Every finding on record at Glen Oaks Nursing Center

Based on staff interview, record review, and facility policy review the facility failed to comply with state nursing facility staffing requirements by failing to designate a charge nurse responsible for supervision of the total nursing activities in the facility during the hours of 3:00 PM to 11:00 PM shift, separate from the medication/treatment nurse assignment for three (3) of (3) shifts reviewed for charge nurse supervision. Findings include:A review of the facility's policy titled, Staffing, revised April 2007, revealed, .Policy Interpretation and Implementation 1. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met.A record review of the Staff Reporting Form revealed there was not a designated charge nurse assigned for the 3:00 PM to 11:00 PM shift on 07/28/26, 07/29/26, or 07/30/26.A record review of the Minimum Standards for Institutions for the Aged or Infirm for Rule 45.4.1 Nursing Facility, revealed, .To be classified as a facility, the institution shall comply with the following staffing requirements.2. Each facility shall have the following licensed personnel as a minimum.D. A registered nurse or licensed practical nurse shall serve as a charge nurse and be responsible for supervision of the total nursing activities in the facility during the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shift. The nurse assigned to the unit for the 11:00 p.m. to 7:00 a.m. shift may serve as both the charge nurse and medication/treatment nurse.On 07/29/26 at 3:22 PM, during an interview, the Director of Nursing (DON) stated he served as the charge nurse from 7:00 AM until approximately 4:30 PM on some days. The DON explained that after 4:30 PM, the medication/treatment nurses also served as the charge nurses. The DON acknowledged the facility did not designate a separate charge nurse from the medication/treatment nurse role. The DON further acknowledged he was unaware the Minimum Standards for Institutions for the Aged or Infirm required a designated charge nurse separate from the medication/treatment nurse assignment for the 3:00 PM through 11:00 PM shift.On 07/29/26 at 3:30 PM, during an interview, the Administrator confirmed the medication/treatment nurses also served as the charge nurses during the 3:00 PM to 11:00 PM shift. The Administrator acknowledged the purpose of a separate charge nurse was to provide supervision of nursing services while allowing the medication/treatment nurse to focus on medication administration and treatments.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to develop and implement comprehensive person-centered care plans, as evidenced by failing to develop a comprehensive care plan for a resident with an active urinary tract infection (UTI) (Resident #27) and failing to implement an existing comprehensive care plan for oxygen therapy (Resident #28) for two (2) of (12) residents reviewed for comprehensive care planning. Findings include: A review of the facility's policy titled, Using the Care Plan revealed, The care plan shall be used in developing the residents daily care routines and will be available to staff personnel who have the responsibility for providing care to the resident. Resident #27 A record review of the admission Record revealed the facility initially admitted Resident #27 on 10/21/2015 and she was readmitted on [DATE]. She had diagnoses including Type 2 Diabetes Mellitus and UTI. A record review of the Patient Visit Information revealed Resident #27 was evaluated at a local hospital on [DATE] and received patient instructions for Female Urinary Tract Infection with a prescription for Cephalexin 500 milligrams (mg) four (4) times daily. A record review of the Order Summary Report revealed Resident #27 had a Physician's Order, dated 7/23/26, for Cephalexin 500 mg four times daily for ten (10) days. A review of the comprehensive care plan for Resident #27 revealed there was no designated care plan with interventions related to the new diagnoses of UTI. On 07/29/2026 at 2:35 PM, in an interview with Registered Nurse (RN) #1, she explained that the floor nurses are responsible for inputting care plans for new physician orders. She reported Medical Records reviews the physician orders daily and makes sure the physician orders are added as an intervention, but it was ultimately her responsibility to make sure care plans are developed. RN #1 confirmed that Resident #27 returned from the hospital on 7/22/26 and had orders for antibiotics and a diagnosis of UTI. She also confirmed there was no care plan developed with a problem or focus of UTI. She explained that she expected a comprehensive care plan to be developed for a new diagnosis, which would include a focus, goal, and interventions. On 07/29/2026 at 3:10 PM, in an interview with the Director of Nursing (DON), he stated he expected a care plan to be developed for residents with new diagnoses to include interventions for staff to follow to take care of residents. Resident #28 A record review of the Care Plan Report for Resident #28 revealed interventions included Oxygen at 3 L (liters) per NC (nasal cannula) to maintain O2 (oxygen) > (greater than) 92%. Obtain O2 sat every shift with a start date of 2/25/2026. On 07/28/26 at 3:39 PM, during an observation, Resident #28 was receiving oxygen via nasal cannula at (2) liters per minute. On 07/29/26 at 2:50 PM, during an observation, Resident #28 continued to receive oxygen via nasal cannula at two (2) liters per minute. On 07/29/26 at 2:54 PM, during an interview, Licensed Practical Nurse (LPN) #1 confirmed Resident #28 was receiving oxygen at (2) liters per minute. LPN #1 reviewed the physician order and confirmed the prescribed oxygen flow rate was three (3) liters per minute. LPN #1 acknowledged there was no physician order authorizing the lower oxygen flow rate and could not explain the discrepancy. On 07/29/26 at 2:55 PM, during an interview, Registered Nurse (RN) #1 confirmed the purpose of the comprehensive care plan was to guide staff in providing resident care. RN #1 confirmed staff were expected to implement the interventions contained in the comprehensive care plan. On 07/30/26 at 1:01 PM, during an interview, the Administrator confirmed staff were expected to verify oxygen flow rates, follow physician orders, notify the physician of discrepancies, monitor residents receiving oxygen therapy, and implement the resident's comprehensive care plan. A record review of the admission Record revealed the facility admitted Resident #28 on 02/25/26 with diagnoses including Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. A record review of the Order Summary Report for Resident #28 revealed orders for oxygen at (3) liters per minute via nasal cannula, dated 3/9/26. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/2/2026 for Resident #28 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating thre resident was cognitively intact.

Based on interview, record review, and facility policy review, the facility failed to provide the resident representative with written notice containing the required transfer information when the resident was transferred to the hospital with return anticipated for one (1) of two (2) residents reviewed for hospitalization. (Resident #38).Findings include:A review of the facility's policy, Transfer or Discharge Notice revised November 2023, revealed, .Policy Interpretation and Implementation.5. The resident and representative will be notified in writing of the following information. a. The specific reason for the transfer or discharge. f. The effective date of the transfer. g. The location to which the resident is being transferred or discharged .A record review of the facility's admission Record revealed the facility admitted Resident #38 on 06/15/2026 with diagnoses including Respiratory Failure, Unspecified with Hypoxia.A record review of the Discharge Return Anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/14/26 revealed Resident #38 was discharged to a short-term general hospital with return anticipated.A record review of the admission MDS with an ARD of 06/22/2026 revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.A record review of the Order Details revealed a physician order dated 07/14/26 for D/C (discharge) to (proper name of local hospital).A record review of Resident #38's medical record failed to identify documentation that the resident representative received the required written transfer notice containing the reason for the transfer, the effective date of the transfer, and the location to which the resident was transferred on 7/14/26.On 07/29/26 at 2:11 PM, during an interview, the Business Office Manager (BOM) acknowledged she did not provide the resident representative with a written transfer notice when Resident #38 was transferred to the hospital on [DATE]. The BOM explained she believed the resident was being discharged rather than transferred with return anticipated. The BOM stated she would verify a resident's discharge status before issuing future transfer notifications.On 07/29/26 at 2:16 PM, during an interview, the Administrator acknowledged the resident representative did not receive a written transfer notice for Resident #38's hospitalization on 07/14/26. The Administrator confirmed the facility expected written transfer notifications to be provided to the resident representative each time a resident was transferred to the hospital.

