 1/13/24, prior to exit. Therefore, the scope and severity for 42 CFR 483.25 (d) (1) (2) - Accidents (F689) was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Record review of the facility policy Elopement dated April 2017, revealed Purpose To establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements . Record review of Facility Investigation Template completed by Administrator documented the following: On 1/7/2024 at 8:10 pm a code 10 was called as resident was unable to be located. Staff completed a room to room audit to ensure all residents were safe and accounted for. At 8:25 pm resident was escorted back into center by Police Department officer . Investigation Summary: Review of the center's maintenance camera revealed the resident exited the center out an unlocked door in the rear of the center . Record review of the City of (proper name) Police Department Incident Report revealed that the Police Officer responded to a call which was was received at 8:00 PM on 01/07/24 from a bystander. Police Officer responded to the area of [NAME] Lane and observed a confused, white female with no coat, sock footed who was walking in the middle of the street on hospital street. Police Officer approached Resident #1 and she told him that she was going back to the nursing home. Police Officer assisted Resident #1 into the back seat of his patrol car and transported her back to the facility. Police Officer was informed by LPN #3 that This was not the first time that this has happened, that one of the doors in the building was not locked and does not have an alarm on it . This Incident Report was completed by the Police Officer on 01/07/24. During an interview on 01/09/24 at 8:45 PM, with Licensed Practical Nurse (LPN) #1, revealed that she was working the night of 01/07/24 when Resident #1 got out of the building. She revealed that she had last seen Resident #1 that night around 7:50 PM walking down B-Hall. LPN #1 revealed that when the staff saw Resident #1 out walking around in the building, they redirected her back to her room. She revealed that Resident #1's cognition was not good, that she had dementia, but they could hold her hand and easily redirect her back to her room. This LPN revealed that a CODE 10 for elopement was called around 8:00 PM, all staff stopped what they were doing and went to look for her. LPN #1 revealed that right before 8:30 PM, Resident #1 was returned to the facility by the police. LPN #1 revealed that someone had called the police, reported that they had seen an elderly woman walking and the police brought her back to the facility. She stated Resident #1 had been seen exit seeking a lot lately and the door alarms went off when she walked near them. After this incident, they had someone watch all the doors until maintenance could get to the facility and check them out that night. Since the incident on 01/07/24, maintenance had put pin pads on the kitchen doors so the residents couldn't get in there. LPN #1 stated, They think she may have exited the kitchen. During an interview with Administrator on 01/09/24 at 9:05 PM, revealed that Resident #1 had gotten out of the building again on 01/07/24 on the night shift. He revealed that according to interviews and statements taken by staff, Resident #1 was last seen around 7:55 PM and that there was about 20 to 25 minutes that Resident #1 was unaccounted for that night. He thought she left through the kitchen door this time. The staff had been doing hourly checks since the last elopement incident on 12/14/23 and that this had happened between the scheduled visual checks. A Code 10 was called around 8:10 PM, Resident #1 was last seen around 7:55 PM and was returned to the facility by a police officer around 8:25 PM or 8:30 PM. He state he wasn't sure of all the details, but someone must have called the police or either he was patrolling and found her. ADM revealed that he was not sure of the exact location where she was picked up from either. Maintenance came in that night and checked all of the windows and doors, checked all of the door alarms and wander guard bracelets and everything worked properly. The only way possible for her to get out was through the kitchen door. He revealed that the two doors that led from the dining room into the kitchen had locks on them from the inside of the kitchen and staff had to push the lock in and turn it for them to lock properly. ADM confirmed that he wasn't aware that Resident #1 had gone back into the kitchen earlier that evening until he read the statements provided by the staff. ADM stated that this resident wanders a lot and according to what he was told, Resident #1 was last seen in the dining room around 7:25 PM. Resident was placed on 1 on 1 supervision after the incident until the new kitchen door locks were installed on 01/08/24 at 1:00 PM. He revealed that the exit doors on the hall doors would not release to open unless the fire alarm was pulled so she couldn't have gotten out there. He stated, The only thing we really changed were the kitchen doorknobs and put a pin lock on the doors so that everyone who entered had to have the code. During an interview on 01/09/24 at 9:55 PM, with Certified Nursing Assistant (CNA) #2, revealed that she was working on D-Hall on 01/07/24 on the night shift. She revealed that she saw Resident #1 that night between 7:30 PM and 8:00 PM coming out of the dining room walking towards the front door. CNA #2 revealed that the kitchen staff had brought her out of the kitchen to C-Wing, and the CNAs went and put her to bed. CNA #2 revealed that about 20 to 30 minutes later, she was missing, and they were looking for her. They checked all the rooms and halls, and she wasn't there, then around 8:25 PM, she saw that a police officer had pulled up and had Resident #1 in the backseat. The nurse opened the front door and let her back into the facility. CNA revealed that Resident #1 was brought in, was assessed, and had seemed to be fine, no skin issues and no injuries. During an interview on 01/09/24 at 10:05 PM, CNA #1 revealed that she was working on the night of 01/07/24 when Resident #1 got out of the facility. She stated that the resident liked to wander at night and sometimes she would walk to the end of the hall, jiggle the door to see if it would open. They would go get her by the hand and redirect her back. It was hard to keep up with Resident #1 most of the time because she was constantly on the move and that the staff worked together and tried to keep her in their sight. On 01/07/24 at around 7:35 PM, a kitchen staff member brought Resident #1 to her CNA on C/D hall and told her that Resident #1 had gotten into the kitchen. CNA #1 revealed that she brought Resident #1 to the CNA she was assigned to for the night, and he took care of her. CNA #1 revealed that a little after 8 PM, Resident #1's CNA asked her if she had seen Resident #1. CNA #1 revealed that they looked down halls, resident rooms, and outside. CNA #1 revealed that a few minutes later, the police brought Resident #1 back to the facility and stated, I have no idea how she got out. During an interview on 01/10/24 at 10:10 PM, the Administrator (ADM) revealed that he was glad that the codes on the doors checked out and worked properly and that everything else checked out, but there was still 20 minutes that Resident #1 was unaccounted for, and he agreed that a lot could have happened to her in 20 minutes. The ADM stated, I'm just glad she was safe, it could have been real bad. During an interview by phone on 01/10/24 at 10:20 AM, with Director of Nursing Services (DON), revealed that on Sunday night 01/07/24, the Administrator called and told her about Resident #1 getting out of the building again. She revealed that she was off; but came on to the facility. She walked around with maintenance, started interviews, took statements, and had all the wander guard bracelets checked and they were all working properly. She then completed elopement assessments on every resident in the building and updated care plans. She stated that maintenance came in and checked all the doors, and she was confident that the kitchen door was the only one she could have gotten out of. The DON revealed that Resident #1 had walked into the kitchen a couple of times that she knew of prior to this night because staff had told her about it. The DON stated, This had happened during the day while we were there. The DON stated that she wasn't aware that Resident #1 had been brought out of the kitchen earlier the night of 01/07/24 until she arrived on that Sunday night around 9:00 PM, but that she did know the resident had been in the kitchen days prior and was attempting to go out the exit door. During an interview on 01/10/24 at 10:45 AM, with Dietary Aide #1 revealed that she was working on the evening of 01/07/24 during the time that Resident #1 got out of the building. She revealed that at approximately 7:30 PM or a little after, she was bent down washing dishes in the washroom next to the kitchen door when she heard something. Dietary Aide #1 revealed that she saw that Resident #1 had come into the kitchen, had walked past her, and was over by the stove walking towards the exit door which led to the outside of the building. This dietary aide revealed that she walked constantly and was seen frequently at doors looking out. Dietary Aide #1 revealed that she was working in the kitchen by herself when this happened because Dietary Aide #2 had taken the trash out. She got Resident #1 by the hand and led her out of the kitchen and took her to CNA #1 who was working out on the hall. About 30 minutes later, she came out of the kitchen to see what a CODE 10 was that was called and found out that Resident #1 was missing. She revealed that Dietary Aide #2 worked in the kitchen with her that evening and had passed the snacks out on the night of 01/07/24. Dietary Aide #1 revealed that Resident #1 walked constantly and was seen frequently at doors looking out. During an interview on 01/10/24 at 11:00 AM, LPN #2 revealed that Resident #1 usually slept during the day until late afternoon or supper time and then walked the floors. LPN #2 stated, She stays busy, just does her thing. She and the CNAs tag teamed to try and keep an eye on her. She stated, We try to work together with the CNAs and do the best we can to keep our eyes on her but it's hard with her constantly on the move. She revealed that when Resident #1 walked the halls, she would push on the doors, then turn around and walk off if they wouldn't open. Resident #1 was not combative and was easily redirected; but would often return to what she was doing. LPN #2 stated, Everyone knows that as soon as you redirect her, she goes right back. LPN #2 revealed that Resident #1 had dementia but said she was smarter than you think, it's like she's watching and waiting. LPN #2 revealed that they had to work together as best they could to keep their eyes on her. During an interview on 01/10/24 at 11:20 AM, the Administrator (ADM) revealed that there were two older video cameras on the Maintenance Shop out behind the facility. He revealed that he knew they were out there but didn't know if they worked or not. The cameras were 50 feet from the facility pointing back towards the back of the Nursing Home where the kitchen exit door was. They played back the video camera footage, and it showed Resident #1 exiting the kitchen door to the outside. ADM stated, We do have evidence of her exiting the building and I know for sure that she went out the side kitchen door, not out the Emergency Exit in the dining room. ADM revealed that it was dietary not keeping the doors from the dining room into the kitchen locked properly that caused Resident #1 to get out. He revealed that the camera footage showed her getting out at 7:55 PM and that she was out of camera view when she turned left at about 8:05 PM. He revealed that it showed that she walked across the back parking lot back to the left, basically, followed the concrete road around. The Administrator revealed that they replaced the kitchen door locks, removed the flex locks, and replaced them with locks that required a code to enter. The ADM stated, Now they don't have an option but to keep the doors locked. Administrator stated that he did not realize Resident #1 had gotten into the kitchen earlier the day of 01/07/24 or on 01/01/24 until he was reading statements. ADM revealed that the kitchen doors would lock but staff were not keeping them locked. ADM stated, I do know that I've been on them about keeping the kitchen doors locked and confirmed they had completed an in-service earlier this month to keep the kitchen doors locked so residents could not enter the kitchen. During an interview on 01/10/24 at 11:55 AM, Dietary Aide #2, revealed she was working on 01/07/24 in the kitchen. She revealed she was outside taking the trash out and when she returned, was told by Dietary Aide #1, that Resident #1 had walked into the kitchen and was headed towards the exit door over by the stove. Dietary Aide #2 revealed that she got snacks together and when she passed out the snacks around 7:30 PM to A/B hall, she saw Resident #1 exiting a resident's room on that hall. She revealed that after 8:00 PM, a CODE 10 was called, and everyone went to look for her. Dietary Aide #2 revealed that Resident #1 had come back to the kitchen pretty often; but most of the time she just opened the door and closed it back without coming in. Dietary Aide #2 revealed that if Resident #1 opened the door, the kitchen staff would get her out of the kitchen and find a nurse or CNA to get her. Dietary Aide #2 stated, If we don't, she would just come back. She revealed that Resident #1 