Every finding on record at Diversicare of Tylertown

Based on interviews, record review and facility policy review, the facility failed to ensure that residents who receive meals in their rooms were informed of their daily menu options and provided the opportunity to make meal choices for two (2) of (14) residents reviewed for choices. Resident #22 and Resident #37.Findings include: A review of the facility policy, Menu revised 10/22, revealed, Menus will be planned in advance to meet the nutritional needs of the residents .will adjust the individual meal plan to meet the individual requests, including cultural, religious or ethnic preferences .Resident #22During an initial interview on 1/11/26 at 11:34 AM, Resident #22 stated that since arriving at the facility a few months ago, she has preferred to eat in her room. She reported that due to health reasons, she is unable to get up freely and requires staff assistance to get out of bed. She explained that during her stay, the staff had not informed her of menu choices or that she could choose something different from what was brought to her. She stated that, because there is no menu in her room, she believed she had to eat whatever was delivered, and if she did not like it, she would wait until dinner and hope it was something she preferred. She added that having more than one option to choose from would be very beneficial.On 1/12/26 at 1:02 PM, during an interview, Resident #22 revealed that no one has come by to let her know her food choices for the day. She said she did not eat her lunch because it was not good and decided to wait until dinner to see what would be served.On 1/13/26 at 10:02 AM, Resident #22 indicated that no one has come by to let her know about her food choices.On 1/14/26 at 9:02 AM, during a final interview, Resident #22 indicated that no one has come to pick up her food choices.A record review of the admission record revealed the facility admitted the resident on 9/12/25 with diagnoses that included Acute Diastolic Congestive Heart Failure.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/25 revealed a Brief Interview Mental Score (BIMS) score of (15) indicating the resident was cognitively intact. Resident #37During an interview on 1/14/25 at 8:30 AM, conducted as a follow-up to the Resident Council Meeting, Resident #37, the Council President, reported that she is dependent on staff to help her get in and out of her room by wheelchair, so she cannot walk to the dining hall to see what is being served. She explained that she is not aware of an alternate menu. She said it was her understanding that she had to eat whatever was brought to her room, and if she did not want it, she simply did not eat. She further noted that no one currently informs her or her roommate about what is being served for lunch or any meal, and there is no menu in their room. She added that she would like to know what she is having ahead of time so she can choose something she likes.At 8:36 AM on 1/14/26, during an interview with the Dietary Manager, she confirmed that there are no menus in the residents' rooms. She reported that she is not sure whether a system exists to honor residents' meal preferences on a day-to-day basis. She acknowledged that residents should have a choice in what they want to eat.At 8:54 AM on 1/14/26, during an interview with Certified Nursing Assistant #1 (CNA), who confirmed she works with Resident #22, indicated that there is no established process in place to ensure residents are aware of their meal choices for the day.At 11:25 AM on 1/14/26, during an interview with the Administrator, she shared that she has identified the need for residents to know their meal options. She explained that this issue has been ongoing for quite some time and that the facility has not yet identified a solution. A record review of the admission Record revealed the facility admitted the resident on 2/9/24 with diagnoses that included Hemiplegia and Hemiparesis following Cerebrovascular Disease Affecting the Left Dominant Side.A record review of the MDS with an ARD of 11/13/25 revealed a BIMS score of 15 indicating the resident was cognitively intact.

Based on observation, interviews, record reviews and facility policy review the facility failed to obtain a physician order to flush Percutaneous Endoscopic Gastrostomy (peg) tubes with water before and after administering medication via peg tube for one (1) of six (6) residents with peg tubes. Resident #32.Findings include: Record review of the facility policy Eternal Tube Medication Administration with a review date of 04/22 revealed .Crushed medications, contents of opened capsules as well as liquid medications are diluted with at least 5 milliliters (ml) of water when fluid is not restricted .Following drug administration, flush the tube with a final flush of at least 30 ml of water. On 01/13/2026 at 2:15 PM, LPN #2 was observed giving peg medications to Resident #32 via peg tube. The following medications were administered Buspirone 10 milligrams (mg) Hydroxyzine 25 mg, and Trazadone 50 mg via peg tube. LPN#2 flushed the peg tube with 30 cc water before and after medications administration. A record review of Resident #32 Order Summary Report with active orders as of 1/13/26 revealed physician orders for Buspirone HCI 10 milligrams (mg), Hydroxyzine 25mg, and Trazadone 50mg via peg tube. The physician's orders did not include an order to flush or the amount to flush before and after administering medications. A record review of Resident #32 admission Record revealed an admission date of 10/22/25 with diagnoses that included of Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, and Dysphagia following Cerebral Infarction. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. On 01/14/2026 at 8:08 AM, in an interview the Director of Nursing (DON) stated we go by our policy for flushing peg tubes with water. She confirmed they do not have a physician order for flushing peg tubes when administering medications.

Based on observation, interview, and facility policy review, the facility failed to properly secure and store medications and wound care supplies for two (2) of four (4) days of survey.Findings include:Record review of the facility policy Medication Storage updated 04/22 revealed .Medications are accessible ONLY to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . On 1/13/26 at 3:07 PM, the wound care cart was observed unattended and unlocked on the resident care unit. The cart remained unsecured until 3:10 PM, when Registered Nurse (RN) #2 was observed walking past and locking it.On 1/13/26 at 3:10 PM, in an interview, RN #2 stated that the wound care nurse was the last to use the cart before going into a resident's room and must not have locked it. She confirmed the cart should remain locked when not in use to prevent resident access.On 1/14/26 at 9:04 AM, the wound care cart was again observed unlocked and unattended in the hallway. It remained unsecured until 9:07 AM, when RN #1 came down the hall and locked it.In an interview on 1/14/26 at 9:13 AM, RN #3, the wound care nurse, stated that the wound care cart should remain locked at all times when not in use because it contains chemicals that could pose a risk to residents if accessed, ingested, or come into contact with eyes.On 1/14/26 at 9:14 AM, a direct observation of the wound care cart revealed the following items were unsecured and readily accessible: a staple remover, wound cleanser, nystatin antifungal cream, aloe moisturizer, Bio freeze topical anesthetic, triple antibiotic ointment, and iodoform gauze.On 1/14/26 at 9:40 AM, during an interview, RN #1 confirmed that the wound care nurse was the last to access the unlocked cart and reiterated that the cart must be locked when unattended to prevent potential harm to residents.On 1/14/26 at 9:55 AM, during an interview, the Director of Nursing (DON) confirmed that the wound care cart should remain locked at all times when not actively in use to ensure residents do not come into contact with any potentially harmful substances stored in the cart.

Based on observation, interviews, record reviews and facility policy review the facility failed to prevent the possibility of spreading infection during wound care and medication administration via Percutaneous Endoscopic Gastrostomy (peg) tube for three (3) of (10) care and medication observations. Resident #4, Resident #32 and Resident #49.Findings included: Record review of the facility's policy Infection Control dated 11/1/17 revealed, Policy Statement: This center's infection control policies and practices are intended to facilitate maintain a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infection . Resident #4 On 01/13/26 at 10:26 AM, during an observation, Resident #4 received Liquid Protein Supplement 30 milliliters (ml) administered by Licensed Practical Nurse (LPN) #1. LPN#1 retrieved the syringe from the pole and attempted to flush peg tube with 30 cubic centimeter (cc) water. She was unable to flush tube. She got a cup off bedside table and poured 30cc water in it. She went to sink in resident room and turned on faucet to get warm water. She checked placement again and attempted to flush peg tube. She was still unable to flush it with 30 cc's of water. She went back to the sink and turned in faucet and to get warm water. She returned and checked placement again. The pump started to beep, and she placed it on hold again at this time she was able to flush line. She administered the liquid protein and flushed with 30 cc's of water after administering protein liquid supplement. LPN #1 did not perform hand hygiene or change gloves throughout the process from the time she entered the room until the actual medication was administered. On 01/13/26 at 2:58 PM, an interview with LPN #1 confirmed that she did not wash hands or change gloves throughout the process. She stated that it left the resident vulnerable to bacteria and germs. Record review of the Order Summary Report with active orders as of 1/13/26 revealed physician orders for Liquid protein supplement one time a day for wound healing. Give 30 milliliters (ml) via peg tube. Record review of Resident #4 admission Record revealed an admit date of 5/9/24 with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, and Dysphagia Oropharyngeal Phase. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident was severely impaired cognitively. Resident #32 Observation on 01/13/2026 at 2:15 PM, LPN #2 was observed giving peg medications to Resident #32 via peg tube. During the process, the nurse put on gloves and touched the bedside pump turning it off with gloves on, then wearing those same gloves to access the peg tube and give the meds. Once she completed the medication administration, LPN#2 used those gloves to turn the pump off, (touching buttons) on the bedside pump with the contaminated gloves. In an interview 1/13/26 at 2:40 PM, with LPN #2, she stated that she should have either used bare hands to turn the pump off or changed gloves after touching the pump prior to accessing the peg tube medications and removed or changed gloves prior to touching the pump at the end of the procedure to turn it off. On 01/14/26 at 9:50 AM, an interview with the Director of Nursing (DON) confirmed that residents have an increase in the chance of infection when hand hygiene is not done. She confirmed that LPN #1 and LPN #2 have should perform hand hygiene and changed gloves during the process. She stated her expectations are for staff to provide care in a way to prevent infection. A record review of Resident #32 Order Summary Report with active orders as of 1/13/26 revealed physician orders for Buspirone HCI 10 milligrams (mg), Hydroxyzine 25mg, and Trazadone 50mg via peg tube. A record review of Resident #32 admission Record revealed an admission date of 10/22/25 with diagnoses that included of Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, and Dysphagia following Cerebral Infarction. A record review of the MDS with an ARD of 10/29/25 revealed a BIMS score of 99 which indicated the resident was unable to complete the interview. Resident #49 During wound care observation on Resident #49 at 9:17 AM, on 1/13/26, the wound care nurse Registered Nurse (RN) #3 provided wound care starting with an open unstageable wound and was observed cleaning four other separate necrotic wounds to the foot (each one at a separate site), during which she wore the same gloves, reaching the contaminated glove hand into a container filled with saline-soaked gauze and using those gauze to clean a separate wound each time without ever changing her gloves between she then doubled back over each wound making a separate pass to clean the each wound again after already cleansing each site while wearing the same gloves. In an interview at 9:40 AM on 1/13/26, with RN #3, stated that she thought the wounds were all considered one wound since they were on the same foot, so it was okay to use the same gloves. In an interview at 11:38 AM on 1/13/26, the DON stated that not changing gloves when you are supposed to can cause cross-contamination to other wounds during the wound care process and lead to infection. In an interview with RN #1, the Infection Preventionist nurse on 1/14/26 at 9:38 AM, stated that not following infection prevention guidelines and changing gloves properly could lead to an increased risk of infection for residents receiving care. A record review of the admission Record revealed the resident was admitted on [DATE] with diagnoses that included hypertensive heart and chronic kidney disease. A record review of the MDS with an ARD of 12/18/25 revealed a BIMS score of 13 which indicated no mental impairment.