Based on observation, interview, record review, and facility policy review, the facility failed to provide care and services in accordance with physician orders by administering oxygen at a flow rate different from the physician-ordered oxygen therapy for one (1) of (1) resident reviewed for oxygen therapy. (Resident #28). Findings include:A review of the facility's policy titled, Oxygen Administration revised October 2010, revealed .The purpose of this procedure is to provide guidelines for safe oxygen administration.review physician orders.for oxygen administration.A review of the facility's policy titled, Conformity with laws and Professional Standards revised April 2007, revealed Our facility operates and provides services in compliance with. professional standards of practice that apply to our facility and types of services provided.During an observation on 07/28/26 at 3:39 PM, Resident #28 was receiving oxygen via nasal cannula at two (2) liters per minute.During an observation, on 07/29/26 at 2:50 PM, Resident #28 continued to receive oxygen via nasal cannula at (2) liters per minute.During an interview on 07/29/26 at 2:54 PM, Licensed Practical Nurse (LPN) #1 confirmed Resident #28 was receiving oxygen at (2) liters per minute. LPN #1 reviewed the physician order and confirmed the prescribed oxygen flow rate was three (3) liters per minute. LPN #1 acknowledged there was no physician order authorizing the lower oxygen flow rate and could not explain the discrepancy.During an interview on 07/30/26 at 1:01 PM, the Administrator confirmed staff were expected to verify oxygen flow rates, follow physician orders, notify the physician of discrepancies, and monitor residents receiving oxygen therapy.A record review of Resident #28's Medication Administration Record (MAR) for July 2026 revealed staff documented oxygen was administered at three (3) liters per minute on 07/28/26 and 07/29/26, the same dates Resident #28 was observed receiving oxygen at (2) liters per minute.A record review of the admission Record revealed the facility admitted Resident #28 on 02/25/26 with diagnoses including Congestive Heart Failure and Chronic Obstructive Pulmonary Disease.A record review of the Order Summary Report for Resident #28 revealed a physician order dated 03/09/26 for oxygen at three (3) liters per minute via nasal cannula.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/2/2026 for Resident #28 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

48181 Based on observation, staff interviews and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated with a use-by-date, food items without an identifying label, and food items opened and exposed for one (1) of three (3) kitchen observations. Findings Include: A review of the facility's Food Storage Labeling Policy, revised ,d+[DATE], revealed, .The facility will ensure the safety and quality of food by following food storage and labeling procedures . 1. All food items that are not in their original containers must be labeled: 4. a. Common name b. Date of preparation or Use By Date c. Example: Food prepared on ,d+[DATE] must be used or discarded by ,d+[DATE] . On [DATE] at 9:41 AM, an observation of the kitchen and interview with the Dietary Manager (DM) revealed the contents of the refrigerator to include, (1) opened plastic container of chicken-flavored base with the facility's received by date of [DATE]. There was no date indicating when the container was opened and there was no facility use by, or manufacturer's expiration date noted on the container. There were two (2) reusable squeeze bottles of ranch dressing and one (1) reusable squeeze bottle of French dressing that was dated by the facility on [DATE]. There was no label indicating when the food items were prepared or when they should be discarded. The DM stated she did not know what the date of [DATE] indicated for those items. There was one (1) plastic food storage bag containing two (2) peeled, pre-boiled eggs, with the facility's received by date of [DATE]. There was no open by date and no use by date to indicate when the eggs should be discarded. There were four (4) unopened plastic bags of liquid scrambled eggs that were not in their original container and were not labeled with the common name, date of preparation or a use by date. The DM revealed that whoever received the food and stocked the items was responsible for dating each item with the facility's received date. She reported that the Cook was responsible for labeling foods with an open date when the foods are opened. The DM explained that all staff are responsible for discarding food items that have reached the expiration or use by date and should be discarded within ,d+[DATE] days after opening. She reported the facility completed staff in-services on food safety every ,d+[DATE] weeks and acknowledged that her expectation was that staff would label all food items and immediately dispose of any expired foods. On [DATE], at 11:15 AM, an interview with Cook #1 confirmed that the Cook that opened a food item was responsible for putting an opened date on it item and kitchen staff should dispose of it within three (3) days. The Cook stated the ranch dressing was prepared from a packet and mixed with buttermilk and should have been dated and discarded within three (3) days. She confirmed that kitchen staff received in-service training three (3) times per month on various topics. On [DATE], at 8:06 AM, an interview with the Administrator revealed that she expected the residents to receive food from the kitchen that was safe for the residents to consume.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the resident's right to make choices that are significant to the residents, as evidenced by not accommodating residents with their smoking choices/preferences of more than one (1) cigarette per break or more than two (2) smoke breaks per day for three (3) of three (3) sampled residents that smoke. Resident #15, Resident #21, and Resident #29 Findings include: A review of the facility's policy Resident Rights, undated, revealed . Policy Interpretation and Implementation . 2. Residents are entitled to exercise their rights to the fullest extent possible . A review of the facility's document Consent and Release for Smoking/Vaping, undated, revealed . We acknowledge and respect an individual's right to smoke/vape. A review of the facility's policy Smoking/Vaping Policy, undated, revealed . It is the intent of the facility . to allow those residents, who wish to smoke/vape the opportunity to do so . A record review of the facility's document Smoker Worksheet revealed there were five (5) residents who currently smoke in the facility and the smoking times were listed as 11:00 AM and 7:00 PM. During a Resident Council meeting on 11/07/23 at 10:05 AM, Resident #21 and #29 reported that the residents who smoke had met with the Administrator approximately one (1) month ago and had asked to have more than one (1) cigarette at smoke breaks because the facility allowed only two (2) smoke breaks daily. The residents expressed to the Administrator they wanted to have two cigarettes during the breaks because they had smoked for years and preferred more than one (1) or two (2) cigarettes daily. The Administrator had not responded to their request. Resident #21 stated that he saw facility staff going out to smoke several times a day. He commented if they can go out and smoke several times a day, why can't we? Resident #21 explained that he had smoked for years, and he specifically chose the facility because they allowed the residents to smoke. Resident #29 explained that she did not like nicotine gum or patches because she wanted to smoke cigarettes. She stated that she was told on admission that she could smoke, but it was not explained to her that the facility did not allow more than one cigarette per smoke break. Resident #29 also stated that the facility staff went out to smoke several times daily. On 11/07/23 at 11:00 AM, during an observation of a smoke break and interview with Certified Nursing Assistant (CNA) #1, she assisted Resident #15, Resident #21, and Resident #23 to the designated smoking area. CNA #1 explained that the staff are not allowed to smoke with the residents. She confirmed that the residents are allowed to smoke one (1) cigarette during the smoke breaks. She stated that the residents have complained about getting only one cigarette at each break and had spoken to the Administrator about it. CNA #1 explained that the scheduled breaks are at 11:00 AM and 7:00 PM, but before the COVID-19 pandemic, the residents had four (4) designated smoke breaks daily. CNA #1 commented that she was a smoker and would hate to be allowed only two cigarettes a day. On 11/07/23 at 11:30 AM, during an interview with Resident #15, she confirmed that she and the other residents who smoked had asked the Administrator for more than one cigarette per smoke break because it was important to them. Resident #15 stated that the Administrator never responded to their request. On 11/07/23 at 02:00 PM, during an interview with CNA #3, she explained she assisted with smoke breaks for the residents. She confirmed that the residents are allowed to smoke one cigarette per smoke break, which was at 11:00 AM and 7:00 PM. She said that she and the staff who smoked take smoke breaks whenever they can, which was usually more than two times a day. On 11/07/23 at 03:45 PM, during an interview with the Administrator, she confirmed the residents who smoke came to her and requested more cigarettes during smoke breaks and she explained to them it would be discussed. At a Quality Assurance Performance Improvement (QAPI) meeting on 10/18/23, the request was presented to the Medical Director, and it was determined that the facility would not allow residents to smoke more than one cigarette per smoke break and smoking would be against medical advice. She explained the facility had always allowed one (1) cigarette at each smoke break because it took 30 minutes to smoke one (1) cigarette and the facility did not have enough staff to allow more than two smoke breaks daily. She confirmed that she had not responded to their request since the decision was determined at the 10/18/23 meeting because she had been too busy. The Administrator also confirmed that she did not consider their concern a grievance, but more of a request, and she did not add the concern to the facility's Grievance Log At 08:55 AM on 11/08/23, during an interview with the Administrator, she confirmed that she completed the admission paperwork with the resident or the Resident Representative (RR). The admission paperwork included smoking/vaping consents, contracts, and the facility policy, but did not include or acknowledge the number of cigarettes allowed by the facility per smoke break or the number of smoke breaks allowed by the facility. The form included that smoking was against medical advice. Resident #15 A record review of the Face Sheet revealed the facility admitted Resident #15 on 10/21/15 and she had a diagnosis of Nicotine Dependence, Cigarettes. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/08/23 revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. A record review of the facility's Smoking Policy and Consent and Release for Smoking dated 05/05/21 revealed Resident #15 signed the forms which did not indicate or include information regarding the number of cigarettes allowed by the facility per smoke break or the number of smoke breaks allowed by the facility. Resident #21 Record review of the Face Sheet revealed the facility admitted Resident #21 on 07/06/23 with a diagnosis of Hemiplegia Following Cerebral Infarction. Record review of the Admission MDS, with an ARD of 07/13/23, revealed Resident #21 had a BIMS score 15, which indicated he was cognitively intact. A record review of the facility's Smoking/Vaping Policy and the Smoking/Vaping Contract, dated 07/05/23, revealed Resident #21 signed the forms which did not indicate or include information regarding the number of cigarettes allowed by the facility per smoke break or the number of smoke breaks allowed by the facility. Resident #29 A record review of the Face Sheet revealed the facility admitted Resident #29 on 01/27/21 with a diagnosis of Type 2 Diabetes Mellitus. A record review of the Annual MDS, with an ARD of 12/26/22, revealed Resident #29 had a BIMS score of 15, which indicated she was cognitively intact. A record review of the facility's Smoking Policy, Consent and Release for Smoking, and Smoking Contract, dated 05/05/21 revealed Resident #29 signed the forms which did not indicate or include information regarding the number of cigarettes allowed by the facility per smoke break or the number of smoke breaks allowed by the facility. 47873

Based on observation, staff, resident, family interview, record review, and facility policy review, the facility failed to ensure Resident #5 and Resident #6 were provided opportunity to participate in activities to meet their needs for two (2) of four (4) dependent residents reviewed for activities. Findings Include: Resident #5 A review of the facilities Activity Policy, titled Activity Assessment, revealed in order to promote the physical, mental and psychosocial well-being of residents, an activity assessment is conducted and maintained for each resident. Within seven (7) days of a resident's admission to the facility an activity assessment will be conducted to help develop an activity plan that reflects the choices and interest of the residents. A review of the facilities Individual Activity Record revealed Resident #5's interest/approaches: Music, spiritual/religious .talks, book reading, television, drag racing and mother visits. Resident #5 up in Geri chair only during bath days. Observation on 04/10/18 at 10:30 AM, revealed Resident #5 was laying in bed with the head of his bed elevated 45 degrees. The resident was non verbal. The tube feeding of [MEDICATION NAME] was infusing at 50 milliliters per hour. The window blinds were closed and the television (TV) was off. Church services were being held in front activity room. Observation on 4/10/18 at 10:55 AM, revealed staff got Resident #5 up and gave him a shower. Resident #5 was returned back to the room and placed in bed. The window blinds were closed and the TV off. During an Interview on 4/10/18 on 11:00 AM, Resident #5's mother revealed the staff said they don't get resident #5 up for church most of the time. Resident #5's mother said she had asked staff on several occasions to get The resident up for church services. Resident #5's mother stated that it was mentioned at the care plan meeting and she has talked to the Administrator and Director of Nursing about getting the resident up for church services. Observation on 4/10/18 at 12:02 PM, 2:07 PM, 3:00 PM, and 4:06 PM, and observation on 4/11/18 at 8:37 AM, 9:15 AM, 10:20 AM, 11:32 AM, 12:44 PM, 1:48 PM, 2:18 PM, and 3:56 PM, revealed Resident #5 continued to lay in his bed with blinds closed and TV off. Observation in the Chapel on 4/10/18 at 10:00 AM, revealed church services had begun. During an interview on 04/13/18 at 10:50 AM, CNA #1 revealed Resident #5's care plan was to get up for activities three (3) times a week on bath days and Sundays. CNA #1 also stated Resident #5 enjoys care racing, looking out the window and church services. CNA #1 said Resident #5's mother comes daily and has asks that the window blinds are opened and the TV on and tuned to the gospel channel. During an interview on 4/13/18 at 10:50 AM, CNA #2 revealed Resident #5 was care planned to get up on bath days and Sunday for church because of a request from his mother. CNA #2 stated the resident enjoys car racing, watching television, church music and looking out of the window. CNA #2 confirmed she was assigned to Resident #5 all week and failed to get Resident #5 up because there wasn't a Geri chair available. During an interview on 4/13/18 at 11:30 PM, the Activity Director revealed Resident #5 enjoyed drag racing, country music, sports, sing a longs and church music. The Activity Director confirmed Resident #5 was care planned to get up on shower days and Sundays for church. The Activity Director confirmed staff failed to bring Resident #5 to activities. During an interview on 04/13/18 at 12:00 PM, the Director of Nursing confirmed the staff failed to get Resident #5 up on shower days and take him to Activities. The Director also stated that resident #5' mother had requested the TV stay, the blinds open during the day, and to get Resident #5 up on shower days and Sundays for church. Resident #6 Observation on 4/10/18 at 10:35 AM-11:10 AM, revealed Resident #6 laying in bed with the head of his bed elevated 45 degrees, watching TV. The feeding pump infused at 50 cc/hr and the blinds were closed. Resident #6 was able to make his needs known, say yes and no, but his speech was slurred. Church services were conducted in the front activity room at this time. During an Interview on 4/10/18 at 11:20 AM, Resident #6 stated that he wants to get up and sit outside, but staff would not get him up. Observation on 4/10/18 at 12:19 PM, revealed Resident #6 continued to lay in bed watching TV with the blinds closed. During an Interview on 4/10/18 at 1:24 PM, Resident #6's Aunt stated that she had asked the facility staff to get Resident #6 in the Geri chair. The Aunt stated that the resident enjoyed socializing with people and going outside, but had not seen the resident up since he'd been in the facility. Observation on 4/10/18 at 2:16 PM, 3:19 PM, and 4:20 PM, revealed Resident #6 continued to lay in bed watching TV with the blinds closed. Observation 4/11/18 on at 8:52 AM, revealed Resident #6 was laying in bed watching TV with the blinds closed. On 04/11/18 at 9:53 AM, an Interview with Resident #6's daughter revealed she had talked to the staff about getting the resident up in a Geri chair because he likes to be around people and he enjoys being outside. Observation on 4/11/18 at 10:04 AM, revealed Resident #6 was in bed watching TV with the blinds closed. Church services were being held in the Chapel. Observation on 4/11/18 at 11:07 AM, revealed Resident #6 continued to lay in bed watching TV with blinds closed. A CNA was in the room giving Resident #6 a bed bath. On 04/11/18 at 12:09 PM, 1:18 PM, 2:19 PM, 3:04 PM, 3:24 PM, and 4:27 PM, observation revealed Resident #6 continued to lay in bed watching television with the blinds closed. Interview Resident # 6 states that he want to get up and go outside. staff has not ask him to get up. Observation on 4/12/18 at 8:28 AM, 9:24 AM, 10:25 AM, 11:35 AM, 12:36 PM, 1:37 PM, 2:38 PM, and 3:39 PM, revealed Resident #6 continued to lay in bed watching TV with the blinds closed. During an Interview on 4/13/18 at 10:03 AM, CNA #1 confirmed Resident #6 should get him on bath days, stated the resident won't get up. CNA #1 confirm that she don't always ask the resident every day if he wants to get up. During an Interview on 4/13/18 at 10:50 AM, CNA #2 confirmed she did not ask Resident #6 if he wanted to get up on his bath days because he refused a lot and she was tired of fighting with him. CNA #2 states that she does not have anywhere to document resident refusals. CNA #2 state she reported the refusal to License Practical Nurse (LPN) #1. During an Interview on 4/13/18 at 11:00 AM, LPN #1 confirmed the staff does not ask Resident #6 if he would like to get up every day. LPN #1 said It is understood that Resident #6 doesn't want to get up. During an Interview on 4/13/18 at 11:30 AM, the Activity Director revealed Resident #6 had been care planned to get up on bath days for activities. The Activity Director also stated Resident #6 enjoyed going outside, church activities, and reading the news paper. The Activity Director confirmed when the staff did not get the resident up, then they didn't give Resident #6 the option to participate in activities daily. During an Interview on 4/13/18 at 12:00 PM, the Director Of Nursing (DON) confirmed Resident #6 should be given the option to get up for activities on bath days. The DON stated Resident #6 should be asked every day.