had come into the kitchen a couple times while she had been at work but couldn't recall the dates. Dietary Aide #2 revealed that they always made sure the kitchen doors were locked before they left at night-time. She revealed that one door they had to manually lock when they were in the kitchen. Dietary Aide #2 revealed that Resident #1 had to have gone into the kitchen while she (Dietary Aide #2) was passing out snacks and while Dietary Aide #1 was washing dishes for them not to have seen her. During an interview on 01/10/24 at 12:10 PM, via telephone with the Police Officer revealed that on 01/07/24 around 8:00 PM, the local Police Department received a 911 call from a bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. Police Officer revealed that he drove to the area and found that Resident #1 was walking in the middle of the street behind the Emergency Department at the County Hospital which was a pretty good way from the nursing home. The resident had a shirt, jogging pants, and socks on. Resident #1 was not wearing a coat or shoes. He revealed that he stopped her, and this resident seemed to be confused. He asked her where she was going, and she told him to the nursing home. He revealed that Resident #1 was hard to understand but told him she was going back to (Proper Name of Facility). He helped her into his car and drove her back to the facility. When he pulled into the parking lot, he did notice that some of staff were in personal vehicles headed out to look for her. The Police Officer revealed that he released her to LPN #3. During an interview on 01/10/24 at 4:25 PM, via phone with LPN #3 revealed that she was working on 01/07/24, the night that Resident #1 got out of the facility. LPN #3 revealed that she had seen Resident #1 several times walking all around on A/B hall and E/F hall and staff members kept bringing her back to her room. Resident #1 was last seen just outside her room a little before 8:00 PM. She revealed that about 8:10 PM, she asked the CNA who was assigned to Resident #1 to go see if the resident was in her room and he found that she was not. LPN #3 revealed that she called a Code 10 and immediately started looking for her. They looked on all halls, in all rooms and outside the building. She went to the front door about 8:25 PM and saw a police car drive up and then saw that he had Resident #1 in the back seat. She revealed that there were a couple staff who had gotten in their cars to go look for her when they saw the police officer drive up with Resident #1. The police officer brought her to the door and stated, I believe I have someone who belongs to y'all and the officer released Resident #1 to them. LPN #3 revealed that Resident #1 had a pair of sweatpants on with a cuff at the bottom, had a long-sleeved shirt on, some gripper socks and had no coat or shoes on. They immediately got her inside, checked her vital signs and did a head-to-toe assessment and there were no injuries noted. LPN #3 revealed that they put her on one-on-one supervision and had someone in the room with her to always have eyes on her. She revealed that Resident #1 went to bed as soon as they got her checked out. LPN #3 revealed that she couldn't see how they could do any better with monitoring this resident. Record review of the Name of local city weather on 01/07/24 revealed that the temperature at the time of the elopement was 39 degrees Fahrenheit with clear skies. Record review of Resident #1's Admission Record revealed admitted [DATE] and had the following diagnoses to include: Alzheimer's Disease, Need for Assistance with Personal Care, Dementia with unspecified severity with other behavioral disturbance, and Unspecified Psychosis. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/27/2023 under Section C revealed a Brief Interview for Mental Status (BIMS) should not be conducted because resident is rarely/never understood. Under C1000, Cognitive Skills for Daily Decision Making was documented that resident was severely impaired. Section P0200 revealed a Wander/Elopement Alarm was used daily. Record review of Resident #1's Elopement Risk Assessment completed on 01/07/24 revealed that resident had history of wandering or elopement. The facility implemented the following Removal Plan: On 1/7/2024 at approximately 8:10 pm the facility called a code 10 that Resident #1 was not found in her room, staff searched the entire building and upon going to look for resident outside an Officer with the local police department was pulling into facility parking lot with resident, resident was assisted back into the facility by nurse and Certified Nursing Assistant (CNA). The nursing staff last saw the resident at approximately 8:00 pm in the dining room and returned to facility at 8:25 pm on 1/7/2024. On January 11 at 3:19 PM the facility was verbally notified that Immediate Jeopardy (IJ) was identified for Federal tag 600 -Abuse, Federal tag 656- Care Plans, Federal tag 689- Failure to Prevent Accidents and Hazards, Federal tag 867 - QAPI (Quality Assurance Performance Improvement). The facility received IJ templates on January 11, 2024, at 3:19 PM. Immediate Corrective Actions for Resident #1: At 8:30 pm on 1/7/2024 the Executive Director and Director of Nursing (DON) begin official investigation of Resident #1 Elopement and determined the resident exited out of the door going through the kitchen. At 8:30 pm on 1/7/2024 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. Upon return to facility Resident # 1 was ambulating independently, awake, alert with usual state of cognition. Resident was examined by Licensed Practical Nurse (LPN) with no injuries noted. Resident was immediately taken to room and vitals and head to toe assessment obtained. Resident was smiling and had no complaints of pain noted. No signs of injury noted, no bruising, scratches, cuts, or bleeding noted blood pressure 135/72, pulse 75, respirations 18, temperature 96.8, blood oxygen saturation 92%. Resident changed b/p. 135/72, p. 75, r. 18, t. 96.8, sa02 92%. Resident changed for bed and CNA in room doing one on one care. Director of Nursing (DON) was notified at 8:27 pm. Upon her return to the center on 1/7/2024, the resident was examined by the staff nurse and noted to have no negative findings. She was placed on 1:1 supervision until 1 PM on 1/8/2024 after the door locks were replaced in the kitchen. After that she was placed on every 15-minute checks to assure her safety. The kitchen doors were monitored until locks were replaced at 1:00pm 1/8/2024. This close supervision continues as of 1/11/2024. Resident #1 will be placed on 15-minute checks until exit-seeking behavior ceases. On 1/7/2024 at 8:55 pm Medical Director (MD), Physician's Assistant (PA) and Nurse Practitioner (NP) was notified of Resident Elopement from facility. On 1/7/2024 maintenance staff arrived at 9:30 pm to assess all facility exit doors, doors were checked for proper functioning by maintenance staff. All doors and wander guard systems were functioning properly. On 1/7/2024 at 9:00 pm all residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. On 1/7/2024 at 9:00 pm, Director of Nursing (DON) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. On 1/7/2024 at 10:00 pm in-services was initiated by Director of Nursing (DON) to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 1/8/2024 with no staff allowed to work until in-service completed. At 10:00 pm on 1/7/2024 Director of Nursing (DON) attempted to notify Resident # 1 Responsible Representative (RR) of the resident elopement from facility with no answer message left for RR to return call. RR returned call at 8:08 AM on 1/8/2024 and was notified of incident. On 1/8/2024, the Administrator and the Director of Nursing (DON) immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 1/8/2024 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing via phone, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing (ADON), Infection Preventionist and Minimum Data Set Nurse (MDS) to discuss Resident #1s exit seeking behavior and all safeguards put in place to ensure safety of all residents. QA identified modification to resident #1's plan of care to include the addition of melatonin and snack at bedtime and involvement in daytime activities. At 2:46 pm on 1/8/2024, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. On 1/8/2024 at 11:30 pm maintenance staff initiated an Elopement Alarm Drill with all employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. On 1/8/2024, the maintenance assistant replaced the lock on the exterior door leaving the kitchen to avoid unsupervised residents leaving the center. On 1/8/2024, the Maintenance supervisor replaced the locks going into the kitchen with automatic door locks to assure that the kitchen doors will lock when they shut and to assure that unsupervised residents are not allowed into the kitchen. On 1/11/24, the psych nurse practitioner conducted a Telehealth visit to determine if medications needed to be adjusted. The nurse practitioner indicated she was pleasant and did not pose a risk to herself and others. On 1/11/2024, the Director of Clinical Education initiated education related to the importance of providing adequate supervision to resident to avoid accidents to including securing unsafe areas in the center. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. On 1/11/2024, the MDS Nurse conducted medical record reviews of all residents to identify which residents were interviewable versus those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed versus those that were considered non interviewable. On 1/11/2024, The Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or neglect. Assessments of these resident revealed no such evidence of abuse or neglect. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 1/11/24. On 1/11/2024, the Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager and interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced abuse or neglect. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 1/11/2024. On 1/11/2024, the Senior Director of Clinical Operations provided training for the Administrator, Director of Nursing (DON) the Assistant Director of Nursing (ADON) regarding abuse and neglect identification, protection, investigation. This action was completed on 1/11/2024. On 1/8/2024, the Director of Clinical Education initiated training on abuse and neglect to include identification of abuse and neglect, protections of residents, investigation, and reporting requirements. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. On 1/12/24, the Senior [NAME] President of Operations provided education to the Administrator regarding the expectation of following the facility Quality Assurance Policy and Procedure in having ADHOC meetings as needed when new concerns are identified to immediately discuss, and determine immediate action needed to correct/address the identified area of concern to prevent safety issues related to elopement and then to continue monthly meetings to review effectiveness of plans and adjust plans as needed to ensure sustained compliance. The Administrator educated the Quality Assurance Committee Members on 1/12/24. The Director of Nursing (DON) will be educated prior to next scheduled shift by the Administrator. Education initiated on 1/12/24 by the Director Clinical Education with all staff regarding the expectations to immediately report any identified deficient practice to the Administrator or Director of Nursing (DON) so that the deficient practice or new concern can be addressed through the facility Quality Assurance Performance Improvement Committee by initiation of a plan of correction to include education, systemic changes, and auditing to ensure correction and sustained compliance. Education included review of the Quality Assurance and Performance Improvement Policy. Staff that did not receive education on 1/12/24 will be educated prior to working next scheduled shift. An adhoc QAPI meeting addressing the finding was initiated and completed 1/12/24 with the attendance of the Administrator, Nurse Practitioner (NP), Human Resources Coordinator, Director of Rehab, Registered MDS Coordinator, Director of Clinical Education (Infection Preventionist), Director of Nursing via phone, Maintenance Director, Dietary Manager, Activity Director, and Health Information Manager and Medical Director via phone. All corrective actions were completed by 1/12/2024 and the facility alleges removal of the Immediate Jeopardy (IJ) 1/13/2024. The State Agency (SA) validated the facility's Removal Plan on 01/22/24. The SA validated through interviews and record review that at 8:30 pm on 1/7/2024 the Executive Director and Director of Nursing (DON) begin official investigation of Resident #1 Elopement and determined the resident exited out of the door going through the kitchen. The SA validated through interviews and record review that at 8:30 pm on 1/7/2024 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. The SA validated through interviews and record review that upon return to facility Resident # 1 was ambulating independently, awake, alert with usual state of cognition. Resident was examined by Licensed Practical Nurse (LPN) with no injuries noted. Resident was immediately taken to room and vitals and head to toe assessment obtained. Resident was smiling and had no complaints of pain noted. No signs of injury noted, no bruising, scratches, cuts, or bleeding noted blood pressure 135/72, pulse 75, respirations 18, temperature 96.8, blood oxygen saturation 92%. Resident changed b/p. 135/72, p. 75, r. 18, t. 96.8, sa02 92%. Resident changed for bed and CNA in room doing one on one care. Director of Nursing (DON) was notified at 8:27 pm. The SA validated through interviews and record review that upon her return to the center on 1/7/2024, the resident was examined by the staff nurse and noted to have no negative findings. She was placed on 1:1 supervision until 1 PM on 1/8/2024 after the door locks were replaced in the kitchen. After that she was placed on every 15-minute checks to assure her safety. The kitchen doors were monitored until locks were replaced at 1:00pm 1/8/2024. This close supervision continues as of 1/11/2024. Resident #1 will be placed on 15-minute checks until exit-seeking behavior ceases. The SA validated through interviews