Based on interviews, record review, policy review, and facility investigation, the facility failed to ensure residents were free from misappropriation of funds for nine (9) of 30 residents who have a resident trust fund. (Residents #2, #5, #7, #12, #13, #25, #28, #32, and #33) Findings include: A review of the facility policy titled, Resident Trust, dated 9/20/17, revealed Purpose . To maintain a Resident Trust Account, for the safekeeping of a resident's personal money, if requested to do so . Policy Statement . Each Center shall have standardized policies for the handling of resident trust accounts . Monitoring systems shall be in place to ensure funds are handled in accordance with applicable state regulations . A review of the facility policy titles, Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019 revealed, Purpose: To prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigation of alleged violations . in accordance with Federal and State Laws . Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the residents consent . Investigation: . The Administrator, or designee will oversee the center in conducting an internal investigation against any violation/alleged violation of .misappropriation of resident property . Reporting/Response: . Immediately reporting all alleged violation to the . state agency .and all other required agencies (e.g. law enforcement when applicable) within specified timeframes . A record review of the facility's investigation regarding misappropriation of resident funds submitted to the State Agency (SA) on 6/27/24, revealed that through routine reconciliation of trust accounts, suspicious activity was discovered related to receipts and resident signatures. The facility investigation detailed the actions of the facility regarding securing resident funds and a detailed audit was conducted. Through investigation, the facility identified multiple receipts, involving a total of nine (9) residents in which receipts involving cash withdrawals from the resident's trust accounts that indicated fraudulent activity on behalf of the Business Office Manager (BOM). Although the BOM denied mishandling the resident's money, she was suspended, and subsequently resigned her position, as a detailed audit was conducted. During the investigation, any suspicious activity involving cash withdrawal receipts were discussed with the residents and the facility's suspicions were confirmed. Some of the residents were unable to remember getting money from their account, however, others were able to confirm that the signatures on the cash receipts were not their signatures. The facility replaced money to the residents for any discrepancies that were identified and the investigation reported that no residents suffered a negative outcome. On 9/4/24 at 10:01 AM, in an interview with the Administrator, she confirmed the details of the investigation regarding misappropriations of resident funds submitted on 6/27/24 were accurate. On 9/4/25 at 12:19 PM, in an interview with Regional Business Office Consultant (RBOC), he explained that he usually does an audit of the trust fund twice a year. During his June audit, he noticed some discrepancies with the receipts in the trust fund. When asking the BOM at the time, she revealed she was putting numbers in to make sure everything in the system matched, although she knew that, in all actuality, nothing was balanced. She surprised him, so he pulled out the monthly reconciliation form for these transactions to get more information because the administrator's signature should prove that everything matched that month. When checking the form and asking the administrator why she signed the reconciliation without acknowledging the accuracy of the money, the Administrator replied, That is not my signature. He and the Administrator then realized that fraudulent activity may have occurred, prompting them to investigate further. It became clear that a thorough audit of the financial records was necessary to uncover the extent of the discrepancies and ensure accountability moving forward. So, they pulled the receipts and went to talk with residents whose names were on some of the receipts. During their interview with the residents, some indicated they could not remember, blatantly denied signing, or stated that it was not their signature. During a phone interview with the Business Office Manager (BOM) at 9:41 AM on 9/5/24, she confirmed that she resigned in June 2024, after being accused of mishandling funds from the trust fund accounts of the residents. She noted that this happened during a corporate BOM audit, where they discovered discrepancies in the finances and receipts. The BOM says that she was aware of the accounts not balancing, but she was able to find a solution by inputting the necessary numbers to make it seem balanced, despite the lack of cash. She explains that in such cases, she would adjust the numbers to ensure the accounts were balanced, even if the actual money did not align. Resident #33 A record review of the facility investigation revealed that Resident #33 confirmed the signature of a receipt dated 5/10/24 for $20.00 was indeed her signature, but denied having received any money within the past two (2) years. A record review of the Manual Check Request, provided by the facility was dated 6/26/24, and payable to Resident #33 for misappropriation, in the amount of $20.00. On 9/3/24 at 12:04 PM, in an interview, Resident #33 stated she remembers something about money being put back in her account, but does not know all the details. A record review of the Admission Record for Resident #33 revealed the facility admitted the resident on 1/17/22. The resident's diagnoses included Heart failure. A record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/18/24 revealed Resident #33 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #28 A record review of the facility investigation revealed that Resident #28 denied the signature on the receipts dated 1/3/24 for $40.00, 2/2/24 for $50.00, 3/1/24 for $40.00, 4/5/24 for $50.00, and 5/6/24 for $40.00, totaling $220 belonged to him. The resident confirmed although there was a receipt, he did not receive the money. A record review of the Manual Check Request, provided by the facility was dated 6/26/24, and payable to Resident #28 for misappropriation, in the amount of $220.00. On 9/4/24 at 8:36 AM in an interview with Resident #28, the resident stated he was not sure if someone told him about money or not. A record review of the Admission Record revealed the resident was admitted by the facility on 3/13/19, with diagnoses that included Peripheral Vascular Disease. A record review of Resident #28's Quarterly MDS with an ARD of 8/8/24 revealed a BIMS score of 7, which indicated the resident had moderate cognitive impairment. Resident # 32 A record review of the facility investigation revealed that Resident #32 stated that she did not receive the cash as detailed in the receipts dated 3/25/24 for $100.00, 4/5/24 for $60.00, 4/24/24 for $50.00, and 5/10/24 for $40.00, totaling $250.00. Additionally, the investigation revealed the receipts were marked with an X and according to the Administrator and RBOC, the resident was not physically able to sign with an X. A record review of the Manual Check Request, provided by the facility was dated 6/26/24, and payable to Resident #32 for misappropriation, in the amount of $250.00. On 9/5/24 at 1:10 PM, in an interview Resident #32 stated that she did not remember anything about money taken from her account. A record review of the Admission Record of resident #32 revealed the facility admitted the resident on 9/14/22. The resident's diagnoses included Anoxic Brain Damage. A record review of the Quarterly MDS with an ARD of 6/3/24 revealed Resident #32 had BIMS score of 10, which indicated the resident had moderate cognitive impairment. Resident #25 A record review of the facility investigation revealed that Resident #25 confirmed the signature on two (2) receipts totaling $50 was not her signature and she did not receive any money. The receipts were dated 3/29/24 for $10.00 and 4/5/24 for $40.00. A record review of the Manual Check Request, provided by the facility was dated 6/26/24, and payable to Resident #25 for misappropriation, in the amount of $50.00. On 9/5/24 at 1:14 PM, in an interview with Resident #25, the resident stated that she did not remember anything about money. A record review of the Admission Record for Resident #25 revealed the facility admitted the resident on 8/2/17, with diagnoses that included Schizophrenia. A record review of the Resident 25's Comprehensive MDS with an ARD of 8/18/24 revealed a BIMS score of 10, which indicated the resident had moderate cognitive impairment. Resident #12 A record review of the facility investigation revealed that Resident #12 confirmed the signature on two (2) receipts totaling $80 was not his signature and she denied receiving any cash. The receipts were dated 3/29/24 for $40.00 and 4/4/24 for $40.00. A record review of the Manual Check Request, provided by the facility was dated 6/26/24, and payable to Resident #12 for misappropriation, in the amount of $80.00. On 9/5/24 at 1:18 PM in an interview with Resident #12, stated he recalled someone coming to talk with him about being refunded money, but he did not remember the details. A record review of the Admission Record for Resident #12 revealed the resident was admitted by the facility on 7/10/23. The resident's diagnoses included Traumatic Brain Injury. A record review of the MDS with an ARD of 7/11/24, revealed a BIMS score of 14, which indicated the resident was cognitively intact. In addition to the above interviews, the facility investigation revealed that there were an additional five (5) residents involved in the misappropriation of resident funds. The residents and the facility finds were as follows: 1) Resident #2 denied a signature on a receipt dated 4/24/24 for $50 belonged to her. She stated she had never gotten any cash. As a result of this interview, the facility provided a copy of the Manual Check Request, dated 6/24/24, and payable to Resident #2 for misappropriation, in the amount of $50. 2) Resident #7 confirmed that the signature on the receipt dated 3/29/24 for $40.00 was not her signature and she did not receive any cash. As a result of this interview, the facility provided a copy of the Manual Check Request, dated 6/24/24, and payable to Resident #7 for misappropriation, in the amount of $40. 3) Resident #5 denied the signatures on the receipts totaling $140.00. The resident also denied receiving the cash. As a result of this interview, the facility provided a copy of the Manual Check Request, dated 6/24/24, and payable to Resident #5 for misappropriation, in the amount of $80. On 9/9/24, the SA contacted the Administrator for clarification, as the facility investigation revealed a total of $140.00 on the receipts. The Administrator responded with an email that stated that there was a typing error on the investigation and the amount that had been misappropriated had actually been $80.00. 4) Resident #13 denied ever receiving cash for a receipt dated 4/24/24 in the amount of $50. As a result of the interview, the facility provided a copy of the Manual Check Request, dated 6/24/24, and payable to Resident # 13 for misappropriation, in the amount of $50.