Based on observation, staff, resident, and family interview, record review, and facility policy review, the facility failed to implement the care plan related to activities for two (2) of four (4) resident care plans reviewed for activities. (Resident #5, #6) Findings include: A review of the facilities care plan policy statement, dated (MONTH) 2014, revealed our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. Each resident shall be allowed to choose activities, schedules and health care that are consistent with his interests, assessments and plans of care. The resident shall be encouraged to make choices about aspects of his or her life in the facility. Residents shall be provided assistance as needed to engage in their preferred activities on a routine basis. Resident #5 A review of Resident #5's Comprehensive Care Plan, dated 6/2/2016, revealed: Assist resident to religious activities when able per conservator goal: resident will be provided opportunity for experiencing sensory stimulation with staff assistance. Interventions: Assist resident to religious activities/church. One on one is provided weekly thru music, read books, and resident maybe up in Geri-chair as needed for activities. On 4/10/18 at 10:30 AM, observation revealed Resident #5 laying in bed with the head of the bed elevated 45 degrees. Resident #5 was non-verbal with the tube feeding [MEDICATION NAME] flowing at 50 milliliters per hour (ml/hr) continuous. The window blinds were closed and television off. Church services were being held in the front activity room by the Hospice Chaplin. Observation on 4/10/18 at 10:55 AM, revealed staff got Resident #5 up and gave him a shower. Resident #5 was returned back to the room and place in bed. The blinds continued closed and the television off. On 4/10/18 at 11:00 AM, interview with Resident #5's mother revealed the staff refused to get Resident #5 up for church. Resident #5's mother said she has ask them on several occasions to get the resident up for church services. Resident #5's mother also stated that it was mentioned at the care plan meeting and she had talked to the Administrator and Director of Nursing (DON). On 4/10/18 at 12:02 PM, 2:07 PM, 3:00 PM and 4:06 PM, Resident #5 continued to lay in bed with the blinds closed and television off. Observation on 4/11/18 at 8:37 AM, 9:15 AM, 10:20 AM, 11:32 AM, 12:44 PM, 1:48 PM, 2:18 PM, 2:53 PM, 3:56 PM revealed Resident #5 laying in bed on his back with the head of bed elevated at 45 degrees. The television was off and the blinds closed. Observation on 4/11/18 at 10:20 AM, revealed the Treatment Nurse changed Resident #5's feeding tube bandage with no concerns noted. Church service in the Chapel started at 10:00 AM. During an interview, on 4/13/18 at 10:50 AM, CNA #1 revealed that Resident #5 was care planned to get up for activities three (3) times a week on bath days and Sundays. During an interview on 4/13/18 at 10:50 AM, CNA #2 revealed that Resident #5 is care planned to get up on bath days and Sunday for church because of his mother's request. During an interview on 4/13/18 at 11:30 AM, the Activity Director (AD) revealed Resident #5 enjoyed drag racing, country music, sports, sing a longs, and church music. The Activity Director confirmed Resident #5 is care planned to get up on shower days and Sundays for church. The Activity Director also stated that staff failed to follow the care plan by not bringing Resident #5 to the Church Activities. On 4/13/18 at 12:00 PM, the Director of Nursing confirmed the staff failed to follow the care plan by not getting Resident #5 up on shower days and taking him to Activities. The Director also stated that Resident #5's mother had requested the television stay on, to keep the blinds open during the day, and to get Resident #5 up on shower days and Sundays for church. Resident #6 A review of Resident #6's Comprehensive Care Plan, dated 6/8/2016, revealed problem onset: Resident is alert and at risk for decline in social interaction or usual life leisure activity routines related to health and functional status: resident chooses his own bedtime: Resident also likes going outdoors as weather permits and participates in religious activities. Goal: will be engaged in group or individual social and leisure activity 1/3 of the time. Resident will receive one-on-one activity 2 x weekly. Resident's preferences will be honored. Interventions: Provide resident with one-on-one in room [ROOM NUMBER] times weekly by reading and talking to him. TV in room. Continue to invite Resident to group activities. Assist outside at resident requests and as weather permits. Observation on 4/10/18 at 10:35 AM, revealed Resident #6 laying in bed with the head of the bed elevated 45 degrees, watching television, with the feeding pump flow at 50 cc/hr. Blinds were closed. Resident #6's speech was slurred, able to make simple needs known, and able to say yes and no. Church services were in progress in the front activity room. Observation on 4/10/18 at 11:18 AM, revealed Resident #6 continued to lay in bed watching television with the blinds closed. On 4/10/18 at 11:20 AM, Interview with Resident #6 revealed he wanted to get up and sit outside. Resident #6 stated the staff won't get him up. Observation on 4/10/18 at 12:19 PM, 2:16 PM, 3:19 PM, and 4:20 PM, revealed Resident #6 continued to lay in bed watching television with blinds closed. Interview on 4/10/18 at 1:24 PM, with Resident #6's Aunt, revealed she asked the facility to get him up in the Geri chair. The Aunt stated the resident enjoyed socializing with people and going outside. The Aunt said she had not seen Resident #6 up since he's been in the facility. Observation on 04/11/18 at 8:52 AM, revealed Resident #6 continued to lay in bed watching television with blinds closed. Interview with Resident #6's daughter on 4/1/18 at 9:53 AM, revealed she had talked to the staff about getting the resident up in a Geri chair because he liked to be around people and he enjoyed being outside. On 4/11/18 at 10:04 AM, observation of Resident #6 revealed he was laying in bed watching television with blinds closed. Church services were being held in the Chapel. Observation on 4/11/18 at 11:07 AM, revealed Resident #6 continued to lay in bed watching television with the blinds closed. A Certified Nursing Assistance (CNA) was in the room giving Resident #6 a bed bath. On 4/11/18 at 12:09 PM, observation revealed Resident #6 continued to lay in bed watching television with the blinds closed. Interview with Resident #6 revealed that he wanted to get up and go outside, but staff has not asked him to get up. Observation on 4/11/18 at 1:14 PM, 2:19 PM, 3:04 PM, 3:24 PM, and 4:27 PM, revealed Resident #6 continued to lay in bed watching television with the blinds closed. Observation on 04/12/18 at 8:28 AM, 9:24 AM, 10:25 AM, 11:35 AM, 12:36 PM, 1:37 PM, 2:38 PM, and 3:39 PM, revealed Resident #6 was laying in bed watching television with the blinds closed. Interview on 4/13/18 at 10:03 AM, with Certified Nursing Assistant (CNA) #1, confirmed Resident #6's care plan documented to get him up on bath days, but stated that the resident won't get up. CNA #1 confirm that she don't ask the resident everyday if he wants to get up. Interview on 4/13/18 at 10:50 AM, with CNA #2, confirmed Resident #6 is not asked if he wants to get up on his bath days, because he refuses a lot. CNA #2 stated that she does not have anywhere to document the resident's refusals. CNA #2 stated that she reported the refusal to License Practical Nurse (LPN) #1. CNA #2 stated that she doesn't ask the resident everyday if he wants to get up because she's tired of fighting with him. Interview with Activity Director on 4/13/18 at 11:30 AM, revealed Resident #6 was care planned to get up on bath days for activities. The Activity Director also stated Resident #6 enjoyed going outside, church activities, and reading the news paper. The Activity Director confirmed the staff did not follow the care plan by not giving Resident #6 the option to participate in activities daily. Interview with the Director Of Nursing (DON) on 4/13/18 at 12:00 PM, confirmed Resident #6 should be given the option to get up for activities on bath days. The DON stated Resident #6 should be asked every day. The DON also said the staff did not follow the care plan by not asking Resident #6 if he would like to get up for activities on bath days.