Based on interviews, record review, and facility policy review, the facility failed to implement effective comprehensive care plan interventions for Resident #1 who was at risk for elopement. Resident #1 was one (1) of three (3) wandering residents reviewed. Resident #1 was allowed to exit the facility on 01/07/24 unnoticed and unsupervised at an unknown time and was discovered to be missing from the facility at approximately 8:10 PM. On 01/07/24 at approximately 8:00 PM, the police department received a 911 call from an unknown bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. A local Police Officer was dispatched and found Resident #1 walking in the middle of the street approximately 1850 feet from the facility and she had no shoes and no coat on. The Police Officer assisted Resident #1 into the backseat of his car and took her to the facility where he discovered that the facility staff were looking for her. Resident #1 was last observed in the facility at 7:55 PM, a Code 10 (elopement) was called at 8:10 PM, and Resident #1 was returned to the facility at 8:25 PM. A head-to-toe assessment was completed immediately upon her return to the facility. Resident #1 was a wandering risk and had previously exited the facility on 12/14/23 and once again eloped from the facility without staff knowledge on 1/7/24. The facility's failure to provide supervision, implement a care plan to prevent an elopement for Resident #1 who was diagnosed with Alzheimer's and Dementia and sustain an effective Quality Assurance and Performance Improvement (QAPI) program. Resident #1 was allowed to leave the facility unnoticed and unsupervised until she was picked up by a local Police Officer in the middle of the street about 1850 feet away from the facility. The elopement placed Resident #1 and other residents who were at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) which began on 01/07/24 when Res #1 eloped from the facility unsupervised. The SA notified the facility's Administrator (ADM) of the IJ on 01/11/24 at 3:19 PM, and provided IJ templates to the ADM. The facility submitted an acceptable Removal Plan on 1/12/24, in which they alleged all corrective actions to remove the IJ were completed on 1/12/24, and the IJ removed on 1/13/24. The SA validated the Removal Plan on 1/22/24 and determined the IJ was removed on 1/13/24, prior to exit. Therefore, the scope and severity for 42 CFR (s): 483.21(b)(1)(i) - Comprehensive Care Plans (F656), and lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Record review of the facility policy titled, Comprehensive Care Plan effective May 1, 2012, revealed, .Practice Guidelines 1. The interdisciplinary care plan is implemented to guide health care center staff in the provision of necessary care and services to obtain and maintain the highest practicable physical, mental, and psychosocial well-being of the resident and promotion of the resident and family in planning care. Record review of Resident #1's Care Plan with revision date of 01/08/24 revealed Focus: I am at risk for elopement Not being able to make good safety decisions. I sometimes have behaviors which include wandering .Goal: My behavior will stop with staff intervention. Interventions: .Check function and placement of wander guard every shift. Help me maintain my favorite place to sit. I enjoy sitting in the dining room . Redirection such as taking her to activities or the area in hallway where she enjoys sitting . Resident currently has one on one staff supervision - date initiated: 01/08/24 .Wander guard: Visual check of resident Q (every) 2 hours. Record review of Facility Investigation Template completed by Administrator documented the following: On 1/7/2024 at 8:10 pm a code 10 was called as resident was unable to be located. Staff completed a room to room audit to ensure all residents were safe and accounted for. At 8:25 pm resident was escorted back into center by Police Department officer. Investigation Summary: Review of the center's maintenance camera revealed the resident exited the center out an unlocked door in the rear of the center Record review of Progress Notes created and completed by Licensed Practical Nurse (LPN) #2 revealed the following on 01/01/2024: At 18:48 Resident constantly trying to get out of building, she got into the kitchen and was headed out the back door before a staff member caught her. We are ensuring that she stays on this side of building however its hard to watch her 24/7. At 18:58 was documented, DON (Director of Nursing) notified, ensured that kitchen doors were locked. Progress notes were documented as Behavior Charting. An interview with Administrator on 01/09/24 at 9:05 PM, revealed that Resident #1 had gotten out of the building again on 01/07/24 on night shift. He revealed that according to interviews and statements taken by staff, Resident #1 was last seen around 7:55 PM and that there was about 20 to 25 minutes that Resident #1 was unaccounted for that night. ADM revealed that he thought she left through the kitchen door this time. He revealed that the staff had been doing hourly checks since the last incident on 12/14/23 and that this happened between the scheduled visual checks. Administrator confirmed that the care plan stated every 2 hour visual checks. A phone interview with Director of Nursing Services (DON) on 01/10/24 at 10:20 AM, revealed that on Sunday night 01/07/24, the Administrator called and told her that Resident #1 got out of the building again. The DON revealed that Resident #1 had walked into the kitchen a couple of times that she knew of prior to this night because staff had mentioned it to her. The DON stated, This had happened during the day while we were there. DON confirmed that they should have made staff aware of her exit seeking behavior through the kitchen doors but they failed to follow the care plan to prevent an elopement. An interview with the Assistant Director of Nursing (ADON) on 01/10/24 at 5:30 PM, revealed that the purpose of the comprehensive care plan was for the staff to be able to look at the resident as a whole, see what condition the resident was in and to look at any assistance the resident might need and to ensure the appropriate care was followed through. The ADON agreed that the facility failed to ensure that an effective care plan was followed through to prevent the resident from eloping from the facility. She confirmed that from interviews and review of the nurses notes that the resident needed more supervision at night and the care plan wasn't being followed. An interview with Minimum Data Set (MDS) Coordinator on 01/11/24 at 11:30 AM, revealed that she was not aware of the wandering incident where Resident #1 was found inside the kitchen heading out the exit door on 01/01/2024. She stated, I didn't know about this incident and should have. She agreed that this incident should have been reported, discussed, and taken care of. She revealed that it should have been care planned, interviews should have been completed, and they should have made sure that the incident was noted, and things were in place. The MDS Coordinator agreed that if the incident with Resident #1 had been taken care of on 01/01/24, it could have prevented the elopement incident on 01/07/24 which put the resident at risk of harm. The MDS Coordinator stated, Apparently we dropped the ball on this one. A phone interview with DON on 01/11/24 at 12:35 PM, revealed that she was made aware after she arrived at the facility on the night of 01/07/24, that Resident #1 had gone into the kitchen earlier in the evening prior to the elopement. DON revealed that they always tried to keep an eye on Resident #1 and the staff had to bring her back to her room constantly. She revealed that the kitchen staff had been in-serviced earlier this month on keeping the kitchen doors locked 24/7 with no exceptions. DON confirmed that Resident #1 wandered all the time, and it was worse in the evenings. DON confirmed that she knew about Resident #1 getting into the kitchen on 01/01/24 prior to the elopement on 01/07/24, and stated that was why they had completed the in-service to keep the kitchen doors locked. DON revealed that LPN #2 had called her and reported to her by phone and I told her to chart the behavior in the computer. DON revealed that she was off on 01/01/24, 01/02/24, and 01/03/24, and was not at work to bring it up in the stand up meeting and had not thought about it, but agreed that she should have reported this to other staff on the management team so it could have been addressed. DON agreed that the elopement on 01/07/24 might have been prevented had this been taken care of on 01/01/24 when it was reported to her. Record review of Resident #1's Admission Record revealed admitted [DATE] and had the following diagnoses to include: Alzheimer's Disease, Need for Assistance with Personal Care, Dementia with unspecified severity with other behavioral disturbance, and Unspecified Psychosis not due to a substance or known physiological condition. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/27/2023 under Section C0100 revealed that the Brief Interview for Mental Status (BIMS) should not be conducted due to resident is rarely/never understood. Under C1000, Cognitive Skills for Daily Decision Making was documented that resident was severely impaired. The facility implemented the following Removal Plan: On 1/7/2024 at approximately 8:10 pm the facility called a code 10 that Resident #1 was not found in her room, staff searched the entire building and upon going to look for resident outside an Officer with the local police department was pulling into facility parking lot with resident, resident was assisted back into the facility by nurse and Certified Nursing Assistant (CNA). The nursing staff last saw the resident at approximately 8:00 pm in the dining room and returned to facility at 8:25 pm on 1/7/2024. On January 11 at 3:19 PM the facility was verbally notified that Immediate Jeopardy (IJ) was identified for Federal tag 600 -Abuse, Federal tag 656- Care Plans, Federal tag 689- Failure to Prevent Accidents and Hazards, Federal tag 867 - QAPI (Quality Assurance Performance Improvement). The facility received IJ templates on January 11, 2024, at 3:19 PM. Immediate Corrective Actions for Resident #1: At 8:30 pm on 1/7/2024 the Executive Director and Director of Nursing (DON) begin official investigation of Resident #1 Elopement and determined the resident exited out of the door going through the kitchen. At 8:30 pm on 1/7/2024 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. Upon return to facility Resident # 1 was ambulating independently, awake, alert with usual state of cognition. Resident was examined by Licensed Practical Nurse (LPN) with no injuries noted. Resident was immediately taken to room and vitals and head to toe assessment obtained. Resident was smiling and had no complaints of pain noted. No signs of injury noted, no bruising, scratches, cuts, or bleeding noted blood pressure 135/72, pulse 75, respirations 18, temperature 96.8, blood oxygen saturation 92%. Resident changed b/p. 135/72, p. 75, r. 18, t. 96.8, sa02 92%. Resident changed for bed and CNA in room doing one on one care. Director of Nursing (DON) was notified at 8:27pm. Upon her return to the center on 1/7/2024, the resident was examined by the staff nurse and noted to have no negative findings. She was placed on 1:1 supervision until 1 PM on 1/8/2024 after the door locks were replaced in the kitchen. After that she was placed on every 15-minute checks to assure her safety. The kitchen doors were monitored until locks were replaced at 1:00pm 1/8/2024. This close supervision continues as of 1/11/2024. Resident #1 will be placed on 15-minute checks until exit-seeking behavior ceases. On 1/7/2024 at 8:55 pm Medical Director (MD), Physician's Assistant (PA) and Nurse Practitioner (NP) was notified of Resident Elopement from facility. On 1/7/2024 maintenance staff arrived at 9:30 pm to assess all facility exit doors, doors were checked for proper functioning by maintenance staff. All doors and wander guard systems were functioning properly. On 1/7/2024 at 9:00 pm all residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. On 1/7/2024 at 9:00 pm, Director of Nursing (DON) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. On 1/7/2024 at 10:00 pm in-services was initiated by Director of Nursing (DON) to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 1/8/2024 with no staff allowed to work until in-service completed. At 10:00 pm on 1/7/2024 Director of Nursing (DON) attempted to notify Resident # 1 Responsible Representative (RR) of the resident elopement from facility with no answer message left for RR to return call. RR returned call at 8:08 AM on 1/8/2024 and was notified of incident. On 1/8/2024, the Administrator and the Director of Nursing (DON) immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 1/8/2024 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing via phone, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing (ADON), Infection Preventionist and Minimum Data Set Nurse (MDS) to discuss Resident #1's exit seeking behavior and all safeguards put in place to ensure safety of all residents. QA identified modification to resident #1's plan of care to include the addition of Elation and snack at bedtime and involvement in daytime activities. At 2:46 pm on 1/8/2024, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. On 1/8/2024 at 11:30 pm maintenance staff initiated an Elopement Alarm Drill with all employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. On 1/8/2024, the maintenance assistant replaced the lock on the exterior door leaving the kitchen to avoid unsupervised residents leaving the center. On 1/8/2024, the Maintenance supervisor replaced the locks going into the kitchen with automatic door locks to assure that the kitchen doors will lock when they shut and to assure that unsupervised residents are not allowed into the kitchen. On 1/11/24, the psych nurse practitioner conducted a Telehealth visit to determine if medications needed to be adjusted. The nurse practitioner indicated she was pleasant and did not pose a risk to herself and others. On 1/11/2024, the Director of Clinical Education initiated education related to the importance of providing adequate supervision to resident to avoid accidents to including securing unsafe areas in the center. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. On 1/11/2024, the MDS Nurse conducted medical record reviews of all residents to identify which residents were interviewable verses those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interviewable. On 1/11/2024, The Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or neglect. Assessments of these resident revealed no such evidence of abuse or neglect. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 1/11/24. On 1/11/2024, the Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager and interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced abuse or neglect. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 1/11/2024. On 1/11/2024, the Senior Director of Clinical Operations provided training for the Administrator, Director of Nursing (DON) the Assistant Director of Nursing (ADON) regarding abuse and neglect identification, protection, investigation. This action was completed on 1/11/2024. On 1/8/2024, the Director of Clinical Education initiated training on abuse and neglect to include identification of abuse and neglect, protections of residents, investigation, and reporting requirements. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. On 1/12/24, the Senior [NAME] President of Operations provided education to the Administrator regarding the expectation of following the facility Quality Assurance Policy and Procedure in having ADHOC meetings as needed when new concerns are identified to immediately discuss, and determine immediate action needed to correct/address the identified area of concern to prevent safety issues related to elopement and then to continue monthly meetings to review effectiveness of plans and adjust plans as needed to ensure sustained compliance. The Administrator educated the Quality Assurance Committee Members on 1/12/24. The Director of Nursing (DON) will be educated prior to next scheduled shift by the Administrator. Education initiated on 1/12/24 by the Director Clinical Education with all staff regarding the expectations to immediately report any identified deficient practice to the Administrator or Director of Nursing (DON) so that the deficient practice or new concern can be addressed through the facility Quality Assurance Performance Improvement Committee by initiation of a plan of correction to include education, systemic changes, and auditing to ensure correction and sustained compliance. Education included review of the Quality Assurance and Performance Improvement Policy. Staff that did not receive education on 1/12/24 will be educated prior to working next scheduled shift. An adhoc QAPI meeting addressing the finding was initiated and completed 1/12/24 with the attendance of the Administrator, Nurse Practitioner (NP), Human Resources Coordinator, Director of Rehab, Registered MDS Coordinator, Director of Clinical Education (Infection Preventionist), Director of Nursing via phone, Maintenance Director, Dietary Manager, Activity Director, and Health Information Manager and Medical Director via phone. All corrective actions were completed by 1/12/2024 and the facility alleges removal of the Immediate Jeopardy (IJ) 1/13/2024. The State Agency (SA) validated the facility's Removal Plan on 01/22/24. The SA validated through interviews and record review that at 8:30 pm on 1/7/2024 the Executive Director and Director of Nursing (DON) begin official investigation of Resident #1 Elopement and determined the resident exited out of the door going through the kitchen. The SA validated through interviews and record review that at 8:30 pm on 1/7/2024 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. The SA validated through interviews and record review that upon return to facility Resident # 1 was ambulating independently, awake, alert with usual state of cognition. Resident was examined by Licensed Practical Nurse (LPN) with no injuries noted. Resident was immediately taken to room and vitals and head to toe assessment obtained. Resident was smiling and had no complaints of pain noted. No signs of injury noted, no bruising, scratches, cuts, or bleeding noted blood pressure 135/72, pulse 75, respirations 18, temperature 96.8, blood oxygen saturation 92%. Resident changed b/p. 135/72, p. 75, r. 18, t. 96.8, sa02 92%. Resident changed for bed and CNA in room doing one on one care. Director of Nursing (DON) was notified at 8:27pm. The SA validated through interviews and record review that upon her return to the center on 1/7/2024, the resident was examined by the staff nurse and noted to have no negative findings. She was placed on 1:1 supervision until 1 PM on 1/8/2024 after the door locks were replaced in the kitchen. After that she was placed on every 15-minute checks to assure her safety. The kitchen doors were monitored until locks were replaced at 1:00pm 1/8/2024. This close supervision continues as of 1/11/2024. Resident #1 will be placed on 15-minute checks until exit-seeking behavior ceases. The SA validated through interviews and record review that on 1/7/2024 at 8:55 pm Medical Director (MD), Physician's Assistant (PA) and Nurse Practitioner (NP) was notified of Resident Elopement from facility. The SA validated through interviews and record review that on 1/7/2024 maintenance staff arrived at 9:30 pm to assess all facility exit doors, doors were checked for proper functioning by maintenance staff. All doors and wander guard systems were functioning properly. The SA validated through interviews and record review that on 1/7/2024 at 9:00 pm all residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. The SA validated through interviews and record review that on 1/7/2024 at 9:00 pm, Director of Nursing (DON) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. The SA validated through interviews and record review that on 1/7/2024 at 10:00 pm in-services was initiated by Director of Nursing (DON) to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 1/8/2024 with no staff allowed to work until in-service completed. The SA validated through interviews and record review that at 10:00 pm on 1/7/2024 Director of Nursing (DON) attempted to notify Resident # 1 Responsible Representative (RR) of the resident elopement from facility with no answer message left for RR to return call. RR returned call at 8:08 AM on 1/8/2024 and was notified of incident. The SA validated through interviews and record review that on 01/08/24, the Administrator and the Director of Nursing (DON) immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. The SA validated through interviews and record review that on 1/8/2024 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing via phone, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing (ADON), Infection Preventionist and Minimum Data Set Nurse (MDS) to discuss Resident #1's exit seeking behavior and all safeguards put in place to ensure safety of all residents. QA identified modification to resident #1's plan of care to include the addition of Elation and snack at bedtime and involvement in daytime activities. The SA validated through interviews and record review that at 2:46 pm on 1/8/2024, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. The SA validated through interviews and record review that on 1/8/2024 at 11:30 pm maintenance staff initiated an Elopement Alarm Drill with all employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. The SA validated through interviews and record review that on 1/8/2024, the maintenance assistant replaced the lock on the exterior door leaving the kitchen to avoid unsupervised residents leaving the center. The SA validated through observation, interviews and record review that on 1/8/2024, the Maintenance supervisor replaced the locks going into the kitchen with automatic door locks to assure that the kitchen doors will lock when they shut and to assure that unsupervised residents are not allowed into the kitchen. The SA validated through interviews and record review that on 1/11/24, the psych nurse practitioner conducted a Telehealth visit to determine if medications needed to be adjusted. The nurse practitioner indicated she was pleasant and did not pose a risk to herself and others. The SA validated through interviews and record review that on 1/11/2024, the Director of Clinical Education initiated education related to the importance of providing adequate supervision to resident to avoid accidents to including securing unsafe areas in the center. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. The SA validated through interviews and record review that on 1/11/2024, the MDS Nurse conducted medical record reviews of all residents to identify which residents were interviewable versus those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed versus those that were considered non interviewable. The SA validated through interviews and record review that on 1/11/2024, The Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or neglect. Assessments of these resident revealed no such evidence of abuse or neglect. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 1/11/24. The SA validated through interviews and record review that on 1/11/2024, the Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager and interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced abuse or neglect. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 1/11/2024. The SA validated through interviews and record review that on 1/11/2024, the Senior Director of Clinical Operations provided training for the Administrator, Director of Nursing (DON) the Assistant Director of Nursing (ADON) regarding abuse and neglect identification, protection, investigation. This action was completed on 1/11/2024. The SA validated through interviews and record review that on 1/8/2024, the Director of Clinical Education initiated training on abuse and neglect to include identification of abuse and neglect, protections of residents, investigation, and reporting requirements. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. The SA validated through interviews and record review that on 1/12/24, the Senior [NAME] President of Operations provided education to the Administrator regarding the expectation of following the facility Quality Assurance Policy and Procedure in having ADHOC meetings as needed when new concerns are identified to immediately discuss, and determine immediate action needed to correct/address the identified area of concern to prevent safety issues related to elopement and then to continue monthly meetings to review effectiveness of plans and adjust plans as needed to ensure sustained compliance. The Administrator educated the Quality Assurance Committee Members on 1/12/24. The Director of Nursing (DON) will be educated prior to next scheduled shift by the Administrator. The SA validated through interview and record review that Director of Nursing had been educated prior to her return to work. The SA validated through interviews and record review that education was initiated on 1/12/24 by the Director Clinical Education with all staff regarding the expectations to immediately report any identified deficient practice to the Administrator or Director of Nursing (DON) so that the deficient practice or new concern can be addressed through the facility Quality Assurance Performance Improvement Committee by initiation of a plan of correction to include education, systemic changes, and auditing to ensure correction and sustained compliance. Education included review of the Quality Assurance and Performance Improvement Policy. Staff that did not receive education on 1/12/24 will be educated prior to working next scheduled shift. The SA validated through interviews and record review that an adhoc QAPI meeting addressing the finding was initiated and completed 1/12/24 with the attendance of the Administrator, Nurse Practitioner (NP), Human Resources Coordinator, Director of Rehab, Registered MDS Coordinator, Director of Clinical Education (Infection Preventionist), Director of Nursing via phone, Maintenance Director, Dietary Manager, Activity Director, and Health Information Manager and Medical Director via phone. The SA validated through observation, interview, and record review that the facility removed the Immediate Jeopardy (IJ) on 01/12/24 and alleged compliance on 01/13/24.