Based on observation, interviews, record review, and policy review the facility failed to provide perineal care in a manner to prevent the possibility of urinary tract infection for one (1) of four (4) residents reviewed for incontinent care. (Resident #5) Findings include: On 09/04/24 at 3:03 PM, during an observation of Certified Nurse Aide (CNA) #1 as she provided perineal care for Resident #5, the CNA assisted the resident to turn on her side to complete her perineal care. The CNA wiped the resident from the back to front, instead of front to back, a total of five (5) times. On 09/05/24 at 9:36 AM, in an interview with CNA #1, she stated she did not do the perineal care on the buttocks correctly. She stated she wiped back to front. She stated she should have wiped front to back. She stated her actions could cause the resident to develop a urinary tract infection (UTI). She stated she has been a CNA for [AGE] years and has had training on perineal care. On 09/05/24 at 9:45 AM, in an interview, the Director of Nursing (DON) stated CNA #1 should have wiped front to back when she provided perineal care. She stated the CNA's actions could increase the risk of infection. Review of Admission Record for Resident #5 revealed the facility admitted the resident on 12/13/21. The resident's diagnoses included Chronic Kidney Disease and Dementia. Review of the Quarterly Minimum Data Set (MDS), for Resident #5, with an Assessment Reference Date (ARD) of 6/4/24, revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated the resident had severe cognitive impairment. Section GG revealed the resident required substantial/maximal assistance with toileting hygiene.

Based on observation, interviews, record reviews and facility policy reviews the facility failed ensure tube feedings were administered as ordered for one (1) of seven (7) residents who recieve enteral feedings. (Resident #1) Findings include: Review of the facility policy titled, Enteral Nutrition, dated 8/1/12 revealed, It is the policy of this facility to ensure that a nutritional assessment is completed for all residents receiving enteral feeding. Orders will reflect specific content to assure quality of enteral delivery .2.The tube feeding order will be recorded. The following information should be included in the diet order or comments section: . e. amount (c.c.s) of formula to be given for each feeding and total c.c.s to be given per 24 hours . On 9/3/24 at 10:48 AM, an observation revealed Resident #1 lying in bed with his PEG (Percutaneous Endoscopic Gastrostomy) tube feeding formula attached to an electronic pump. Jevity 1.5 was infusing per pump at the rate of 70 ml/hr. (milliliters/ per hour). On 9/3/24 at 2:19 PM, in an attempt to verify the physician orders regarding the infusion rate of Resident #1's tube feeding in the resident's electronic chart, the orders were not available. There were orders regarding the flushing and care of the PEG tube, but no order available for review for the rate and type of feeding the resident was to receive. On 9/3/24 at 2:23 PM, in an interview with the Director of Nurses (DON), she was unable to locate the order when asked for a printed copy of the tube feeding orders for Resident #1. At that time, the DON stated that there had recently been an electronic update to their charting system and that she would check the MAR (Medication Administration Record). On 9/3/24 at 2:37 PM, the DON reported that within the electronic system, there were no current active orders for Resident #1's tube feeding rate or type of feeding to be administered. During an observation, interview and record review at 2:57 PM on 9/3/24, the DON provided an updated print out of Resident #1's Order Summary Report, with active orders as of 8/14/24, in which the order had been corrected to include the resident's tube feeding order that included the type and rate of feeding the resident had been receiving since the initial order written on 1/25/16. The DON observed and confirmed the tube feeding was now infusing with Jevity 1.5 @ 75 ml/hr. as ordered. Further review of the order revealed that the physician's order included a time frame for the infusion in which the resident was to receive the feeding for 18 hours per day from 6:00 AM until 12 MN (midnight) A record review of the Admission Record for Resident #1 revealed that the facility admitted the resident on 6/6/2008. The resident's diagnoses included Dysphagia, Aphasia, and Unspecified Intellectual Disabilities.

Based on observation, staff interview, and facility policy review, the facility failed to prevent the possible transmission of diseases and infections by storing clean durable medical equipment (DME) in a room marked for biohazard materials for two (2) of three (3) days of survey. Findings include: Review of the facility's, Policies and Practices - Infection Control, dated 11/1/2017, revealed, .This center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage the transmission of diseases and infections . On 9/3/24 at 11:27 AM, in an observation of the biohazard room and interview with Maintenance #1, revealed the room was clearly marked as a biohazard area. Inside the room, a biohazard container with a red bag was placed on the right side, while oxygen concentrators, covered in plastic bags, were located on the left side of the room. Maintenance #1 stated the oxygen concentrators were considered clean since they were bagged, though he acknowledged the room was marked as a biohazard area. In a subsequent observation and interview on 9/4/24, at 9:41 AM, with Registered Nurse (RN) # 1 the same biohazard room was observed. On the right side, the biohazard container with the red bag was still present, while on the left side, the oxygen concentrators with plastic coverings remained. Additionally, an unclean bedside commode was placed on top of the concentrators. RN #1 acknowledged that while the biohazard room was technically considered dirty, she believed the concentrators were clean because staff had cleaned and bagged them. On 9/4/24 at 9:59 AM, in an interview with the Director of Nursing (DON), she revealed the facility's policy and practices were intended to facilitate maintaining a safe, sanitary comfortable environment and to help prevent and manage the transmission of diseases and infections. She confirmed the facility to follow infection control practices by storing cleaned oxygen concentrators in the biohazard room. 50751

Based on observation, interviews, record review, and facility policy review, the facility failed to provide an ongoing resident centered activities program for nine (9) of the nine (9) residents sampled. This has the potential to affect 49 of the 49 residents residing in the facility. Residents #5, #12, #15, #18, #20, #21, #30, #31, and #38 Findings include: Review of the facility's policy, Activities, dated April 2022, revealed, POLICY: It is the policy of this center to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Center-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community . An observation on 3/13/23, at 10:58 AM, revealed five (5) residents sitting in front of the nurse's station. There were no activities taking place in the facility at this time. Record review of the facility's activity calendar dated 3/13/23, revealed Morning Social and Reminiscing, were scheduled during this time. An observation on 3/13/23, at 2:30 PM, revealed several residents sitting in front of nurse's station, with no activities taking place. Record review of the facility's activity calendar dated 3/13/23, revealed Who's Bag, is it? scheduled for this time. Observation on 3/14/23, from 10:00 to 11:00 AM, once again revealed residents sitting in front of the nurse's station, with no activities taking place. Record review of the facility's activity calendar dated 3/14/23, revealed Morning Social and Current Events were scheduled during this time. During interviews with the nine (9) residents present on 3/14/23 at 2:00 PM, at the Resident Council meeting, each resident confirmed that they usually had activities during the week, unless the Activity Director was off. They confirmed that with the Activity Director off this week, they haven't had any of the activities listed on the activity calendar. The Council members complained that there had been nothing to do. They also complained that they didn't have activities on Saturdays, because the Activity Director was off on the weekends. They did, however, confirm that they had church services on Sundays, but that was the only thing scheduled during the weekends. An observation on 3/15/23 from 10:00 AM to 11:00 AM, once again revealed residents sitting in front of the nurse's station with no activities taking place. Record review of the facility's activity calendar dated 3/15/23, revealed Morning Social and Parachute had been scheduled for that time. During an interview on 3/15/23 at 2:39 PM, the Administrator confirmed the Activity Director is on vacation this week and doesn't work on weekends. The Administrator revealed the Social Worker is responsible for providing activities for the residents this week. During an interview on 3/15/23 at 11:07 AM, with the Social Worker, she stated she had tried to assist with activities when she could, but with the referrals that she gets, she had not been available to consistently oversee the scheduled activities when the Activity Director was unavailable this week or at any time on the weekends, as she is also off on the weekends. The Social Worker said she thought the Activity Director and one of the certified nurse aides (CNA's) had talked about the CNA assisting with activities when the Activity Director was unavailable. Resident #5 Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/21/22, revealed, Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. Review of section F revealed, it was very important to Resident #5 to do favorite activities. Resident #12 Record review of the MDS, with an ARD of 11/9/22, revealed, Resident #12 had a BIMS score of 13, which indicated the resident was cognitively intact. Review of section F revealed, it was somewhat important for Resident #12 to do favorite activities. Resident #15 Record review of the MDS, with an ARD date of 11/22/22, revealed, Resident #15 had a BIMS score of 15. Review of section F revealed, it was very important to the resident do favorite activities. Resident #18 Record review of the MDS, with an ARD date of 7/5/22, revealed, Resident #18 had a BIMS score of 15, which indicated the resident was cognitively intact. Review of section F revealed, it was very important to Resident #18 to do favorite activities. Resident #20 Record review of MDS, with an ARD of 4/13/22, revealed, Resident #20 had BIMS score of 15, which indicated the resident was cognitively intact. Review of section F revealed, it was very important to Resident #20 to do favorite activities. Resident #21 Record review of the MDS, with an ARD of 1/30/23, revealed, Resident #21 had a BIMS score of 15, which indicated the resident was cognitively intact. Review of section F revealed, it was very important to Resident #21 to do favorite activities. Resident #30 Record review of the MDS with an ARD of 10/3/22, revealed, Resident #30 had a BIMS score of 15, which indicated the resident was cognitively intact. Review of section F revealed, it was very important to Resident #30 to do favorite activities. Resident #31 Record review of the MDS with an ARD of 11/10/22, revealed, Resident #31 had a BIMS score of 13, which indicated the resident was cognitively intact. Review of section F revealed, it was important to Resident #38 to do favorite activities. Resident #38 Record review of the MDS, with an ARD of 1/17/23, revealed Resident #1 had a BIMS score of 15, which indicated the resident was cognitively intact. Review of section F revealed, it was very important to Resident #38 to do favorite activities.