Based on facility record review, facility policy review and facility staff interview, the facility failed to identify necessary measures to ensure corrective actions were developed to remove the immediate jeopardy to residents as evidenced by the facility failed to ensure the meeting held on 09/14/17 to investigate the fall involving Resident #8 included a physician for one (1) of seven (7) Quality Assurance (QA) meetings reviewed. Review of the QA meeting sign in sheet and staff interview revealed the facility held a meeting on 09/14/17 to investigate the incident in which facility CNAs dropped Resident #8 from a mechanical lift onto the floor. The resident subsequently sustained [REDACTED]. The sign in sheets of those in attendance revealed there was no physician present. The facility's failure to hold a QA meeting with all members present to discuss the incident on 09/13/17 when the facility staff failed to transfer Resident #8 safely from the geri-chair to her bed by failing to use the appropriate sling and technique placed other residents in a situation that was likely to cause serious harm, injury, impairment, or death. The SA determined the facility was not in compliance with the requirements for participation in Medicare and Medicaid. The State Agency (SA) substantiated MS Complaint # with Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) identified on 09/20/17 and was determined to exist on 09/13/17. On 09/20/17 at 4:30 PM the SA notified the facility's Administrator of the IJ and SQC existed at 42 CFR 483.75 (g) (1) (ii) F520 - Administration. The facility submitted an acceptable Allegation of Compliance (A(NAME)) on 09/21/17, in which the facility alleged removal of the IJ on 09/22/17. The State Agency validated the facility's A(NAME) on 09/22/17, and determined the IJ was removed as of 09/22/17, prior to exit. Based on the facility's corrective actions, initiated 09/13/17 and completed on 09/22/17, the SA determined the IJ and SQC to be removed as of 09/22/17 at 42 CFR 483.75 (g) (1) (ii) F520 - Administration, and the scope and severity was lowered to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility document Accidents/Incidents - Medical Director Review of, no date, revealed as part of the Quality Assurance (QA) process the medical director will work with the Director of Nurses (DON), Administrator, and other departments to evaluate trends, patterns, and interventions. QA documentation will include the Medical Director's input on these issues. The Medical Director will inform physicians about their responsibilities regarding risk assessment and management of residents who have accidents with or without injuries. Review of the facility document, dated 09/14/17, titled Quality Assessment and Improvement Committee Summary revealed the committee member's signatures did not contain a physician's signature. The facility noted this was a special called meeting. According to the facility, this meeting was related to the fall of Resident #8. A statement below signature area read the Quality Assessment and Improvement committee identified issues with respect to which quality assessment and assurance activities were necessary and developed and implemented appropriate plans of action to correct identified quality deficiencies. Review of a facility memo to the files of the incident from the administrator revealed the statement that a special called meeting of the QA committee was held as per attached sign in sheet to discuss further investigation and correction of the incident. The medical director was unable to attend on short notice but was made aware of the situation per memo with copy attached. Review of the memo from the administrator to the medical director with a date of 09/14/17 revealed we are currently conducting an investigation of the matter. Interview with the Administrator of the facility, on 09/20/17 at 3:30 PM, revealed the Administrator confirmed that neither the Medical Director nor any physician was present at the QA Committee meeting on 09/14/17 either in person or by teleconference. She stated that she was unaware that a physician had to be present this type of QA meeting. On 09/20/17 at 2:15 the State Agency (SA) attempted to contact the Medical Director and was unsuccessful. On 09/28/17 at 8:45 AM, the SA requested again that the Medical Director contacted the SA. On 09/22/17 at 11:30 AM, the SA exited the facility without being able to speak with the Medical Director. The facility provided an acceptable Allegation of Compliance (A(NAME)) on 09/21/17 for the Immediate Jeopardy (IJ). Review of the facility's A(NAME) revealed the facility took the following actions to remove the Immediate Jeopardy. 1. 09/13/17 6:04 PM - Resident #1(IJ Resident #8) involved in an incident/accident, she fell out of a Vander Lift sling during a transport form Geri-chair to the bed. resident sustained [REDACTED]. 2. 09/13/17 6:05 PM - RN #1 administered first aid to the resident 3. 09/13/17 6:05 PM - RN #2 phoned ambulance service and reported the emergency and requested ambulance be sent. 4. 09/13/17 6:12 PM - RN #2 phoned and notified the DON 5. 09/13/17 6:14 PM - Licensed Particle Nurse (LPN) #2 phoned Responsible Person (RP) of the incident, no answer to phone call and left message to call facility. 6. 09/13/17 6:15 PM - The ambulance arrived at the facility and proceeded to room [ROOM NUMBER]. 7. 09/13/17 6:20 PM - The DON arrived at the facility and immediately went to room [ROOM NUMBER]. 8. 09/13/17 6:30 PM - The DON notified the Administrator of the incident. 9. 09/13/17 6:40 PM - The Ambulance personnel left the facility with resident and transferred her to the ER 10. 09/13/17 6:40 PM - RN #2 called report to the ER and called and left message for the MD on call to call facility. 11. 09/13/17 6:45 PM - The Administrator arrived at the facility and began reviewing the surveillance video/cameras to establish a time line for the employee actions. 12. 09/13/17 6:45 PM - The DON removed CNA #1 and CNA #2 from their duties, obtained their written statements and conducted the initial interviews. CNA's were then informed they were both suspended from work until the investigation of this incident was completed. 13. 09/13/17 6:50 PM - The RP returned phone call to the facility and she was notified of the incident and that the resident was at the ER. 14. 09/13/17 7:00 PM - The DON inspected the Vander Lift and the lift sling that was used in the transfer and both were removed from use. 15. 09/13/17 7:25 PM - The MD on call returned a phone call to the facility and he was notified of the incident and the injury which had occurred to the resident. 16. 09/13/17 8:45 PM - The DON spoke with the RP regarding the incident. She was informed that an investigation had been started and the two (2) CNA's that were involved in the incident had been suspended. Also that the Administrator would notify the Mississippi State Department of Health (MSDH) and Attorney General's office. 17. 09/13/17 9:42 PM The Administrator notified the Corporate President 18. 09/14/17 8:00 AM - The Administrator instructed the maintenance supervisor to inspect all Vander Lifts and to report any problems. There were no problems identified. 19. 09/14/17 8:00 AM - The DON began an in-service with the CNA's who were on duty at that time on the proper use of the Vander Lift, utilizing the proper size of sling, where to look for the information regarding transfers for a specific resident, the Activities of Daily Living (ADL) Care Plan and following the resident ADL care plan. 20. 09/14/17 8:20 AM - The Administrator notified the MSDH of the incident via phone call. 21. 09/14/17 8:46 AM - The Administrator then notified the Attorney General's Office of the incident via an on line report. 22. 09/14/17 9:20 AM - The DON began and completed the inspection of all the Vander Lift slings in the building and examined slings for any problems. Four (4) unused slings were removed from the lift sling inventory. 23. 09/14/17 11:20 AM - The Administrator held a meeting with the DON, Corporate President, Minimal Data Set (MDS) Coordinator, Staff Development/Infection Control Nurse, Social Services Designee, Patient Activity Coordinator and Dietary Manager to discuss the incident and the plan of action to include staff in-service, following the resident specific ADL Care Plans for transfer instructions, auditing of all the residents with the potential to be affected by this incident. 24. 09/14/17 2:00 PM - A Directed in-in-service was initiated for all the direst care staff (Nurses and CNA's) and was conducted by a Loss Control & Prevention Manager along with the Staff Development Nurse. This in-service was titled; The use of the Vander Lift II which included Lift techniques, safety procedures, the resident assessment for the transfers, proper sling selection. Proper placement of lift sling and following the resident specific ADL care plan. No direct care employee will be allowed to work, (regular employee, contract or agency staff) until this in-service is completed 25. 09/18/17 10:40 AM - The DON called CNA #1 and asked the CNA to come to the facility to discuss the investigation findings which included; CNA#1 did not use the correct size of the lift sling for the resident, and the lift sling was placed improperly underneath the resident(placed inside out). She did not verify with the resident specific ADL care plan the correct size of the lift sling to be used nor did she verify the correct placement of the lift sling before beginning the transfer. DON informed CNA #1 that these actions directly impacted the transfer of Resident #1 and caused the resident to fall out of the sling and suffer injuries. DON informed CNA #1 that due to the findings of the investigation her employment with the facility was terminated and was effective immediately. 26. 09/18/17 12:45 PM - The DON called CNA #2 and requested she came to the facility. DON then discussed the findings of the investigation which included that the incorrect size of lift sling was used; the lift sling was not properly placed underneath the resident by CNA#1. Also CNA #2 did not verify the correct size of the lift sling to be used in the transfer nor did she verify or check the correct placement of the lift sling underneath the resident before the transfer was initiated. DON informed CNA#2 that due to the failure to follow the resident specific ADL care plan and the failure verify and check the size of the sling, the proper placement of the lift sling directly impacted the transfer of resident and caused the resident to fall out of the lift sling and suffer injuries. The DON informed CNA #2 that due to these findings of the investigation her employment with the facility was and was terminated and was effective immediately 27. 