Based on staff interviews, record review and facility policy review the facility failed to supervise and prevent the elopement of Resident #1, who was assessed as an elopement risk and left Facility #1 through an unarmed door on 12/14/23 unnoticed. Resident #1 was one (1) of three (3) residents reviewed. The facility failed to provide supervision to prevent the elopement of Resident #1, who was a wandering risk. Res #1 walked 380 yards away from Facility #1 to Facility #2 and was discovered by staff at Facility #2 as Res #1 was attempting to get inside their building. Resident #1 left Facility #1 unnoticed and unsupervised at an unknown time. Facility #2 allowed the resident inside their nursing home and contacted Facility #1 at 9:04 PM to see if they had any resident missing and they discovered that it was Resident #1 and went to pick her up and return her to the facility. Resident #1 was last observed on 12/14/23 at 8:15 PM prior to the elopement. Resident #1 was transported back to Facility #1, where a head to toe assessment was completed and there were no noted injuries or complaints of pain or discomfort. During the investigation on 12/19/23 the State Agency (SA) identified an Immediate Jeopardy (IJ), and Substandard Quality of Care (SQC) which existed on 12/14/23 when Res #1 eloped from Facility #1 unsupervised. IJ and SQC existed at: 42 CFR (s): 483.25 (d) (1) (2) - Free of Accidents/Supervision/Devices (689) - Scope and Severity J. The elopement placed Resident #1 and other residents at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or death. The SA notified the facility's Administrator of the IJ and SQC on 12/19/23 at 2:40 PM and provided the Administrator with the IJ templates. Based on the facility's implementation of corrective actions on 12/14/23 through 12/15/23, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 12/16/23, prior to the SA's entrance on 12/19/23. Findings include: Review of the facility policy titled Elopement dated April 2017, revealed, Purpose: To establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements . Record review of the facility investigation revealed that Resident #1 was allowed to exit Facility #1 on 12/14/23 unnoticed and unsupervised at an unknown time and was discovered by the staff at another nursing home, Facility #2, which was 380 yards away from Facility #1. The staff of Facility #2 heard someone trying to enter their facility by jerking on the door. Facility #2 let Resident #1 inside their building and contacted Facility #1 to see if they had a missing resident and they discovered it was Resident #1 and the staff from Facility #1 went to pick her up and returned her back to the facility. Resident #1 was last observed in Facility #1 at 8:15 PM and the call was received from Facility #2 at 9:04 PM informing them that this said resident was in their building. An interview with the Administrator (ADM) on 12/19/23 at 9:00 AM, revealed that on 12/14/23, Resident #1 left Facility #1 unsupervised and unnoticed and she walked over to Facility #2. The ADM revealed that there were statements from staff members taken saying no door alarms went off. He revealed that it was reported to him that Resident #1 was last seen standing at the C/D Nursing Station around 8:15 PM on 12/14/23. He revealed that it was also reported to him that at 9:04 PM on 12/14/23, Licensed Practical Nurse (LPN) #1 received a call from Facility #2 reporting that Resident #1 was at their facility and that her Wander Guard had set the alarm system off and they had her safe inside the building. ADM revealed that LPN #1 and Certified Nursing Assistant (CNA) #1, both from Facility #1 went to Facility #2 and picked the resident up and brought her back. He revealed that on 12/14/23, there was about forty-five minutes that resident was unaccounted for. ADM revealed that he hated it and that they couldn't prevent everything from happening; but tried really hard. The ADM stated, It's our mess up and we are trying to minimize the damage and not let it happen again. He revealed that the breakdown was the system at the door, maintenance had discovered that the antenna on the left side of the door was not working properly and was not picking up on the wander guards; therefore, not triggering the alarm to go off. He revealed that they did not have a camera system and they could only speculate that the resident had exited out the front door. He revealed that the alarm should have triggered it, but the staff members revealed that the alarm never went off to indicate a problem. He revealed that the staff members changed out the resident's wander guard bracelet when she returned to the facility just to be safe. On 12/19/23 at 10:00 AM, a phone interview with CNA #1 revealed that she was working the night of 12/14/23 and had last observed Resident #1 around 8:00 PM trying to enter the dining room beside the C/D nurse's station. CNA #1 revealed that at 9:04 PM, a call was received from Facility #2 that they had a resident come into their facility and her name was (proper name) as stated by Resident #1 and she, CNA #1 went with LPN #1 to pick Resident #1 up. CNA #1 revealed that they arrived at Facility #2 to get Resident #1 at 9:13 PM and arrived back at Facility #1 with her at 9:23 PM. CNA #1 revealed that Facility #1's door alarms never went off as they were supposed to when a resident with a wander guard went through the door. CNA #1 recalled what Resident #1 was wearing that night and revealed that she had on a pair of gray sweatpants, a long-sleeved top, she was wearing socks, and no shoes. She revealed it was pretty chilly outside that night. On 12/19/23 at 10:30 AM, an interview with the Maintenance Supervisor revealed that the expiration dates on all wander guards were checked monthly. He revealed that he made rounds and checked to make sure all doors were secure every morning and on a weekly basis, he checked the doors with a wander guard to make sure they were working properly. The Maintenance Supervisor revealed that when a resident with a wander guard bracelet was within 5 feet of the door, the keypad, which required a special code, would not work. The Maintenance Supervisor revealed that it would lock down the system so as not to allow anyone to get out. He stated, We take this serious and realize that anything could have happened. The Maintenance Supervisor also revealed that if the door was opened and a resident with a wander guard walked up, the alarm would go off to alert staff members. The Maintenance Supervisor revealed that the alarm system on the doors were checked first thing on the morning of 12/15/23 and it was determined that there was an internal malfunction with the antenna located on the left door which would not activate the alarm system. The Maintenance Supervisor revealed that normally the antenna would pick up the signal from the wander bracelet if a resident tried to exit the doors and the door alarm would go off. He revealed that they put a new antenna on the door, and everything was working fine now. The Maintenance Supervisor measured the distance from Facility #1 to Facility #2 which was 1,140 feet which equaled 380 yards resident walked on the night of 12/14/23. On 12/19/23 at 11:00 AM, a phone interview with LPN #1 revealed that she was working on the night of 12/14/23 and had last observed Resident #1 standing at the C/D Nursing Desk at 8:15 PM. LPN #1 revealed that this resident walked up and down the halls all the time; but would usually walk up to the windows, look outside, turn around and walk the other way. She revealed that Resident #1 had never been noticed to try and get out of the doors. She revealed that at 9:04 PM, Facility #2 called and asked if they had a resident missing by the name of Proper Name. She revealed that she and CNA #1 got into her car and went to Facility #2 and brought Resident #1 back to Facility #1. LPN #1 revealed that Resident #1 was in no distress and her vital signs were all normal. LPN #1 revealed that when they returned to Facility #1, she called and reported the incident to the Administrator and to the Director of Nursing. LPN #1 revealed that Resident #1 had Dementia and mumbled speech frequently. She also revealed that she had never witnessed Resident #1 pushing on the doors or trying to leave the facility. LPN #1 revealed that the door alarms never went off at Facility #1 to alert them that she had gotten out. On 12/19/23 at 11:30 AM, an interview with Director of Nursing, revealed that LPN #1 had called and reported the elopement around 9:30 PM to her. The DON revealed they did a full body audit on Resident #1, watched all doors and initiated one on one care for Resident #1. Resident #1's son was notified as well. DON stated that Resident #1 always walked and mumbled. She stated, Everyone just knows to watch her, she's constantly on the move. DON revealed that Resident #1 was on hourly checks already as a latest intervention updated on her Care Plan. DON revealed that it was reported to her that Resident #1 went to the old part of Facility #2 that wasn't used anymore which was A straight shot from here. She revealed that Resident #1's wander guard bracelet had set off Facility #2's alarm system when she tried to get their door open; but had not set off the alarm at Facility #1 where she left from. DON revealed that the next morning, maintenance came in, investigated the door situation, and found that the antenna on the left side of the entrance door wasn't working properly, replaced it, and turned up the sensitivity. She revealed that on the night of 12/14/23, that Resident #1 had been on hourly checks and the nurse had not missed any of them. She revealed that the incident happened between her scheduled checks and that the staff members never knew she was out of the building until Facility #2 called them. She revealed that they also called for an on-site inspection of the door alarm system by the company and they expected them to be there December 27, 2023. She revealed that she reported the incident to the State Agency and to the Attorney General's Office, initiated an immediate investigation, In-services on abuse, neglect, elopement. She revealed that they had been conducting monthly elopement drills; but, after this incident, more frequently. She revealed that Maintenance Department was checking doors weekly. DON revealed that Nurses checked all wander guard bracelet function and location every shift and document on the Medication Administration Record (MAR). Record review of Progress Notes dated 12/10/23 at 7:35 AM was documented that resident was alert with some confusion, had slurred speech at times but can be understood sometimes. Resident #1 ambulates throughout the facility with redirection and supervision. Record review of the weather in (proper name of city) on 12/14/23 documented that the temperature at the time of the elopement was 52 degrees Fahrenheit, clear skies and no rain. Record review of the Admission Record revealed the facility admitted Resident #1 on 04/14/2017 with diagnoses of Alzheimer's Disease, Need for Assistance with Personal Care, Dementia, and Unspecified psychosis. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/2023 revealed Section C0100 that the Brief Interview for Mental Status (BIMS) should not be conducted due to resident is rarely/never understood. Under C1000 Cognitive Skills for Daily Decision Making was documented that resident was severely impaired. Section P0200 revealed that a Wander/Elopement Alarm was used daily. The facility implemented the following Corrective Action Plan prior to the State Agency's (SA) entrance on 12/19/23: On 12/14/23 at 9:23 PM, Resident #1 was assisted back into Facility #1 with easy redirection, one on one monitoring was initiated, Physician and Resident Responsible Party were notified. Resident #1 was assessed by nursing staff, elopement risk assessment performed, care plans, and elopement book were updated to reflect elopement risk and monitoring. Staff completed a room-to-room audit of all residents to assure them all were safe and accounted for. All residents with Code Alert Bracelets were checked for functionality and positioning. All doors and windows were checked for proper function and operation. ADM began an investigation to determine how this resident went outside and assessed each resident for potential risk for elopement. In-Services on Elopement guidelines, Abuse, Neglect, prevention of accidents and supervision of residents. Elopement drills were conducted on all three shifts beginning 12/15/23, then weekly was initiated. Care plans were updated for Wander Guard bracelets to be checked every shift rather than once a day. Initiated door checks daily. It was determined that Resident #1 was last seen by Facility #1 staff on 12/14/23 at 8:15 PM and was notified of resident being inside Facility #2 at 9:04 PM. The facility was notified that IJ's were identified for Federal Tag 656 Care Plans and Federal Tag 689 Failure to Prevent Accidents and Hazards on 12/19/23 at 2:20 PM. On 12/14/23 the facility was notified by Long Term Care Facility #2 at 9:04 pm that Resident #1 was trying to enter their facility. The nursing staff last saw the resident at 8:15 pm at C/D wing nurses' station. It was determined that Resident # 1 was last seen by facility staff at 8:15 pm and returned to facility at 9:23 pm on 12/14/23. On December 19 at 2:40 PM the facility was verbally notified that Immediate Jeopardy (IJ) was identified for Federal tag 656- Care Plans and Federal tag 689- Failure to Prevent Accidents and Hazards. The facility received IJ templates on December 19, 2023, at 2:40 PM. Immediate Actions: At 9:30 pm on 12/14/23 Executive Director notified Resident # 1 Responsible Representative of the resident elopement from facility. At 9:45 pm on 12/14/23 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. Upon return to facility Resident # 1 was assessed by Licensed Practical Nurse (LPN) with no injuries noted. On 12/14/23 all doors were monitored throughout the night until maintenance staff arrived on 12/15/2023 at 8:00 am to assess all facility exit doors, doors were checked for proper functioning by Maintenance Assistant and PRN Maintenance personnel. It was discovered that a bad antenna could have caused the door not to alarm when resident exited the facility. A new antenna was immediately put in place and troubleshooting was completed with the vendor via phone to ensure proper functioning. On 12/15/23 at 8:30 am residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. At 9:23 pm on 12/14/2023 the Executive Director and Director of Nursing begin official investigation of Resident #1 Elopement. On 12/14/23 at 11:00pm in-services was initiated by Director of Nursing to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 12/15/2023 with no staff allowed to work until in-service completed. On 12/15/23 at 9:00 am, Infection Preventionist Registered Nurse (RN) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. On 12/15/23 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing, Director of Clinical Education and Minimum Data Set Nurse (MDS). At 2:57 pm on 12/15/23, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. On 12/15/23 at 3:20 pm Maintenance Assistance initiated an Elopement Alarm Drill with employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. All corrective actions were completed on 12/15/23 and the facility alleges removal of the Immediate Jeopardy (IJ) on 12/16/2023. The State Agency (SA) validated the facility's Past Non-Compliance (PNC) Removal Plan/Corrective Action on 12/19/23: The SA validated through interviews and record review that on 12/14/23 at 9:30 PM Executive Director notified Resident #1 Responsible Representative of the resident elopement from facility. The SA validated through interview and record review that on 12/14/23 at 9:45 PM the facility completed a 100% head count of all other residents to ensure they were accounted for. The SA validated through interview and record review that on 12/14/23 upon return to facility Resident #1 was assessed by Licensed Practical Nurse (LPN) with no injuries noted. The SA validated through interviews and record review that on 12/14/23 all doors were monitored throughout the night until maintenance staff arrived on 12/15/23 at 8:00 AM to assess all facility exit doors, doors were checked for proper functioning by Maintenance Department. It was discovered that a bad antenna could have caused the door not to alarm when resident exited the facility. A new antenna was immediately put in place and troubleshooting was completed with the vendor via phone to ensure proper functioning. The SA validated through interviews and record reviews that on 12/15/23 residents with risk of elopements were reevaluated and updated to ensure all residents at risk had appropriate interventions in place. The SA validated through interviews and record review that on 12/14/23 at 9:23 PM, the Executive Director and Director of Nursing began official investigation of Resident #1 elopement. The SA validated through interview and record review that on 12/14/23 at 11:00 PM that In-Services were initiated by Director of Nursing to include all staff on Elopement Policy and Procedures, Abuse-Neglect, In-Services were completed by 12/15/23. The SA validated through interview and record review that on 12/15/23 Infection Preventionist Registered Nurse checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. The SA validated through interview and record review that on 12/15/23 at 9:30 AM, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing, Director of Clinical Education and Minimum Data Set Nurse (MDS). The SA validated through interview and record review that on 12/15/23 at 2:57 PM, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Director of Nursing. The SA validated that on 12/15/23 at 3:20 PM Maintenance Assistant initiated an Elopement Alarm Drill with employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. The SA validated through observations, record reviews, and facility policy reviews that all corrective actions were completed on 12/15/23 and the facility alleges removal of the Immediate Jeopardy (IJ) on 12/16/2023.

Based on interviews, record review, and facility policy review, the facility failed to implement the plan of care for Resident #1 who was at risk for elopement. Resident #1 was one (1) of three (3) residents reviewed. The facility failed to provide supervision to prevent the elopement of Resident #1, who was a wandering risk. Resident #1 had a Care Plan that documented that she was at risk for elopement. Facility #1 did not provide the supervision as outlined in the care plan to Resident #1 to prevent her from eloping. Resident #1 left the facility unnoticed and unsupervised at an unknown time and was discovered by the staff at another nursing home (Facility #2) approximately 380 yards from the facility. Facility #2 let the resident inside their nursing home and contacted Facility #1 at 9:04 PM to see if they had a resident missing and they discovered that it was Resident #1 and went to pick her up and return her to the facility. Resident #1 was last observed on 12/14/23 at 8:15 PM, prior to the elopement. Resident #1 was transported back to Facility #1, where a head-to-toe assessment was completed and there were no noted injuries or complaints of pain or discomfort. During the investigation on 12/19/23 the SA identified an Immediate Jeopardy (IJ) which began on 12/14/23 when Res #1 eloped from Facility #1 unsupervised and was identified at: 42 CFR (s): 483.21(b)(1) - Comprehensive Care Plans (F656) Scope and Severity J. The elopement placed Resident #1 and other residents at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or death. The SA notified the facility's Administrator of the IJ on 12/19/23 at 2:40 PM and provided the Administrator with the IJ templates. Based on the facility's implementation of corrective actions on 12/14/23 through 12/15/23, the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on 12/16/23, prior to the SA's entrance on 12/19/23. Findings Include: Review of the facility policy Comprehensive Care Plan, effective date May 1, 2012, revealed, The interdisciplinary care plan is implemented to guide health care center staff in the provision of necessary care and services to obtain and maintain the highest practicable physical, mental, and psychosocial well-being of the resident and promotion of the resident and family in planning care . Record review of Resident #1's Care Plan revealed, Focus: I am at risk for elopement, Not being able to make good safety decisions, I sometimes have Restlessness, agitation and increased confusion .Interventions: .Check function of Wanderguard every shift, Check placement of Wanderguard every shift . Redirection such as taking her to activities or the area in hallway where she enjoys sitting. Wander guard: Visual check of resident Q2 (every two) hours and chart location Record review of the facility investigation revealed that Resident #1 was allowed to exit Facility #1 on 12/14/23 unnoticed and unsupervised at an unknown time and was discovered by the staff at another nursing home, Facility #2, which was 380 yards away from Facility #1. The staff of Facility #2 heard someone trying to enter their facility by jerking on the door. Facility #2 let Resident #1 inside their building and contacted Facility #1 to see if they had a missing resident and they discovered it was Resident #1 and the staff from Facility #1 went to pick her up and returned her back to the facility. Resident #1 was last observed in Facility #1 at 8:15 PM and the call was received from Facility #2 at 9:04 PM informing them that this said resident was in their building. On 12/19/23 at 9:00 AM, an interview with Administrator (ADM), revealed that on 12/14/23, Resident #1 left Facility #1 unsupervised and unnoticed and she walked over to Facility #2. ADM revealed that there were statements from staff members taken saying no door alarms went off. He revealed that it was reported to him that Resident #1 was last seen standing at the C/D nursing station around 8:15 PM on 12/14/23. ADM revealed that it was also reported to him that at 9:04 PM on 12/14/23, Licensed Practical Nurse (LPN) #1 received a call from Facility #2 reporting that Resident #1 was at their facility and that her Wander Guard had set the alarm system off and they had her safe inside the building. ADM revealed that LPN #1 and Certified Nursing Assistant (CNA) #1, both from Facility #1 went to Facility #2 and picked the resident up and brought her back. He revealed that on 12/14/23, there was about forty-five minutes that resident was unaccounted for. ADM stated that he hated it and that they couldn't prevent everything from happening; but they tried really hard. ADM stated, It's our mess up and we are trying to minimize the damage and not let it happen again. He revealed that he knew as soon as it happened what it would be, and he confirmed understanding that the facility failed to implement the care plan effectively to prevent a resident with dementia who required a wander guard from leaving the facility. ADM revealed that the breakdown was the system at the door, maintenance had discovered that the antenna on the left side of the door was not working properly and was not picking up on the wander guards; therefore, not triggering the alarm to go off. He revealed that they did not have a camera system and they could only speculate that the resident had exited out the front door. He revealed that the alarm should have triggered it, but the staff members revealed that the alarm never went off to indicate a problem. He confirmed that the staff members changed out the resident's wander guard bracelet when she returned to the facility just to be safe. Record review of Resident #1's Admission Record revealed an admitted [DATE] with diagnoses including Alzheimer's Disease, Need for Assistance with Personal Care, Dementia, and Unspecified psychosis. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/2023 revealed in Section C Item 0100 that the Brief Interview for Mental Status (BIMS) should not be conducted due to the resident is rarely/never understood. Item C1000 Cognitive Skills for Daily Decision Making was documented as severely impaired. Section P Item 0200 revealed that a Wander/Elopement Alarm was used daily. The facility implemented the following Corrective Action Plan prior to the State Agency's (SA) entrance on 12/19/23: On 12/14/23 at 9:23 PM, Resident #1 was assisted back into Facility #1 with easy redirection, one on one monitoring was initiated, Physician and Resident Responsible Party were notified. Resident #1 was assessed by nursing staff, elopement risk assessment performed, care plans, and elopement book were updated to reflect elopement risk and monitoring. Staff completed a room-to-room audit of all residents to assure them all were safe and accounted for. All residents with Code Alert Bracelets were checked for functionality and positioning. All doors and windows were checked for proper function and operation. ADM began an investigation to determine how this resident went outside and assessed each resident for potential risk for elopement. In-Services on Elopement guidelines, Abuse, Neglect, prevention of accidents and supervision of residents. Elopement drills were conducted on all three shifts beginning 12/15/23, then weekly was initiated. Care plans were updated for Wander Guard bracelets to be checked every shift rather than once a day. Initiated door checks daily. It was determined that Resident #1 was last seen by Facility #1 staff on 12/14/23 at 8:15 PM and was notified of resident being inside Facility #2 at 9:04 PM. On 12/14/23 the facility was notified by Facility #2 at 9:04pm that Resident #1 was trying to enter their facility. The nursing staff last saw the resident at 8:15 pm at C/D wing nurses' station. It was determined that Resident # 1 was last seen by facility staff at 8:15 pm and returned to facility at 9:23 pm on 12/14/23. On December 19 at 2:40 PM the facility was verbally notified that Immediate Jeopardy (IJ) was identified for Federal tag 656- Care Plans and Federal tag 689- Failure to Prevent Accidents and Hazards. The facility received IJ templates on December 19, 2023, at 2:40 PM. Immediate Actions: At 9:30 pm on 12/14/23 Executive Director notified Resident # 1 Responsible Representative of the resident elopement from facility. At 9:45 pm on 12/14/23 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. Upon return to facility Resident # 1 was assessed by Licensed Practical Nurse (LPN) with no injuries noted. On 12/14/23 all doors were monitored throughout the night until maintenance staff arrived on 12/15/2023 at 8:00 am to assess all facility exit doors, doors were checked for proper functioning by Maintenance Assistant and PRN Maintenance personnel. It was discovered that a bad antenna could have caused the door not to alarm when resident exited the facility. A new antenna was immediately put in place and troubleshooting was completed with the vendor via phone to ensure proper functioning. On 12/15/23 at 8:30 am residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. At 9:23 pm on 12/14/2023 the Executive Director and Director of Nursing begin official investigation of Resident #1 Elopement. On 12/14/23 at 11:00pm in-services was initiated by Director of Nursing to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 12/15/2023 with no staff allowed to work until in-service completed. On 12/15/23 at 9:00 am, Infection Preventionist Registered Nurse (RN) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. On 12/15/23 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing, Director of Clinical Education and Minimum Data Set Nurse (MDS). At 2:57 pm on 12/15/23, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. On 12/15/23 at 3:20 pm Maintenance Assistance initiated an Elopement Alarm Drill with employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. All corrective actions were completed on 12/15/23 and the facility alleges removal of the Immediate Jeopardy (IJ) on 12/16/2023. The State Agency (SA) validated the facility's Past Non-Compliance (PNC) Corrective Action Plan on 12/19/23: The SA validated through interviews and record review that on 12/14/23 at 9:30 PM Executive Director notified Resident #1 Responsible Representative of the resident elopement from facility. The SA validated through interview and record review that on 12/14/23 at 9:45 PM the facility completed a 100% head count of all other residents to ensure they were accounted for. The SA validated through interview and record review that on 12/14/23 upon return to facility Resident #1 was assessed by Licensed Practical Nurse (LPN) with no injuries noted. The SA validated through interviews and record review that on 12/14/23 all doors were monitored throughout the night until maintenance staff arrived on 12/15/23 at 8:00 AM to assess all facility exit doors, doors were checked for proper functioning by Maintenance Department. It was discovered that a bad antenna could have caused the door not to alarm when resident exited the facility. A new antenna was immediately put in place and troubleshooting was completed with the vendor via phone to ensure proper functioning. The SA validated through interviews and record reviews that on 12/15/23 residents with risk of elopements were reevaluated and updated to ensure all residents at risk had appropriate interventions in place. The SA validated through interviews and record review that on 12/14/23 at 9:23 PM, the Executive Director and Director of Nursing began official investigation of Resident #1 elopement. The SA validated through interview and record review that on 12/14/23 at 11:00 PM that In-Services were initiated by Director of Nursing to include all staff on Elopement Policy and Procedures, Abuse-Neglect, In-Services were completed by 12/15/23. The SA validated through interview and record review that on 12/15/23 Infection Preventionist Registered Nurse checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. The SA validated through interview and record review that on 12/15/23 at 9:30 AM, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing, Director of Clinical Education and Minimum Data Set Nurse (MDS). The SA validated through interview and record review that on 12/15/23 at 2:57 PM, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Director of Nursing. The SA validated that on 12/15/23 at 3:20 PM Maintenance Assistant initiated an Elopement Alarm Drill with employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. The SA validated through observations, record reviews, and facility policy reviews that all corrective actions were completed on 12/15/23 and the facility alleges removal of the Immediate Jeopardy (IJ) on 12/16/2023.

CI MS Based on observation, interview, record review and policy review the facility failed to follow medication policy and procedures for identifying the right medication and route of administration to ensure a significant medication error did not occur for one (1) of four (4) residents reviewed; Resident #1, as evidenced by [MEDICATION NAME] Ear drops were administered to Resident #1's left eye on 11/16/15 by Licensed Practical Nurse (LPN) #1 which caused pain and burning of the left eye. Resident #1 visited the eye doctor later that day who confirmed the [DIAGNOSES REDACTED]. Resident #1's Keratitis healed by the next visit on 11/24/15. Findings included: Review of the facility's policy Administration Procedures for All Medications dated 05/12 revealed: C. Review 5 rights (3) times: 1)Prior to removing the medication package/container from the cart/drawer. 2) Prior to removing the medication from the container. 3) After the dose has been prepared and before returning the medication to storage. The 5 rights of Medication Administration per Mosby 5th edition and Continuum Pediatric Nursing are: 1) Right Medication; 2) Right Dose; 3) Right Time; 4) Right Route; and 5)Right Patient. Review of an online Medical Dictionary (http://www.emedicinehealth.com) revealed the definition of Keratitis as inflammation of the cornea, usually associated with decreased visual acuity and, sometimes resulting in [MEDICAL CONDITION]. Eye pain, tearing, light sensitivity, and low vision are the most common symptoms. Review of a Medication Error Reporting Form dated 11/16/15 revealed Resident #1 had received the wrong medication to the left eye. The nurse failed to verify that correct medication was being administered. An appointment was made for 11/16/15 at 16:30 for the eye clinic and [MEDICATION NAME] Suspension one (1) drop to left eye three (3) times daily was ordered. Review of Resident #1's November 2015 physician's orders [REDACTED].#1 also had an order for [REDACTED]. Review of a Nurse's Note dated 11/16/15 at 11:17 revealed one (1) drop of medication was administered in Resident #1's left eye during medication pass by Licensed Practical Nurse (LPN) #1. Resident #1 complained of pain in her eye after administration. The nurse re-read the box and notified (LPN #2) of the medication error. A drop of saline was administered to Resident #1's left eye with no relief. The physician was contacted and appointment obtained for (Eye Doctor) at 4:30. Resident #1's left eye was flushed twice with normal saline by LPN #2 and resident did not complain of discomfort at that time. Review of a Report of Consultation (From the eye doctor) dated 11/16/15 revealed a finding of Corneal SPK and trace injection of the left eye for Resident #1 with a [DIAGNOSES REDACTED]. Recommendations for [MEDICATION NAME] one (1) drop left eye three (3) times daily for three (3) days. Further documentation included: Eye will heal with no long term effects. Review of the Nurse's Notes for Resident #1 on 11/18/15 revealed Resident #1 had complaint of pain in the left eye and was medicated with Tylenol with relief. No further documented complaint of pain in her eye until 11/23/15 at 15:23. The Eye Doctor was contacted for a follow up appointment on 11/24/15. The note documented (The Doctor's Nurse) stated resident would always have trouble with left eye due to multiple problems with eye prior to surgery as well as have chronic dry eye. Review of a Report of Consultation (From the eye doctor) dated 11/24/15 revealed a finding of Keratitis healed, trace dry stain interior with a [DIAGNOSES REDACTED]. Further documentation by LPN #1 on the sheet revealed: Clarification from the CPOT (Certified Paraoptometric Technician) via telephone: one (1) drop each eye four (4) times daily unless needed more often. Interview with LPN #1 on 12/8/15 at 1:44 PM revealed she was orienting on the medication cart with LPN #2 (11/16/15) and pulled Resident #1's medication and LPN #2 stepped away from the cart to get a call. LPN #1 stated she pulled the drops last and administered what she thought was eye drops to Resident #1's left eye. LPN #1 stated Resident #1 complained of burning in her eye. LPN #1 stated she looked at the medication and saw it was ear drops and not eye drops. LPN #1 stated she notified LPN #2 who was coming toward the cart and told Resident #1 she'd administered the wrong drop. LPN #1 stated she had not followed the 5 rights of medication administration to make sure it was the right medication, thought the label said eye drop. LPN #1 stated Resident #1's eye was flushed with normal saline and an appointment was made for the eye doctor that afternoon. LPN #1 stated Resident #1 complained of pain after the eye flush but not as much as when it occurred. LPN #1 stated she clarified the Refresh PRN (as needed) order after Resident #1's follow up checkup to be up to four (4) times daily as needed. LPN #1 stated Resident #1 complained more about the mistake itself, rather than pain in her eye over the next week or so after the incident. Interview with LPN #2 on 12/9/15 at 9:10 AM revealed LPN #1 had oriented with her on the medication cart 11/15/15 and on 11/16/15. LPN #2 stated she had stepped away to get a medication from backup and upon return she heard Resident #1 say Oh my God, what did you do, my eye is burning. LPN #2 stated LPN #1 reported she'd put the wrong drop in the resident's eye. LPN #2 stated she looked and told LPN #1 that is was [MEDICATION NAME] ear drops, not eye drops. LPN #2 stated she notified the physician who said to flush Resident #1's eyes with Normal Saline and she flushed twice. LPN #2 stated Resident #1 still complained of pain so she called physician again and got appointment with the eye doctor that afternoon. LPN #2 stated when Resident #1 returned from the eye doctor she was screaming and hollering about her eye and how we tried to kill her. LPN #2 stated Resident #1 wasn't complaining of pain at that time but was hysterical because the event happened. LPN #2 stated Resident #1 had a corneal burn and [MEDICATION NAME] was ordered for three (3) days. LPN #2 stated Resident #1 had complained of pain in her left eye off and on since cataract surgery because she thought the doctor had messed up the surgery. LPN #2 stated Resident #1 has not complained about pain in her eye recently. LPN #2 stated she did look at Resident #1's eye after the wrong drops were administered and it was red, but not watery. Interview with Certified Nursing Assistant (CNA) #1 on 12/8/15 at 10:50 AM revealed she heard Resident #1 complain of her eyes burning and LPN #1 or LPN #2 said ear drops instead of eye drops were administered. CNA #1 stated Resident #1 made a big deal about the nurse making a mistake and talked about it for weeks to anyone who would listen. CNA #1 stated Resident #1 went about her everyday activities after the event and had not complained of pain to her. Interview with the Director of Nursing (DON) on 12/9/15 at 9:45 AM revealed LPN #1 had made a significant medication error by putting ear drops instead of eye drops in Resident #1's left eye which could have been avoided if she'd followed the 5 rights and looked closer at the medication. The DON agreed the resident did have a corneal irritation/burn that healed within a week and had the potential to be worse. Interview with Registered Nurse (RN) #1 on 12/8/15 at 4:15 PM stated she was not present when the medication error occurred with Resident #1 but was aware of the error. RN #1 stated Resident #1 never really complained to her about pain much after the incident, no more than what she complained prior to the event. RN #1 stated the resident was more upset about the error itself more than the burning it caused. RN #1 confirmed Resident #1 had a [DIAGNOSES REDACTED]. Interview with the Certified Paraoptometric Technician (COPT) at the Eye Clinic on 12/8/15 at 2:00 PM confirmed Resident #1 did have a chemical burn from the ear drop used in the eye. The COPT stated it was superficially irritate and would be harder to get over because of not making tears on her own due to Dry Eye Syndrome. The COPT stated Resident #1 would always have problems with the left eye due to chronic problems, not necessarily related to the drops (ear drops). Observation and interview with Resident #1 on 12/8/15 at 11:45 AM revealed she was alert and oriented to person, place and time but stated she was having some difficulty remembering things at times. Resident #1 stated she received a medication to her left eye from LPN #1 a few weeks ago and started having pain and burning in the eye and told LPN #1 something was wrong. Resident #1 stated LPN stated she had used the wrong drops, it was ear drops and not eye drops. Resident #1 stated she'd had pain in the left eye since cataract surgery but the medication made it burn and hurt worse and she could not see as well at the time of the incident. Resident #1 stated her eye was washed out and it helped some but she wanted to see her regular eye doctor. Resident #1 stated she visited the eye doctor later that same evening and was told she had a chemical burn of the eye due to the ear drop. Resident #1 stated she did have pain off and on but doesn't recall whether she received medication. She recalled eye drops for the chemical burn. She could not recall whether her eye was flushed out but thought it was. (Resident had already stated it had been flushed). Resident #1 denied eye pain and burning at present time and both eyes were observed to be without redness or drainage. Resident #1 stated the doctor told her the eye was back to normal but it still hurts sometimes. Resident #1 appeared nervous, upset about the incident and kept referring the conversation back to how she thought the nurse may have administered the medication in her eye on purpose and how the nurse should have known better. Resident #1 stated her left eye hurt more the day the ear drop was put in but no worse now than usual because had hurt off and on since the cataract surgery. The facility admitted Resident #1 on 7/10/14 and has [DIAGNOSES REDACTED]. Review of a history and physical date 8/12/15 revealed Resident #1's left eye is a little injected from recent cataract surgery. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/16/15 revealed a Brief Interview for Mental Status (BIMS) score of 15. Scores of 13-15 indicates no cognitive impairment. Resident #1 had complaint of occasional pain rating 4-6 (10 indicates severe and 0 indicates no pain).

CI MS # Based on observation, interview, record review and policy review the facility failed to ensure the care plan was followed for one (1) of four (4) residents reviewed, Resident #1, as evidenced by LPN #1 administered ear drops in Resident #1's left eye causing pain and burning. Outside medical assistance was required with new orders for eye medication with a [DIAGNOSES REDACTED]. Findings included: Review of the RAI Version 3.0 Manual, used by the facility for care plan procedure revealed: The services provided or arranged must be consistent with each resident's written plan of care. Review of Resident #1's care plan initiated 3/18/15, revealed the care plan was updated on 8/11/15 for Cataract Surgery. Interventions included: Eye drops as ordered with an initiation date of 8/13/15. Interview with the Director of Nursing (DON) on 12/9/15 at 12:50 PM revealed LPN #1 did not follow the original care plan for Resident #1 to give medications as ordered because ear drops are not supposed to go in the eyes. The DON did confirm Resident #1 had an eye injury from the ear drop instilled in the resident's eye which had healed within a week. Review of a Medication Error Reporting Form dated 11/16/15 revealed Resident #1 had received the wrong medication to the left eye. The nurse failed to verify that correct medication was being administered. [MEDICATION NAME] Suspension one (1) drop to left eye three (3) times daily was ordered. Review of Resident #1's November 2015 physician's orders [REDACTED].#1 also had an order for [REDACTED]. Review of a Nurse's Note dated 11/16/15 at 11:17 revealed one (1) drop of medication was administered in Resident #1's left eye during medication pass by LPN #1. Resident #1 complained of pain in her eye after administration. The nurse re-read the box and notified (LPN #2) of the medication error. A drop of saline was administered to Resident #1's left eye with no relief. The physician was contacted and appointment obtained for (Eye Doctor) at 4:30. Resident #1's left eye was flushed twice with normal saline by LPN #2. Review of a Report of Consultation (From the eye doctor) dated 11/16/15 revealed Resident #1's finding of Corneal SPK (Superficial Punctate Keratitis), and trace injection of the left eye with a [DIAGNOSES REDACTED]. Recommendations for [MEDICATION NAME] one (1) drop left eye three (3) times daily for three (3) days. Review of the Nurse's Notes for Resident #1 on 11/18/15 revealed Resident #1 had complaint of pain in the left eye and was medicated with Tylenol with relief. Resident #1 complained of pain in her eye 11/23/15 at 15:23 and the Eye Doctor was contacted for a follow up appointment on 11/24/15. Interview with LPN #1 on 12/8/15 at 1:44 PM revealed she was orienting on the medication cart with LPN #2 (11/16/15) and administered what she thought was eye drops to Resident #1's left eye. LPN #1 stated Resident #1 complained of burning in her eye, she looked at the medication and saw it was ear drops, and not eye drops. LPN #1 stated she had not followed the 5 rights of medication administration to make sure it was the right medication and thought the label said eye drop. LPN #1 stated Resident #1's were flushed with normal saline and an appointment was made for the eye doctor that afternoon. LPN #1 stated Resident #1 complained of pain after the eye flush but not as much as when it occurred. Interview with LPN #2 on 12/9/15 at 9:10 AM revealed LPN #1 had oriented with her on the medication cart 11/15/15 and on 11/16/15. LPN #2 stated she heard Resident #1 say Oh my God, what did you do, my eye is burning. LPN #2 stated LPN #1 reported she'd put the wrong drop in the resident's eye. LPN #2 stated she looked and told LPN #1 that is was [MEDICATION NAME] ear drops, not eye drops. LPN #2 stated she notified the physician who said to flush Resident #1's eyes with Normal Saline and she flushed twice. LPN #2 stated Resident #1 still complained of pain so she called physician again, and got appointment with the eye doctor that afternoon. Interview with the Certified Paraoptometric Technician (COPT) at the Eye Clinic on 12/8/15 at 2:00 PM confirmed Resident #1 did have a chemical burn from the ear drop used in the eye. Observation and interview with Resident #1 12/8/15 at 11:45 AM revealed she was alert and oriented to person, place. Resident #1 stated she received a medication to her left eye from LPN #1 a few weeks ago and started having pain and burning in the eye Resident #1 stated LPN said she had used the wrong drops, it was ear drops and not eye drops. Resident #1 stated she'd had pain in the left eye since cataract surgery, but the medication made it burn and hurt worse, and she could not see as well at the time following the incident. Resident #1 stated she visited the eye doctor later that same evening and was told she had a chemical burn of the eye due to the ear drop. Resident #1 stated her left eye hurt more the day the ear drop was put in but no worse now than usual because had hurt off and on since cataract surgery. The facility admitted Resident #1 on 7/10/14 and had [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/16/15 revealed a Brief Interview for Mental Status (BIMS) score of 15. Scores of 13-15 indicates no cognitive impairment.