Based on observations, interviews, record review, and facility policy review, the facility failed to post cautionary and safety signs indicating the use of oxygen for one (1 )of one (1) sampled residents. Resident #198 Findings include: A record review of the facility's policy, Applying An Oxygen-Delivery Device, undated, revealed . IMPLEMENTATION . 9. Post Oxygen in Use signs on wall behind bed and at entrance to room .12 . Alerts visitors and are providers that oxygen is in use . On 3/13/23 at 11:02 AM, an observation of Resident #198 revealed the resident lying in bed, wearing a nasal cannula. An oxygen concentrator (a medical device used to deliver oxygen) was noted next to the resident's bed and turned on. There was no cautionary signage posted at the entrance to the resident's room or within the room to indicate that oxygen was in use. Observations on 3/14/23 at 3:00 PM and again on 3/15/23 at 11:36 AM, revealed Resident #198, the resident sitting in his room with oxygen in use. There continued to be no cautionary signage within the resident's room or near the entrance to the resident's room that indicated oxygen was in use. A record review of Resident #198's Admission Record, revealed the facility admitted the resident on 3/2/23, with the diagnosis of Chronic Obstructive Pulmonary Disease Heart Failure and Chronic Kidney Disease. A record review of the Order Summary Report, for Resident #198 with active orders as of 3/16/23, revealed an order for O2 (oxygen) via nasal cannula at 2L/min (two liters per minute) continuous every shift related to Chronic Obstructive Pulmonary Disease. A record review of Resident #198's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/9/23, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact, and review of Section O revealed, oxygen in use. On 3/14/23, at 11:36 in an interview with Registered Nurse (RN) #1, she confirmed the resident was receiving oxygen. The nurse also confirmed that there was not a sign in the resident's room or upon entrance to the room indicating that oxygen was in use. On 3/16/23 at 10:15 AM, in an interview with the Director of Nursing (DON) she confirmed there should have been a sign near the entrance to the resident's room and in the resident's room to inform staff and visitors that oxygen was in use. She explained the purpose of the signage is to ensure resident and staff safety.

Based on observation, staff interview, facility policy review, the facility failed to prevent cross contamination of milk products as evidenced by failure to separate expired milk from milk that was in date, for one (1) of three (3) kitchen observations. Findings include: Review of the facility's Food Storage: Cold Foods policy, with a revision date of ,[DATE], revealed: All foods would be stored, labeled, dated, and arranged in a manner to prevent cross contamination. An observation during the initial tour, on [DATE] at 1:13 PM, with Dietary Staff (DS) #1, revealed four (4) 8 ounce (oz) cartons of 2% milk, with an expiration date of [DATE], in the milk refrigerator. The expired milk was mixed in with the milk that was in date, and not separated. On [DATE] at 1:18 PM, an interview with DS #1, revealed she stated the milk delivery person was suppose to check and remove the expired milk. DS #1 revealed she did not know why the expired milk was mixed with the fresh milk. DS #1 confirmed the expiration date on the 4 cartons of milk was [DATE]. On [DATE] at 4:14 PM, an interview with Dietary Manager (DM), confirmed the milk was expired. The DM revealed she moved the expired milk to another area of the milk refrigerator, and placed a sign of do not use. The DM stated the milk delivery person came once a week, on Tuesday, and would swap them out. On [DATE] at 1:18 PM, an interview with the DM, revealed the responsibility of checking the dates on the milk cartons between the milk deliveries was with the dietary aides. The DM stated the expectation was for the expired milk to be removed and separated from the rest of the milk, with a label placed of do not use until the next milk delivery. The DM stated the concern was related to cross contamination.

Based on staff interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to the use of a Continuous Positive Airway Pressure ([MEDICAL CONDITION]) machine, Resident #31, for one (1) of 14 resident MDS assessments reviewed. Findings include: A review of the facility's MDS Coding policy, dated (MONTH) (YEAR), revealed: MDS coding is completed by utilizing Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual and the State of Mississippi Division of Medicaid Case Mix Index (CMI). A review of the CMS RAI Version 3.0 Manual, Chapter 1, revealed an accurate assessment required collecting information from multiple sources, some of which are mandated by regulations. Resident #31 A review of the Admission MDS for Resident #31, with an Assessment Reference Date (ARD) of 8/26/19, revealed Special Treatments and Programs (Section O), was not coded for [MEDICAL CONDITION] usage. Observations on 12/15/19, 12/16/19, and 12/17/19, revealed Resident #31 had a [MEDICAL CONDITION] machine on her night stand. On 12/16/19 at 8:38 AM, an interview with Resident #31, revealed she used her [MEDICAL CONDITION] machine every night. A review of Resident #31's physician orders, dated 9/26/17, documented C-PAP at bedtime every evening shift. On 12/17/19 at 3:45 PM, an interview with Registered Nurse (RN)/MDS Nurse #1, revealed Resident #31 did use the [MEDICAL CONDITION] machine. RN #1 confirmed, Resident #31's MDS was coded inaccurately. RN #1 stated she used the Resident Assessment Instrument (RAI) Manual as a guideline to complete the MDS. On 12/18/19 at 9:26 AM, an interview with the Director of Nurses (DON), revealed she would expect the MDS Nurse to Mark the correct box on the MDS assessment. A review of the facility's Face Sheet, revealed the facility admitted Resident #31, on 9/25/17, with a [DIAGNOSES REDACTED].

Based on staff interview, record review, and facility policy review, the facility failed to revise the comprehensive care plans for two (2) of 14 resident care plans reviewed, Residents #31 and #40. Findings include: A review of the facility's Care Plans policy, dated 6/17, revealed: The care plans would be developed for all residents based upon the Resident Assessment Instrument (RAI) Manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. Resident #40 Review of Resident #40's comprehensive care plan related to use of [MEDICAL CONDITION] medications, initiated 3/18/19, revealed, the resident was to attend Intensive Outpatient Program (IOP) weekly on Monday, Wednesday and Friday. Review of Resident #40's physician's orders [REDACTED]. During an interview with Licensed Practical Nurse (LPN) #1, on 12/16/19 at 2:22 PM, she stated Resident #40 had graduated and no longer attends IOP. On 12/17/19 at 3:43 PM, an interview with Registered Nurse (RN) #1/Minimum Data Set (MDS) Nurse, confirmed Resident #40 was no longer on IOP. RN #1 stated the resident had graduated the program. RN #1 stated the care plan was not correct because it was not updated when Resident #40 completed IOP. On 12/18/19 at 9:43 AM, an interview with the Director of Nurses (DON), revealed she was aware of the incorrect care plan for Resident #40. The DON stated the staff met daily to put new orders in the computer. The DON stated the intervention should have been removed the day the order was discontinued. The DON stated the care plan was a guidance for the staff to take care of the resident, and it should be updated timely. Resident #31 A review of Resident #31's comprehensive care plan related to [DIAGNOSES REDACTED]. The care plan did not indicate any interventions related to storage of the [MEDICAL CONDITION] mask. An observation on 12/15/19 at 2:20 PM, revealed Resident #31's [MEDICAL CONDITION] mask lying on her bed unbagged. On 12/15/19 at 4:43 PM, an observation revealed Resident #31's [MEDICAL CONDITION] mask lying on her bed, unbagged. An observation on 12/16/19 at 8:35 AM, revealed Resident #31's [MEDICAL CONDITION] mask to be lying on her bed and unbagged. During an interview, on 12/16/19 at 8:38 AM, Resident #31 revealed she used her [MEDICAL CONDITION] machine every night. An observation on 12/17/19 at 10:00 AM, revealed Resident #31's [MEDICAL CONDITION] mask was lying on her night stand unbagged. During an interview, on 12/17/19 at 3:45 PM, RN #1 stated she would expect the staff to review and follow the comprehensive care plan once it is revised and completed. On 12/18/19 at 9:29 AM, an interview with the DON, revealed the care plan was a guide for the staff to care for the residents. The DON stated the staff should read it and do what the care plan tells them to do.