09/18/17 1:00 PM The facility Medical Director came into the facility for her monthly rounds. The DON discussed with the Medical Director the incident, the findings of the investigation which revealed two (2) CNA's failure to follow the policy and procedure for the operation of the Vander Lift, and failure to follow the resident specific ADL care plan by using the improper lift sling and the improper placement of the lift sling which directly resulted in the incident that occurred and the eventual death of the resident. The DON discussed the plan of action and the interventions that had already been put in place and the on-going in-servicing that is to be completed. 28. 09/20/17 8:30 AM - The Administrator and the DON met with the resident's family and discussed the incident and the investigation findings. 29. 09/20/17 5:20 PM - The QA meeting was held, present in the meeting was the Administrator, DON, Corporate Nurse Consultant, MDS Coordinator, Staff Development/Infection Control Nurse, Patient Activities Coordinator, Social Services Designee, and Dietary Manager. The Medical Director attended the meeting via teleconference. A review of the QA policy and procedures was completed. Discussion in the meeting also included the Immediate Jeopardy Status, new policy updates required and revised (Lifting Machine, Using a Portable) and was verbally approved by the Medical Director. Re-auditing all the residents who have the potential to be affected by this incident. The re-in-service of all the direct care staff on the new policy updated, following the resident specific ADL care plan for the transfer requirements of each resident. 30. 09/20/17 8:00 PM - The DON initiated audit of all the 16 residents who have potential to be affected by the incident. Audit was complete and updates were made. 31. 09/20/17 10:45 PM - The Vander Lift II and updated policy for Lifting Machine, Using a Portable, following the residents specific ADL care plans for instructions for the transfer of a resident. The in-service was initiated for 3-11 and 11 - 7 shifts. Handouts were given and a return demonstration of the use of the Vander Lift and the placement of the lift sling was given by the Staff Development Nurse and the Don. Employees were given a post test and were checked off to verify competency after the return demonstration of the use of the Vander Lift II, selecting the proper lift sling and the proper placement of sling. 09/21/17 8:00 AM - A titled in-service, Vander Lift II and Updated policy for Lifting machine, using a portable, following the resident specific ADL care plans for the instruction for a transfer of a resident is continued for the direct care staff. No facility employee, contract or agency staff will be allowed to work until this in-service has been completed. 32. 09/21/17 5:05 PM - An in-service was initiated by the DON on the Abuse and Neglect policy and procedures which includes the definitions of Abuse and neglect, The 7 components of abuse which include the screening, training, prevention, identification, protection and reporting of suspected abuse of neglect, Resident rights, stress and burn out and Vulnerable Adult were also included in the in-service. No facility staff or agency/contract staff will be allowed until in serviced on Abuse and Neglect. The facility alleges that the IJ has been removed as of 09/22/2017 at which time all areas addressed will be corrected. The State Agency (SA) validated the facility's Allegation of Compliance (A(NAME)) on 09/21/17. Interview with the DON on 09/22/17 at 10:00 AM revealed she along with the Staff Development Nurse performed all in-service training and discussed all aspects of Neglect/Abuse and Resident Rights. The DON stated that she instructed the staff following on requirements to follow all aspects of the resident's care plan. She also stated that she had instructed the CNA's that it is their responsibility to review each resident's ADL care plan for type of lift and size of sling prior to transferring a resident with the Vander Lift. The DON stated that she instructed staff that failure to follow a resident's care plan in providing was considered neglect. She also stated that she instructed staff that failure to ensure proper equipment was used in the correct manner was neglect. The DON stated that she had required all staff to be checked off on using the lifts. 1. The SA verified by record review and interview the incident on 09/13/17 at 6:04 in which Resident #1 (IJ Resident #8) was dropped out of the lift while being transferred from the Geri-chair. The facility's nurses performed first aid at starting at 6:05 PM and phoned the ambulance service to notify them of the incident and request an ambulance. Staff nurses notified the DON and the on call physician. Staff called the resident's family at 6:14 and there was no answer so a message was left to call the facility. The family returned the call and was informed of the incident and that the resident was being sent to the ER. The DON went directly to the resident's room on her arrival at the facility and also notified the Administrator. The facility called report to the ER, When the administrator arrived at the facility she began reviewing the video/cameras to establish a time line. The administrator notified the Corporate President. 2. The SA validated through interview and record review that the DON removed the CNA's involved from duty, obtained their written statements and conducted initial interviews and suspended them from work. Time card review revealed the CNA's were sent home and did not work again after the incident. The SA also confirmed that the DON spoke with the RP and informing her an investigation had been started and the two (2) CNA's that were involved had been suspended and the Administrator would notify the Attorney General (AG) an the Department of Health (DOH) 3. The SA verified through interview that the DON inspected and took the lift and sling involved out of service on 09/13/7. The SA validated through interview and record review the DON inspected all the lift slings in the building and four (4) unused slings were removed from service. The Administrator and DON instructed the maintenance supervisor to inspect the lifts and slings. 4. The SA confirmed through interviews with CNA's, Licensed Practical Nurses (LPN's) and Registered Nurses (RN's) and in-service sign in sheets validated that the DON conducted in-service training on proper use of the Vander Lift, utilizing proper sling size, where to find the information regarding transfers for a specific resident, the ADL care plan and following the resident ADL care plan. The SA validated through interviews and sign in sheets the in-service training for direct care staff, titled The use of the Vander Lift II which included lift techniques, safety procedures, the resident assessment for the transfers, proper sling selection, proper sling placement and following the resident specific ADL care plan was conducted by the staff development nurse and a Loss Control and Prevention Manager and that no direct care staff were allowed to work until this in-service was completed. 5. The SA verified the facility notified the MSDH and AG's Office of the incident. 6. The SA verified through record review and interview with the Administrator, the DON, the Staff Development Nurse and the MDS nurse held a facility meeting to discuss the incident and plan of action. 7. The SA validated through record review and interviews with CNA #1, the facility Administrator and the DON that CNA #1 was terminated as of 09/18/17 because the investigation had revealed The CNA failed to use the appropriate sling size, failed to check the ADL care plan, placed the sling under the resident wrong side out and failed to check sling placement before starting to lift the resident thereby causing the resident to be dropped from the lift, suffer injuries that subsequently lead to the resident's death. 8. The SA validated through record review and interviews with CNA #2, the facility Administrator and the DON that CNA #2 was terminated as of 09/18/17 because the investigation revealed the CNA failed to verify the size sling needed by checking the ADL care plan and failed to check the size of sling used and failed to verify correct placement of the sling before the transfer which directly impacted the transfer of the resident and cause the resident to fall out of the lift sling and suffer injuries that led to the resident's death 9. The SA validated through interview with the Administrator and record review that the Facility Medical Director was made aware of the incident and subsequent death of the resident on 09/18/17. 10. The SA validated through interview with the Administrator and RP that the Administrator and DON met with the resident's family and discussed the findings of their investigation. 11. The SA validated through interview with the DON and the Administrator and the Quality Assurance (QA) Committee sign sheet that a QA meeting was held on 09/20/17 in which the QA policies and procedures were reviewed. New policy updates regarding the lift policy were approved by the medical Director who attended by teleconference. 12. The SA validated through interview with the DON and Staff Development Nurse and document review the facility audited all 16 residents who had the potential to be affected. 13. By interviews with CNA's and LPN's, sign in sheets and record review the SA confirmed the DON and the Staff Development nurse began in-service training staff on the updated policy for lifts. This in-service was continued and no staff was allowed to work until this in-service was completed. 14. The SA validated by record review and staff interview an in-service by the DON on Neglect and Abuse definitions, the Seven Components of Abuse, Resident Rights and Vulnerable Adult was initiated. Staff members were called and instructed they would not be able to work until the training was completed.

Complaint Investigation #MS Based on record review, facility policy review and staff interview the facility failed to follow the Comprehensive Care Plan as evidenced by failure to use an X-Large lift pad as the resident had been care planned resulting in the facility staff dropping Resident #8 from the lift for one (1) of eight (8) care plans reviewed. The facility failure to ensure Resident #8's care plan was followed placed this resident and other residents in a situation that was likely to cause serious harm, injury, impairment, or death. On [DATE] facility Certified Nursing Assistants (CNA) transferred Resident #8 from a Geri-chair to her bed with a lift pad that was not the assessed size and failed to ensure the pad was placed under the resident according to manufacturer's instructions. The resident fell , sustained a skull fracture and intracranial bleeding, and expired at the hospital. The SA determined the facility was not in compliance with the requirements for participation in Medicare and Medicaid. The State Agency (SA) substantiated MS Complaint # with Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) identified on [DATE] and was determined to exist on [DATE]. On [DATE] at 4:30 PM the SA notified the facility's Administrator of the IJ and SQC existed at 42 CFR 483.21(b)(3)(ii)- F282 Resident Assessment. The facility submitted an acceptable Allegation of Compliance (A(NAME)) on [DATE], in which the facility alleged removal of the IJ on [DATE]. The State Agency validated the facility's A(NAME) on [DATE], and determined the IJ was removed as of [DATE], prior to exit. Based on the facility's corrective actions, initiated [DATE] and completed on [DATE], the SA determined the IJ and SQC to be removed as of [DATE] for 42 CFR 483.21(b)(3)(ii)- F282 Resident Assessment and the scope and severity was lowered to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy with the title Comprehensive Care Plans, no date, revealed each resident's care plan is designed to: incorporate risk factors associated with identified problems, identify professional services that responsible for each element of care aid in preventing or reducing declines in the resident's functional levels and reflect current recognized standards of practice for problem areas. Review of the facility's document entitled Care Plans, Goals and Objectives, no date, revealed goals and objectives are entered on the resident's care plan so that all disciplines have access to such information. Review of the facility document entitled Using a Portable Lifting Machine, no date, revealed the first step is to review the resident's care plan to assess for any specific needs of the resident. Review of Resident # 8's Certified Nurse Assistant (CNA) Activities of Daily Living (ADL) guidance revealed, Transfer per Vander Lift (total mechanical lift) with extra-large (XL) sling per two (2) caregivers. Review of the resident's Comprehensive Care Plan revealed a Lift Care Plan with a problem onset date of [DATE] and a statement that the resident is dependent on staff for ADL care related to mobility deficits. The and the goal states the resident's ADL care will be completed by staff interventions. The approach states transfer per Vander Lift with XL sling with two (2) caregivers. Responsible staff were identified as CNAs. The resident's Fall Care Plan with a problem onset date of [DATE] documented the resident has the potential for falls related to left side [MEDICAL CONDITION] and no safety awareness. with the stated goal that resident will be safe in the facility. Approaches included lift with XL sling with two (2) caregivers and staff responsible identified as CNAs. Review of facility document entitled Report of Incident/Accident with a date of [DATE], revealed the facility investigated an incident on [DATE] at 6:04 PM, in which CNA #1 and CNA #2 dropped Resident #8 during transfer with a Vander Lift from Geri-chair to bed. The resident sustained [REDACTED]. Interview with Registered Nurse (RN) #2 who was responsible for care plans on [DATE] at 2:00 PM revealed CNAs have ADL Care Plans that they must follow. She confirmed that using the wrong sling/pad size and incorrect placement of the lift pad/sling would constitute failing to follow the care plan. Interview with RN #3, Staff Development Nurse, on [DATE] at 4:00 PM, revealed that CNAs are taught to look in the ADL Care Plan to see what kind of lift to use and what size lift pad to use. Interview with the DON on [DATE] at 11:15 AM revealed not using appropriate sling is failing to follow the Care Plan. Review of the facility's documentation of their investigation of the incident revealed that during the investigation the Director of Nurses (DON) questioned CNA #1 and CNA #2 about the incident and the CNAs verbalized information about a resident's transfer needs was located in the ADL Care Plan. Interview with CNA #1 on [DATE] at 10:00 AM revealed that she just used the sling that was in the room that day. She further stated I didn't check the pad for size or correct placement before lifting the resident and that she took responsibility for the incident because she should have. Review of CNA #1's orientation packet revealed that on [DATE] the CNA signed a statement indicating that she understood and must follow the ADL care plan for the amounts of assistance that each resident requires for each ADL. The document further stated that residents are assessed and the amount of assistance required is for safety purposes and that transfers must be performed with the amount of assistance stated in the ADL record. Review of CNA #2's orientation packet revealed that on [DATE] the CNA signed a statement indicating that she understood and must follow the ADL care plan for the amounts of assistance that each resident requires for each ADL. The document further stated that residents are assessed and the amount of assistance required is for safety purposes and that transfers must be performed with the amount of assistance stated in the ADL record. Review of the DON's written synopsis of her investigation of the incident with a date of [DATE] revealed CNA #1 was the primary CNA for Resident #8 and CNA #2 was assisting her to move the resident from the chair to the bed. CNA # 1 did not use the correct positioning of the lift pad. Neither CNA checked placement of the lift pad before beginning the transfer and the wrong size lift pad was used. Interview with CNA #6 and #7 on [DATE] at 3:55 PM revealed CNA #6 stated that the resident's ADL Care Plan tells which lift to use and what size lift pad/sling to use. CNA #7 stated that failure to use the correct size sling would be failing to follow the Care Plan. Interview with CNAs #3 and #10 on [DATE] at 9:10 AM revealed ADL Care Plan tells the size of sling to use. They further stated that the ADL Care Plan is located at the nurse's desk. Interview with CNA #4 on [DATE] at 9:30 AM revealed she stated that the care plan must be followed. A review of the facility's face sheet revealed the facility admitted Resident #8 on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the resident's most recent Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) Score of five (5) indicating severe cognitive impairment. The facility provided an acceptable Allegation of Compliance (A(NAME)) on [DATE] for the Immediate Jeopardy (IJ). Review of the facility's A(NAME) revealed the facility took the following actions to remove the Immediate Jeopardy. 1. [DATE] 6:04 PM - Resident #1(IJ Resident #8) involved in an incident/accident, she fell out of a Vander Lift sling during a transport form Geri-chair to the bed. resident sustained [REDACTED]. 2. [DATE] 6:05 PM - RN #1 administered first aid to the resident 3. [DATE] 6:05 PM - RN #2 phoned ambulance service and reported the emergency and requested ambulance be sent. 4. [DATE] 6:12 PM - RN #2 phoned and notified the DON 5. [DATE] 6:14 PM - Licensed Particle Nurse (LPN) #2 phoned Responsible Person (RP) of the incident, no answer to phone call and left message to call facility. 6. [DATE] 6:15 PM - The ambulance arrived at the facility and proceeded to room [ROOM NUMBER]. 7. [DATE] 6:20 PM - The DON arrived at the facility and immediately went to room [ROOM NUMBER]. 8. [DATE] 6:30 PM - The DON notified the Administrator of the incident. 9. [DATE] 6:40 PM - The Ambulance personnel left the facility with resident and transferred her to the ER 10. [DATE] 6:40 PM - RN #2 called report to the ER and called and left message for the MD on call to call facility. 11. [DATE] 6:45 PM - The Administrator arrived at the facility and began reviewing the surveillance video/cameras to establish a time line for the employee actions. 12. [DATE] 6:45 PM - The DON removed CNA #1 and CNA #2 from their duties, obtained their written statements and conducted the initial interviews. CNA's were then informed they were both suspended from work until the investigation of this incident was completed. 13. [DATE] 6:50 PM - The RP returned phone call to the facility and she was notified of the incident and that the resident was at the ER. 14. [DATE] 7:00 PM - The DON inspected the Vander Lift and the lift sling that was used in the transfer and both were removed from use. 15. [DATE] 7:25 PM - The MD on call returned a phone call to the facility and he was notified of the incident and the injury which had occurred to the resident. 16. [DATE] 8:45 PM - The DON spoke with the RP regarding the incident. She was informed that an investigation had been started and the two (2) CNA's that were involved in the incident had been suspended. Also that the Administrator would notify the Mississippi State Department of Health (MSDH) and Attorney General's office. 17. [DATE] 9:42 PM The Administrator notified the Corporate President 18. [DATE] 8:00 AM - The Administrator instructed the maintenance supervisor to inspect all Vander Lifts and to report any problems. There were no problems identified. 19. [DATE] 8:00 AM - The DON began an in-service with the CNA's who were on duty at that time on the proper use of the Vander Lift, utilizing the proper size of sling, where to look for the information regarding transfers for a specific resident, the Activities of Daily Living (ADL) Care Plan and following the resident ADL care plan. 20. [DATE] 8:20 AM - The Administrator notified the MSDH of the incident via phone call. 21. [DATE] 8:46 AM - The Administrator then notified the Attorney General's Office of the incident via an on line report. 22. [DATE] 9:20 AM - The DON began and completed the inspection of all the Vander Lift slings in the building and examined slings for any problems. Four (4) unused slings were removed from the lift sling inventory. 23. [DATE] 11:20 AM - The Administrator held a meeting with the DON, Corporate President, Minimal Data Set (MDS) Coordinator, Staff Development/Infection Control Nurse, Social Services Designee, Patient Activity Coordinator and Dietary Manager to discuss the incident and the plan of action to include staff in-service, following the resident specific ADL Care Plans for transfer instructions, auditing of all the residents with the potential to be affected by this incident. 