Based on observation, staff interview, record review, and facility policy review, the facility failed to store Resident #31's Continuous Positive Airway Pressure ([MEDICAL CONDITION]) mask in a manner to prevent cross contamination for one (1) of two (2) residents reviewed for respiratory care. Findings include: A review of the facility's Infection Control policy, dated (MONTH) (YEAR) revealed, Bi-level Positive Airway Pressure (Bi-PAP) and Continuous Positive Airway Pressure ([MEDICAL CONDITION]) will be maintained including cleaning per the manufactured guidelines of the product. Review of an untitled and undated document, provided by the facility, revealed instructions on [MEDICAL CONDITION] hygiene. Mask and tubing need a full bath once a week to keep it free of dust, bacteria and germs. An observation, on 12/15/19 at 2:20 PM, revealed Resident #31's [MEDICAL CONDITION] mask lying on her bed unbagged. On 12/15/19 at 4:43 PM, an observation revealed Resident #31's [MEDICAL CONDITION] mask lying on her bed, unbagged. An observation on 12/16/19 at 8:35 AM, revealed Resident #31's [MEDICAL CONDITION] mask to be lying on her bed and unbagged. During an interview, on 12/16/19 at 8:38 AM, Resident #31 revealed she used her [MEDICAL CONDITION] machine every night. An observation, on 12/17/19 at 10:00 AM, revealed Resident #31's [MEDICAL CONDITION] mask lying on her night stand unbagged. During an interview, on 12/17/19 at 10:41 AM, the Assistant Director of Nurses (ADON) revealed, Resident #31's [MEDICAL CONDITION] mask should be stored in a clean plastic bag. On 12/17/19 at 1:43 PM, an interview with the Director of Nurses (DON), confirmed the [MEDICAL CONDITION] mask should be stored in a plastic bag because of infection control issues. A review of the facility's Face Sheet, revealed the facility admitted Resident #31 on 9/25/17 with a [DIAGNOSES REDACTED].

Based on observation, staff interview, record review, and facility policy review, the facility failed to administer medications in a manner to prevent medication errors for one (1) of five (5) residents observed for medication pass administration, Resident #16. The facility had a medication error rate of 6.45%. Findings include: A review of the facility's Medication Administration policy, dated (MONTH) (YEAR), revealed, the facility follows (Name of Pharmacy)/Pharmacy Consultant, policies and procedures for medication administration. A review of the (Name of Pharmacy)/Pharmacy Consultant General Dose Preparation and Medication Administration policy, dated 12/01/07, revealed: The facility should verify that the medication name and dose are correct. The pharmacy should be contacted to provide the correct dose. The facility should verify each time a medication is administered that it is at the correct dose. A record review of Resident #16 physician's orders [REDACTED]. A review of Resident #16's (MONTH) 2019, Electronic Medication Administration Record [REDACTED]. An observation on 12/16/19 at 9:00 AM, revealed Licensed Practical Nurse (LPN) #2 retrieved a bottle labeled [MEDICATION NAME] 325 MG tablets from the medication cart, poured 2 tablets into a medication cup, and gave them to Resident #16 along with resident's other medications. During an interview, on 12/16/19 at 11:37 AM, LPN #2 confirmed she had given 2 of the Tylenol 325 MG tablets to Resident #16. LPN #2 stated she gave 2 of the 325 MG Regular Strength Tylenol to equal the 650 MG dose. LPN #2 also stated she was thinking the Tylenol 325 MG Regular Strength and the Tylenol 8 hour Arthritis Pain Tablet Extended Release 650 MG ([MEDICATION NAME] ER) were the same as long as they were not [MEDICATION NAME] coated tablets. An interview on 12/16/19 at 11:47 AM, with the Consultant Pharmacist revealed, the Regular Strength 325 mg tablet of Tylenol was not an extended release tablet. The Consultant Pharmacist stated if the medication bottle did not have extended release, then the medication was not extended release. During an interview, on 12/17/19 at 1:36 PM, the Director of Nurses (DON) stated, if LPN #2 looked on her medication cart and saw she did not have the correct dosage of the medication, she should have checked the supply room. The DON stated if the medication was unavailable, the nurse would need to call the physician and get the medication order changed. The DON stated the nurse should give the medication as ordered. A review of the facility's Face Sheet revealed, the facility admitted Resident #16 on 9/19/17, with a [DIAGNOSES REDACTED].

Based on record review, staff interview, and facility policy review, the facility failed to revise Resident #1's comprehensive care plan to address activities. This concern was identified for one (1) of 25 resident care plans reviewed. Findings include: Review of a typed statement on the facility's letterhead revealed: The facility's policy for completing the Minimum Data Set (MDS) and Care Plan is the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument User's Manual, version 1.14. There was no date or signature on the statement. On 11/19/18 at 8:50 AM, an observation revealed Resident #1 was sitting upright in her bed with her eyes closed. Record review of the physician's orders [REDACTED].#1 had a [DIAGNOSES REDACTED]. Further review of the medical record revealed no care plan for activities. Review of the most recent comprehensive Admission MDS assessment, with an Assessment Reference Date (ARD) of 5/25/18, included a [DIAGNOSES REDACTED]. On 11/19/18 at 9:05 AM, an interview with Social Service Director (SSD) #1, revealed Resident #1 has confusion, but not behaviors. Social Service Director #1 stated Resident #1 has not had behaviors that she is aware of. On 11/19/18 at 9:15 AM, an interview with Certified Nursing Assistant (CNA) #1, revealed Resident #1 may state she does not want to get up when the staff tries to get her up, but after encouragement Resident #1 will allow staff to assist her with getting dressed, and getting out of bed. An interview, on 11/19/18 at 9:20 AM, with Activity Director #1 revealed, Resident #1 enjoys reading the newspaper in her room, word search puzzles, and will play card games. Activity Director #1 stated Resident #1 does not have an activity care plan. Activity Director #1 also stated Resident #1 would need a care plan to tell the staff what activities to do for her. On 11/19/18 at 9:25 AM, an interview with the Registered Nurse (RN) #1, revealed the Activity Director would need a care plan to show what Resident #1 is doing, and to show what Resident #1 likes or dislikes. A review of the facility's Face Sheet revealed, the facility admitted Resident #1, on 5/15/18, with an included [DIAGNOSES REDACTED].

Based on observation, staff interview, record review, and facility policy review, the facility failed to knock on Resident #7 and #21's doors prior to entering the rooms to administer medications, and ensure privacy to administer medications via Resident #21's Gastrostomy Tube. This concern was identified for two (2) of four (4) residents observed for medication administration. Findings include: Review of the facility's Resident Rights, not date, revealed each of us has a personal responsibility to our patients/residents and their rights. We treat our patients and residents with dignity and respect. We treat our patients and residents with dignity and respect at all times. The patients/residents has the right to a dignified existence, self -determination and communication. The patient/resident has the right to personal privacy and confidentiality of his or her personal clinical records. Resident #7 An observation during the medication administration observation, on 11/19/2018 at 9:32 AM, with Licensed Practical Nurse (LPN) #1, revealed LPN #1 failed to knock on Resident #7's door prior to entering the room. During an interview, on 11/20/2018 at 11:54 AM, with LPN #1, she confirmed she failed to knock on the door prior to entering Resident #7's room. LPN #1 said she was nervous, and had never administered medications with a surveyor before. A review of the facility's Face Sheet revealed the facility admitted Resident #7, on 11/06/2016, with diagnoses, which included [MEDICAL CONDITION] Disease, Hypertension, and Wedge Compression Fracture of T 11-T 12 Vertebra. A review of Resident #7's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/15/2018, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #21 An observation, on 11/19/2018 at 9:30 AM, revealed LPN #1 failed to knock on Residents #21's door prior to entering the room. LPN also #1 failed to close the curtain and door prior to administering medications via Resident #21's Gastrostomy Tube. An interview, on 11/20/18 at 11:49 AM, revealed LPN #1 confirmed she failed to knock on Resident #21's door prior to entering the room, and close the curtain and door prior to administering Resident #21's medications via the Gastrostomy Tube to provide privacy. LPN #1 said the facility in-serviced them all the time on knocking on the residents' doors. A review of the facility's Face Sheet revealed the facility admitted Resident #21, on 06/06/2018, with diagnoses, which included unspecified Intellectual Disabilities, Gastrostomy Tube, Dysphasia, and Convulsions. A review of Resident #21's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/11/2018, revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the facility was unable to complete the BIMS due to the resident was severely cognitively impaired.

Based on observation, Record Review, Staff Interview and facility Policy Record Review, the facility failed to ensure a dressing was maintained on pressure ulcers for two (2) of three (3) wound observations, to ensure wounds did not worsen or get infected, which affected Resident #1 and Resident #3. Findings Include: A policy was not provided for Pressure Ulcer treatment for [REDACTED]. A review of the facility's Skin Care System Guidelines revealed residents will be observed by CNAs daily for reddened/ open areas and [MEDICAL CONDITION] of feet or sacrum. Changes will be reported to the licensed nurse and documented. A review of the facility's stop and watch dated 6/27/2017, revealed CNA's should review and mark on the stop and watch form of any changes in the resident's skin. Resident #1 A review of Resident #1's Treatment Administration Record (TAR), dated August 2017, revealed a treatment to cleanse the sacral wound with wound cleanser and dry well with 4 x 4 gauze. Pack wound bed with [MEDICATION NAME] Alginate AG. Using q-tips, apply venelex ointment to periwound. Sure prep around area, secure with [MEDICATION NAME] gentle wound dressing every three (3) days and as needed. The as needed treatment was not signed by the Nurse for the month of August. An Observation of wound and incontinent care on 8/9/2017 at 11:30 AM, with The Director of Nursing (DON), Certified Nursing Aide (CNA) #2, CNA #1 and LPN #1 present, revealed Resident #1 did not have a dressing on a stage 3 sacral Pressure Ulcer. The ulcer was red in the middle with white maceration around the edges. The resident's brief was saturated in urine. During an interview, on 8/9/2017 at 12:00 PM, CNA #2 revealed she had provided care for Resident #1 on 8/8/17 and 8/9/17, and the resident's sacral dressing was off both mornings when she came in. CNA #2 said the nurse was notified of both incidents. During an interview on 8/9/2017 at 12:45 PM, Licensed Practical Nurse (LPN) #1 stated that CNA#2 notified her that Resident #1's wound was not covered on 8/8/2017 and 8/9/2017, when she came in on dayshift around 8:00 AM. LPN #1 stated that she put a bandage on the resident on 8/8/17, and was waiting until after her medication pass to put the bandage on Resident #1 on 8/9/17. During an interview on 8/10/2017 at 9:00 AM, CNA #4 stated that she'd worked the 11-7 shift and did not notify the nurse that Resident #1 did not have a dressing on the sacral wound on 8/9/17. An interview with the DON on 8/9/2017 at 12:30 PM, confirmed the facility failed to ensure a dressing was on Resident #1's stage 3 pressure ulcer to the sacrum. The DON said the CNA's are trained to notify the nurse when bandages are soiled or come off the wounds. A review of the facility's face sheet revealed the facility admitted Resident #1 on 2/7/2017, with [DIAGNOSES REDACTED]. A review of Resident #1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/12/2017, revealed Resident #1 did not complete a Brief Interview for Mental Status (BIMS) assessment. Resident #3 A review of Resident #3's TAR, dated on August 2017, revealed a treatment to clean a stage 2 sacral pressure ulcer with wound cleanser, dry with a 4 x 4, apply Hydrogel and cover with 4 x 4's every day and every evening. An observation of wound and incontinent care on 8/9/2017 at 2:30 PM, with the DON, CNA #6, LPN #2, and CNA # 5 present, revealed Resident #3 did not have a dressing on the stage 2 sacral pressure ulcer. During an interview on 8/9/2017 at 3:00 PM, CNA #5 confirmed that she failed to tell the nurse that Resident #3's dressing was soiled. CNA #3 said I forgot to notify the nurse. During an interview on 8/9/2017 at 3:30 PM, The DON confirmed that CNA #5 failed to notify the nurse that the dressing on Resident #3's sacral dressing was soiled. The DON said the staff is trained to notify the nurse when a dressing is soiled or comes off. The DON also said she was going to in-service her staff to make sure this does not happen again. A review of the facility's face sheet revealed the facility admitted Resident #3 on 7/3/2017, with [DIAGNOSES REDACTED]. A review of Resident #3's Quarterly MDS, with an ARD of 07/10/17, revealed Resident #2 had a BIMS score of 11, which indicated the resident had moderate cognitive impairment.

Based on observation , staff interview, record review, and facility policy review, the facility failed to ensure the comprehensive Care Plan was followed for pressure ulcers as evidence by no dressing on a resident's pressure ulcer, for one (1) of 12 care plans reviewed, Resident #3. Findings include: Review of a statement on letterhead, not dated/signed, revealed the facility did not have a Care Plan Policy, they followed Chapter 4 of The Resident Assessment Instrument (RAI) Manual. The RAI manual, dated 10/2011, reveaeled that the services provided or arranged must be consistent with each resident's written plan of care. Resident #3: Review of Resident #3's care plan, revised 7/17/17, revealed a Stage 2 to the sacral area and the resident was at risk for further alteration in skin integrity. Interventions included treatments as ordered. An Observation of incontinent care/wound care on 8/9/2017 at 11:30 AM with the DON, CNA #6, LPN #2, and CNA #5 present, revealed Resident #3 did not have a dressing on a Stage 2 pressure ulcer to the sacral area. Review of Resident #2's physician orders [REDACTED]. An interview with the DON on 8/9/2017 at 3:30 PM, confirmed the facility failed to ensure a dressing was on a Stage 2 pressure ulcer to Resident #3's sacrum, per care plan. The DON said the CNA's are trained to notify the nurse when dressings are soiled or come off the wounds. Review of the Face Sheet revealed the facility admitted Resident #3 on 7/3/2017, with [DIAGNOSES REDACTED]. A review of the current quarterly MDS assessment with an ARD of 07/10/2017, revealed Resident #3 scored 11 on the BIMS, which indicated moderate cognitive impairment.

Based on observation, interview, record review and policy review, the facility failed to revise the care plan for Resident #1's pressure ulcer and treatment for one (1) of 12 care plans reviewed. Findings include: Review of a statement on letterhead, not dated/signed, revealed the facility did not have a Care Plan Policy, they followed Chapter 4 of The Resident Assessment Instrument (RAI) Manual. The RAI manual, dated 10/2011, revealed that the results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive plan of care and services provided or arranged must be consistent with each resident's written plan of care. Resident #1 A review of the Comprehensive Care Plan, dated 2/28/2017, revealed Resident #1 was at risk for skin problems and additional pressure areas due to incontinence and decreased mobility requiring assistance with bed mobility and toileting and wears incontinent briefs. There was no documented care plan for the Stage 3 pressure ulcer and treatment to the sacral area. Review of Resident #1's physician's orders [REDACTED]. An observation of incontinent care/wound care on 8/9/2017 at 11:30 AM, with The Director of Nursing (DON) and Certified Nursing Assistant (CNA) #1 and CNA #2, and LPN #1 present, revealed Resident #1 did not have a dressing on the Stage 3 pressure ulcer to the sacral area. An interview with the DON on 8/09/2017 at 12:30 PM, confirmed the facility failed to ensure a dressing was on Resident #1's Stage 3 ulcer to the sacrum. The DON said the CNA's are trained to notify the nurse when dressings are soiled or come off the wounds. The DON stated that there should be a care plan and the care plan followed. Review of the Face Sheet revealed the facility admitted Resident #1 on 02/7/2008, with [DIAGNOSES REDACTED]. A review of the current quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/12/2017, revealed Resident #1 did not complete the Brief Interview for Mental Status (BIMS) for cognitive status.

CI MS # Based on observation, interview, policy review and record review, the facility failed to provide adequate supervision to prevent one (1) of nine (9) residents reviewed for the potential of elopement, Resident #15, from exiting the building. Resident #15 exited the building (time between 6:50 p.m. and 7:14 p.m.) on 4/17/12 unsupervised and without staff knowledge. On 4/17/12, at 6:00 p.m., Resident #15 was sitting beside his bed in his room watching television (Room 108), which is located next to the window, as witnessed by Registered Nurse (RN) #2. On 4/17/12 at 6:50 p.m., RN #2 checked on him again before going to her lunch break. Resident #15 was next seen by RN #2 through the break room window at 7:14 p.m., 80 feet from the break room outside of the facility. Resident #15 was assisted back inside the facility by Licensed Practical Nurse (LPN) #1. Registered Nurse (RN) #2, Certified Nursing Assistant (CNA) #1, and CNA #2 returned Resident #15 to his room where the screen from the window in the resident's room was noticed to be inside propped up against the closet doors. The window was able to be raised fully without difficulty. The screws that would normally keep the window from being raised more than four (4) inches were noted to be missing from the window frame. The lack of implementation of safety measures to ensure that all windows were maintained at all times, and lack of visual monitoring of Resident #15 who exhibited exit seeking behavior, failed to prevent Resident #15 from exiting the building without staff supervision or knowledge. This was deemed an Immediate Jeopardy (IJ) on 4/19/12 at 2:30 p.m. The Administrator and the Director of Nursing (DON) were notified of the IJ on 4/19/12 at 2:30 p.m. The facility provided a credible Allegation of Compliance (AoC) on 4/20/12 at 2:20 p.m. Based on verification of the facility's implementation of corrective actions through observations, staff interviews and in-service reviews, the Immediate Jeopardy was removed and the scope and severity was lowered on 4/20/12 at 7:10 a.m. to a "D" level, which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor and evaluate interventions for effectiveness. Findings Include: Resident #15 Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/12 revealed a score of three (3) on a Brief Interview for Mental Status (BIMS). A score of 0-7 equals severe cognitive impairment. Observation and pacing of the suspected reported path by the facility of Resident #15, on 4/20/12 at 2:34 p.m. to 2:40 p.m., noted that Resident #15 had ambulated from the window in the resident's room, to the back of building where Resident #15 was seen from the break room window. The observation revealed the following: The window in Resident #15's room, Room 108, measured 62 inches by 49 inches and 30 inches from the window sill to the floor on the interior side. The exterior of window measured 38 inches from the window sill to the ground. There were 150 paces (footsteps) from the suspected exit of the window through a grassy lawn to 5 feet tall chain link fence, and onto to the concrete drive in the back of building where initially spotted. Then, an additional 75 steps across the concrete drive to the corner of the building by the dietary window. This was a total of 225 footsteps. The care plans for Resident #15 documented: 1) Immediate plan of care at risk for elopement dated 3/13/12 - related to history of exit seeking and Dementia. Interventions dated 3/17/12 stated "wander guard removed 3/17/12 with no exit seeking noted since admission." 2) Care plan reviewed and continued 4/2/12 - Resident is at risk for elopement related to wandering episodes and Dementia, (dated 3/21/2012). Intervention listed was "do not place wander guard on Resident as it causes him to be agitated." 3) Care plan reviewed and continued 4/2/12 - Resident noted during "rainy" "bad weather" becomes focused on keeping window in room open possibly related to history of being trapped in house in hurricane Katrina in New Orleans, LA. Review of a Psychiatric Evaluation, dated 2/24/12 from a Behavioral Unit prior to admission, revealed that Resident #15 was "running in the halls, saying that he needs to get outside. The staff saw him trying to get out of a window." Also, at home Resident #15 was taking the windows out of the home. "He has poor memory recall, delusions, and disorientation." Nurses Note, dated 3/13/12 at 10:55 a.m., revealed that wander guard bracelet with two bands was off of Resident #15's right (R) wrist and Resident #15 denies ever having a bracelet on his right (R) arm. Applied new wander guard bracelet but old bracelet not found. Nurses Note, dated 3/17/12 at 3:16 p.m., revealed that Resident #15's spouse informed staff that Resident #15 had removed wander guard from his right (R) wrist and that she stated that she remembered it was not in place the night before when she visited. Staff suspects that Resident #15 may have flushed wander guard down toilet. Nurses Note, dated 3/26/12 at 9:53 a.m., revealed Resident #15 had risen up window and stated that it was stuck but he fixed it. Maintenance was notified of window being up. Nurses Note, dated 3/26/12 at 7:21 p.m., revealed a transfer of Resident #15 to room 108 -A bed for safety reasons. Nurse Note, dated 4/1/12 at 10:05 a.m., revealed that Resident #15 had his window open about a foot in height. Window was closed and locked. Staff attempted to redirect Resident #15 using a jigsaw puzzle on his nightstand, but the resident refused. Nurse Note, dated 4/9/12 at 9:25 a.m., revealed that Resident #15 had changed beds with his roommate on their own. Resident #15 wanted to be by the window. Nurses Note, dated 4/16/12 at 3:08 p.m., revealed that Resident #15 had taken the screw out of the window so it would open all the way up. Nurses Note, dated 4/16/12 at 8:30 p.m., revealed that Resident #15 was sitting in chair by window. Resident #15 is known by staff to raise window up at different times during the evening. Window was put back down when rounds were made. Resident #15 was observed by staff to be trying to pull at the interface of window. Nurses Note, dated 4/17/12 at 11:41 p.m., revealed that at approximately 7:14 p.m. Registered Nurse (RN) #2 was in break room waiting to clock back in from lunch. When Resident #15 was observed walking by the dumpsters, staff and Executive Director were notified and the staff went out the back door to get Resident #15. Resident #15 stated he was going to work. Resident #15 was redirected inside to room. Upon entering room, Resident #15 went back through window and attempted to start cleaning the windows. Resident #15 was very adamant the windows needed to be cleaned on the inside and the outside. The Physician was notified and an order was obtained to consult a Geri-Psychiatric facility. The spouse was notified of incident and new order to transfer was obtained. Interview with Registered Nurse (RN) #1 on 4/19/12 at 3:05 p.m., revealed that she had noticed the window all the way up. Stated, "I figured he got the screws out ...I was going to report it or go back, but I forgot." "(Resident #15) has always been preoccupied with the window." Resident #15 was moved to new room because the staff were fearful of him climbing out the window and that the lawn area behind the new room was fenced in. RN #1 was not aware of Resident #15 ever trying to exit out of the doors. Interview with Licensed Practical Nurse (LPN) #1 on 4/19/12 at 3:15 p.m., revealed that she heard staff members stating that a resident was outside. Several employees went outside to retrieve Resident #15. LPN #1 talked to Resident #15 and was able to escort him back inside the building through the back door by laundry. LPN #1 stated, when we walked back to room, "the window was all the way down, it wasn't locked but it was closed and the screen was off." LPN #1 stated that she sat with Resident #15 in room for about thirty (30) minutes or so. LPN #1 left Resident #15's room when Certified Nursing Assistant (CNA) #2 came in to relieve her. Interview with CNA #1 on 4/19/12 at 3:45 p.m., revealed that she was in the break room with RN #2, CNA #2, and CNA #6 when RN #2 stood up and shouted out "Oh No that is (Resident #15)." CNA #1 and CNA #2 went out the back door and the other staff went to the front door. CNA #1 stated, "He was walking really fast toward the side of the building and just turned the corner by the dietary window." Resident #15 stated that he was going to work. CNA #1 also stated, "when I was in there he opened the window in front us ... and started to climb back out again. We told him he had to come back in and we got him to watch T.V. until his wife came." Interview with Business Office Manager, on 4/19/12 at 3:45 p.m., revealed that the Business Office Manager entered into Resident #15's room after he was returned and put a new screw into the side of the window. The Business Office Manager stated, "Frame was bent, but window was down though et (and) I put another screw into window." Interview with RN #2, on 4/19/12 at 3:55 p.m., revealed that RN #2 was in break room on 4/17/12 at 7:14 p.m. and noticed Resident #15 outside of the window. RN #2 stated that Resident #15 was obtained and returned to his room. Staff sat with Resident #15 and RN #2 went to call the physician and the spouse. RN #2 also revealed that the window was closed the entire shift leading up to the incident. RN #2 stated, "I last checked on him @ (at) 6:50 p (p.m.) before I went to lunch break." Interview with CNA #2, on 4/19/12 at 4:00 p.m., revealed that she was in the break room when RN #2 looked out the window and saw Resident #15 walking fast by the dumpsters. CNA #2 ran out the back door and stated some staff ran out the front door. CNA #2 stated, "When we got to him he turned the corner by dietary and was heading toward the front." Resident #15 said he was going to work. Resident #15 was convinced to come back inside the building and staff returned him to his room. As CNA #2 left the room she (CNA #2) was called back in and witness Resident #15 sitting outside of the window. After convincing Resident #15 to come back in he was redirected by sitting with him until spouse came. CNA #2 revealed that Resident #15 was previously in Room 131 when he first admitted to the facility then moved to room 108. CNA #2 stated that she asked the nursing staff, "Why are you moving him, and they told me because it would be better if he got out of the window if the yard is fenced in." CNA #2 replied that Resident #15 tried to get out of the window in the old room, but his behavior got worse with the room change. Interview with the Executive Director, on 4/19/12 at 5:00 p.m., revealed that on 4/17/12 at approximately 7:10 p.m. she went in to the break room and RN #2 noticed that Resident #15 was outside of the facility. The staff went to retrieve Resident #15 and the Executive Director stated that she went straight to Resident #15's room and checked the window. The Executive Director stated, "noticed the screen off the window propped in front of the closet doors and window was closed. I noticed that the stops were out and the window frame was bent." The Executive Director also stated that the reason for Resident #15's room transfer was to be closer to the nurses' station and to have a roommate for companionship. Interview with CNA #3, on 4/20/12 at 9:15 a.m., revealed that Resident #15 was in room 131 when first admitted and began raising the window every day. CNA #3 stated, "I told the nurse every time it was raised." CNA #3 revealed that the furniture was re-arranged a lot in his room. Also stated that the wander guard had been cut off. CNA #3 was never instructed on doing any extra one -on -one care or visual checks after the wander guards disappeared. Interview with Housekeeping Staff #2, on 4/20/12 at 9:30 a.m., revealed that Resident #15 had his window open in his room most days while she was in the room cleaning. Housekeeping Staff #2 stated, Resident #15's window was open on 4/17/12 in the morning time and Resident #15 was sitting in a chair looking out the window. Housekeeping Staff #2 also revealed that Resident #15 wasn't very talkative. Interview with CNA #5, on 4/20/12 at 9:55 a.m., revealed that Resident #15 had his window open on the morning of 4/17/12 right before lunch time. CNA #5, stated that when Resident #15 left room to go to dining room CNA #5 closed the window and turned on the air conditioning. CNA #5 revealed that the window stayed closed the rest of the shift and that she checked on Resident #15 every two (2) hours until the shift ended. Interview with Social Services (SS) #1, on 4/20/12 at 12:10 p.m., revealed that she had been informed that Resident #15 was being admitted and that he met all the criteria for admission to the facility. SS #1 stated that she was not informed of the potential for risk of elopement. SS #1 stated that his behavior was usually fine if he was kept busy. SS #1 also stated, "He raised the window up every day because he enjoyed the fresh air." SS #1 revealed that Resident #15 had destructive behavior while in room (131) by himself. SS #1 stated, "About one week after admission Resident had broken window and also tied a coat hanger to the bathroom door. " Interview with Director of Operations, on 4/20/12 at 2:10 p.m., revealed that two (2) days after the elopement he toured the grounds outside of the facility. The Director of Operations stated, when walking from Resident #15's window to the location that Resident #15 was spotted he discovered that both gates of the chain link fence were open and not secured even with a pad lock in place. Interview with LPN #1, on 4/20/12 at 2:20 p.m., revealed that Resident #15 was wearing jeans, a striped shirt, and a pair of black shoes. The clothes were clean and dry and no injuries visible. LPN #1 stated, "I did not look @ (at) the gates to fence but I know that they have been only 'dumby' locked so that the funeral home or ambulance could get back there." Interview with the Executive Director, on 4/20/12 at 2:45 p.m., demonstrated that the gate on the chain link fence will just push open even with the pad lock in place. The two (2) metal posts at the bottom of the double entry gate is not secured into the ground and enabling the gate to be opened. Facility Policy Review revealed a Memo, sent on 9/10/09, addressed to Directors of Operations with the subject: "Facility Window Assessment Project" that stated, "window openings must be limited to four (4) inches ....Facilities will need to conduct an assessment of every window in the facility including all non-resident area." Facility Policy Review on "Elopement Policy and Procedure Guide", revised 1/2011, revealed that the purpose of the policy is to identify residents at risk for elopement, minimize episode of elopement, protect residents that are not capable of protecting themselves, provide the techniques and equipment to minimize safety risks, and to educate the Staff. The policy also stated that, "Staff will: Observe that each resident's bracelet alarm/device is still in place each shift." In regards to 'Door alarms and resident protection alarms' the policy stated, "Only the Executive Director/or designee may authorize disabling the alarm system and is responsible for the method of monitoring for residents' safety and resetting the alarm." The policy also stated under 'Environmental Guidelines', "The living center will identify any external environmental hazards as well as entrances, stairwells or exits that pose a foreseeable danger to residents who wander or have an exit seeking behavior." The facility provided a credible Allegation of Compliance (AoC) on 4/20/12 at 2:20 p.m. "Credible Allegation of Compliance" "1. On 4/17/12, at 6:50 pm, Resident #15 was sitting in his room, bedside his bed, Bed B, in room 108, watching television as witnessed by Registered Nurse #2. Resident #15 was next seen on 4/17/12, at 7:14 pm, by Registered Nurse #2 through the break room window, 80 feet from the break room outside the Living Center. Resident #15 was immediately returned to the Living Center by Licensed Practical Nurse #3 at 7:15 pm. Resident #15 was assessed by Registered Nurse #2 with no injury noted at 7:15 pm. Resident #15 was placed on 1:1 monitoring continuously until he was discharged to Geri-Psychiatric Facility on 4/17/12 at 9:28 p.m. The one on one was conducted by Licensed Practical Nurse #3 from 7:15 pm to 7:35 pm, the Executive Director conducted the one on one observation from 7:35 pm to 8:45 pm; Registered Nurse #3 did the one on one observation from 8:45 pm to 9:28 pm when Resident #15 was discharged to the Geri-Psychiatric Facility. The physician was notified of Resident #15 exiting the building through the window in his room by Registered Nurse #2 at 7:20 pm and Resident #15's wife was notified of Resident #15 exiting the building through his window at 7:22 pm by Registered Nurse #2. New order was received on 4/17/12 at 7:20 pm from physician to consult Geri-Psychiatric services and send to outpatient Geri-Psychiatric services if appropriate. This order was received by Registered Nurse #2. Registered Nurse #2 called the Geri-Psychiatric facility at 7:30 pm. Resident #15 remains at in-patient Geri-Psychiatric facility at this time. The Executive Director called the Geri-Psychiatric facility at 7:50 pm on 4/19/12 regarding discharge plans for Resident #15. The Clinical Liaison returned her call at 8:55 pm to state that the Psychiatrist felt the Resident #15 needs to be in a locked unit and plans to discharge Resident #15 to a locked unit at local nursing center and that the wife is in agreement with this plan. 2. On 4/17/12 at 7:30 pm, the Business Office Employee #1 did a visual head count of all residents in the living center as she was checking the windows in each resident room. She confirmed the head count matched the facility census of 58. 3. On 4/17/12 at 7:30 pm, the Business Office Employee #1 completed an audit of all windows that residents have free access to including 1 window in the employee break room, 12 windows in resident rooms on A wing, 8 windows in resident rooms on B wing, 12 windows on C wing, and 2 windows in the living room to ensure no window would raise above 4 inches and all windows were secure. The only negative finding was the window in Resident #15's room (108B) which would open freely because the screws had been removed. The window was repaired by the Business Office Employee #1 at 8:55 pm on 4/17/12. 4. On 4/17/12 at 8:50 pm, the Executive Director checked all door alarms for proper functioning and all were found to be properly functioning. The door alarms are located on the exit doors located inside therapy, laundry, dietary and on the exit doors at the end of A, B, and C halls and on the front door for a total of 7 alarmed doors. 5. On 4/18/12 at 1 pm, Registered Nurse #5 initiated training to Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants on the elopement policy including responsibility, definition, purpose, documentation guidelines, assessment of risk, visual checks, door alarms, use of wander guards, and identification of risks present to residents with wandering behaviors. This training also included actions to take when a resident is missing including assessment, reporting and QAA monitoring. As of 4/19/12 at 8 pm Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Business Office employees, Medical Records employee, Restorative, Dietary staff, Social Service employee, Housekeeping employees, Maintenance Director, Laundry employees, Therapy employees, and Activity employee was not allowed to work until training was provided on the elopement policy. 6. On 4/18/12 at 3 pm, the Executive Director checked all door alarms for proper functioning and all were found to be properly functioning. The door alarms are located on the exit doors located inside therapy, laundry, dietary and on the exit doors at the end of A, B, and C halls and on the front door for a total of 7 alarmed doors. 7. On 4/18/12, at 4 pm, Registered Nurse #5 and the Director of Nursing checked all 9 residents assessed to be at risk for elopement to ensure wander guard bracelet in place and functioning properly. There were no negative findings in this audit. 8. On 4/18/12, at 5:18 pm, the Director of Nursing notified the Attorney General's office via the electronic reporting system that Resident #15 was found outside on facility grounds. The Director of Nursing notified the Department of Health via the complaint line that Resident #15 was found outside the facility on the facility grounds and that an investigation was being conducted. This call was placed at 5:40 pm on 4/18/12. 9. On 4/19/12, 57 of 57 Resident Medical Records were reviewed by Registered Nurse #4 to ensure elopement assessments were current and accurate. The facility's census on 4/19/12 was 57. This audit was completed by 5 pm 4/19/12 with no negative findings. 10. On 4/19/12 at 2 pm, Registered Nurse #5 checked all the windows in the facility to ensure they all were secured and would not open more than 4 inches. The windows checked in this audit were 10 windows in therapy, 1 window in the conference room, 1 window in the business office, 1 window in laundry, 1 in the Executive Director office, 1 in the employee break room, 1 in the Director of Nursing office, 1 in the Social Service office, 1 in medical records, 12 windows in resident rooms on A wing, 8 windows in resident rooms on B wing, 12 windows in resident rooms on C wing, 2 windows in the kitchen, and 2 in the living room for a total of 54 windows. During this check, Registered Nurse #5 determined that 4 windows in therapy, 1 window in the conference room, and 1 window in the laundry room would open freely. These windows were repaired by the Maintenance Director by 9 pm on 4/19/12. 11. On 4/19/12, at 1 pm, Registered Nurse #4 checked all of the 9 residents assessed to be at risk for elopement to ensure wander guard bracelet in place and functioning properly. There were no negative findings in this audit. 12. On 4/19/12 at 7 pm, the Director of Nursing Services initiated training to Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, and Business Office employees on Abuse and Neglect Prohibition/Reporting and Supervision to Prevent Accidents including Reporting Alleged Violations; Responsibility; Prevention; Policy, Definition, Identification of types of abuse and resident protection, means of mitigating the risk of an accident, obligation to provide adequate supervision to prevent accidents based on the residents needs and identified hazards in the resident environment, and may vary from resident to resident and from time to time, the same resident. As of 4/19/12 at 8 pm Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Business Office employees, Medical Records employee, Restorative, Dietary staff, Social Service employee, Housekeeping employees, Maintenance Director, Laundry employees, Therapy employees, and Activity employee was not allowed to work until training was provided on Abuse and Neglect Prohibition/Reporting and Supervision to Prevent Accidents to include Reporting Alleged Violations; Responsibility; Prevention; Policy, Definition, Identification of types of abuse and resident protection. (,) intervention and means of mitigating the risk of an accident, obligation to provide adequate supervision to prevent accidents based on the residents needs and identified hazards in the resident environment, and may vary from resident to resident and from time to time, the same resident. 13. On 4/19/12 at 4:30 pm, the Director of Operations trained the Executive Director and Maintenance Director that if a resident removes screws and opens window, additional security to the window tract must be installed. 14. On 4/19/12 at 7:30 pm, the Clinical Services Consultant Registered Nurse trained the Executive Director and Director of Nursing that if a resident assessed at risk for elopement will not wear wanderguard bracelet or continually removes wanderguard bracelet, that resident must remain on 1:1 supervision or discharged to a level of care appropriate for that resident. When resident is at risk for elopement, not utilizing technology to assist with supervision is not an option. 15. On 4/18/12 at 5 pm a special QA&A meeting was held with Medical Director, Registered Nurse #3, Registered Nurse #6, Director of Nursing, Executive Director, Licensed Practical Nurse #3, and Certified Nursing Assistant #1. The discussion at QAA included Resident #15's history since admission and the events of 4/17/12 when Resident #15 exited the building through the window in his room, 108B. The discussion included actions taken by the facility to protect Resident #15 and all other Residents and the reporting of the event to the appropriate regulatory agencies. The plan for the training of staff was also discussed. 16. An elopement drill was conducted on 4/19/12 at 5:35 pm with the 3-11 shift by the Director of Operations. A second elopement drill was conducted at 11:30 pm with the 11-7 shift on 4/1912 (4/19/12) by Registered Nurse #2. A third elopement drill was conducted 4/20/12 with the 7-3 shift at 7:10 am by the Executive Director." Verification of AOC: In summary, in- service records were reviewed with the Director of Nursing (DON) on 4/20/12 at 2:45 p.m. to ensure that all staff had been in-serviced on wandering/elopement protocols, missing residents, and Abuse/Neglect policies. The Elopement Policy and Procedure Guide was reviewed with Executive Director (ED) on 4/20/12 at 3:00 p.m. to ensure that all components were present in the policy to properly train and educate staff on elopement, and missing residents. Random interviews were conducted at varies times on 4/19/12 and 4/20/12 to verify that one-on-one monitoring continued with Resident #15 after the incident occurred leading up to the transfer out of the facility. Based on verification of the facility's corrective actions that was validated by staff interviews, observation and in-service form reviews, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 4/20/12 at 7:10 a.m. to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.