24. [DATE] 2:00 PM - A Directed in-in-service was initiated for all the direst care staff (Nurses and CNA's) and was conducted by a Loss Control & Prevention Manager along with the Staff Development Nurse. This in-service was titled; The use of the Vander Lift II which included Lift techniques, safety procedures, the resident assessment for the transfers, proper sling selection. Proper placement of lift sling and following the resident specific ADL care plan. No direct care employee will be allowed to work, (regular employee, contract or agency staff) until this in-service is completed 25. [DATE] 10:40 AM - The DON called CNA #1 and asked the CNA to come to the facility to discuss the investigation findings which included; CNA#1 did not use the correct size of the lift sling for the resident, and the lift sling was placed improperly underneath the resident(placed inside out). She did not verify with the resident specific ADL care plan the correct size of the lift sling to be used nor did she verify the correct placement of the lift sling before beginning the transfer. DON informed CNA #1 that these actions directly impacted the transfer of Resident #1 and caused the resident to fall out of the sling and suffer injuries. DON informed CNA #1 that due to the findings of the investigation her employment with the facility was terminated and was effective immediately. 26. [DATE] 12:45 PM - The DON called CNA #2 and requested she came to the facility. DON then discussed the findings of the investigation which included that the incorrect size of lift sling was used; the lift sling was not properly placed underneath the resident by CNA#1. Also CNA #2 did not verify the correct size of the lift sling to be used in the transfer nor did she verify or check the correct placement of the lift sling underneath the resident before the transfer was initiated. DON informed CNA#2 that due to the failure to follow the resident specific ADL care plan and the failure verify and check the size of the sling, the proper placement of the lift sling directly impacted the transfer of resident and caused the resident to fall out of the lift sling and suffer injuries. The DON informed CNA #2 that due to these findings of the investigation her employment with the facility was and was terminated and was effective immediately 27. [DATE] 1:00 PM The facility Medical Director came into the facility for her monthly rounds. The DON discussed with the Medical Director the incident, the findings of the investigation which revealed two (2) CNA's failure to follow the policy and procedure for the operation of the Vander Lift, and failure to follow the resident specific ADL care plan by using the improper lift sling and the improper placement of the lift sling which directly resulted in the incident that occurred and the eventual death of the resident. The DON discussed the plan of action and the interventions that had already been put in place and the on-going in-servicing that is to be completed. 28. [DATE] 8:30 AM - The Administrator and the DON met with the resident's family and discussed the incident and the investigation findings. 29. [DATE] 5:20 PM - The QA meeting was held, present in the meeting was the Administrator, DON, Corporate Nurse Consultant, MDS Coordinator, Staff Development/Infection Control Nurse, Patient Activities Coordinator, Social Services Designee, and Dietary Manager. The Medical Director attended the meeting via teleconference. A review of the QA policy and procedures was completed. Discussion in the meeting also included the Immediate Jeopardy Status, new policy updates required and revised (Lifting Machine, Using a Portable) and was verbally approved by the Medical Director. Re-auditing all the residents who have the potential to be affected by this incident. The re-in-service of all the direct care staff on the new policy updated, following the resident specific ADL care plan for the transfer requirements of each resident. 30. [DATE] 8:00 PM - The DON initiated audit of all the 16 residents who have potential to be affected by the incident. Audit was complete and updates were made. 31. [DATE] 10:45 PM - The Vander Lift II and updated policy for Lifting Machine, Using a Portable, following the residents specific ADL care plans for instructions for the transfer of a resident. The in-service was initiated for ,[DATE] and 11 - 7 shifts. Handouts were given and a return demonstration of the use of the Vander Lift and the placement of the lift sling was given by the Staff Development Nurse and the Don. Employees were given a post test and were checked off to verify competency after the return demonstration of the use of the Vander Lift II, selecting the proper lift sling and the proper placement of sling. [DATE] 8:00 AM - A titled in-service, Vander Lift II and Updated policy for Lifting machine, using a portable, following the resident specific ADL care plans for the instruction for a transfer of a resident is continued for the direct care staff. No facility employee, contract or agency staff will be allowed to work until this in-service has been completed. 32. [DATE] 5:05 PM - An in-service was initiated by the DON on the Abuse and Neglect policy and procedures which includes the definitions of Abuse and neglect, The 7 components of abuse which include the screening, training, prevention, identification, protection and reporting of suspected abuse of neglect, Resident rights, stress and burn out and Vulnerable Adult were also included in the in-service. No facility staff or agency/contract staff will be allowed until in serviced on Abuse and Neglect. The facility alleges that the IJ has been removed as of [DATE] at which time all areas addressed will be corrected. The State Agency (SA) validated the facility's Allegation of Compliance (A(NAME)) on [DATE]. Interview with the DON on [DATE] at 10:00 AM revealed she along with the Staff Development Nurse performed all in-service training and discussed all aspects of Neglect/Abuse and Resident Rights. The DON stated that she instructed the staff following on requirements to follow all aspects of the resident's care plan. She also stated that she had instructed the CNA's that it is their responsibility to review each resident's ADL care plan for type of lift and size of sling prior to transferring a resident with the Vander Lift. The DON stated that she instructed staff that failure to follow a resident's care plan in providing was considered neglect. She also stated that she instructed staff that failure to ensure proper equipment was used in the correct manner was neglect. The DON stated that she had required all staff to be checked off on using the lifts. 1. The SA verified by record review and interview the incident on [DATE] at 6:04 in which Resident #1 (IJ Resident #8) was dropped out of the lift while being transferred from the Geri-chair. The facility's nurses performed first aid at starting at 6:05 PM and phoned the ambulance service to notify them of the incident and request an ambulance. Staff nurses notified the DON and the on call physician. Staff called the resident's family at 6:14 and there was no answer so a message was left to call the facility. The family returned the call and was informed of the incident and that the resident was being sent to the ER. The DON went directly to the resident's room on her arrival at the facility and also notified the Administrator. The facility called report to the ER, When the administrator arrived at the facility she began reviewing the video/cameras to establish a time line. The administrator notified the Corporate President. 2. The SA validated through interview and record review that the DON removed the CNA's involved from duty, obtained their written statements and conducted initial interviews and suspended them from work. Time card review revealed the CNA's were sent home and did not work again after the incident. The SA also confirmed that the DON spoke with the RP and informing her an investigation had been started and the two (2) CNA's that were involved had been suspended and the Administrator would notify the Attorney General (AG) an the Department of Health (DOH) 3. The SA verified through interview that the DON inspected and took the lift and sling involved out of service on [DATE]. The SA validated through interview and record review the DON inspected all the lift slings in the building and four (4) unused slings were removed from service. The Administrator and DON instructed the maintenance supervisor to inspect the lifts and slings. 4. The SA confirmed through interviews with CNA's, Licensed Practical Nurses (LPN's) and Registered Nurses (RN's) and in-service sign in sheets validated that the DON conducted in-service training on proper use of the Vander Lift, utilizing proper sling size, where to find the information regarding transfers for a specific resident, the ADL care plan and following the resident ADL care plan. The SA validated through interviews and sign in sheets the in-service training for direct care staff, titled The use of the Vander Lift II which included lift techniques, safety procedures, the resident assessment for the transfers, proper sling selection, proper sling placement and following the resident specific ADL care plan was conducted by the staff development nurse and a Loss Control and Prevention Manager and that no direct care staff were allowed to work until this in-service was completed. 5. The SA verified the facility notified the MSDH and AG's Office of the incident. 6. The SA verified through record review and interview with the Administrator, the DON, the Staff Development Nurse and the MDS nurse held a facility meeting to discuss the incident and plan of action. 7. The SA validated through record review and interviews with CNA #1, the facility Administrator and the DON that CNA #1 was terminated as of [DATE] because the investigation had revealed The CNA failed to use the appropriate sling size, failed to check the ADL care plan, placed the sling under the resident wrong side out and failed to check sling placement before starting to lift the resident thereby causing the resident to be dropped from the lift, suffer injuries that subsequently lead to the resident's death. 8. The SA validated through record review and interviews with CNA #2, the facility Administrator and the DON that CNA #2 was terminated as of [DATE] because the investigation revealed the CNA failed to verify the size sling needed by checking the ADL care plan and failed to check the size of sling used and failed to verify correct placement of the sling before the transfer which directly impacted the transfer of the resident and cause the resident to fall out of the lift sling and suffer injuries that led to the resident's death 9. The SA validated through interview with the Administrator and record review that the Facility Medical Director was made aware of the incident and subsequent death of the resident on [DATE]. 10. The SA validated through interview with the Administrator and RP that the Administrator and DON met with the resident's family and discussed the findings of their investigation. 11. The SA validated through interview with the DON and the Administrator and the Quality Assurance (QA) Committee sign sheet that a QA meeting was held on [DATE] in which the QA policies and procedures were reviewed. New policy updates regarding the lift policy were approved by the medical Director who attended by teleconference. 12. The SA validated through interview with the DON and Staff Development Nurse and document review the facility audited all 16 residents who had the potential to be affected. 13. By interviews with CNA's and LPN's, sign in sheets and record review the SA confirmed the DON and the Staff Development nurse began in-service training staff on the updated policy for lifts. This in-service was continued and no staff was allowed to work until this in-service was completed. 14. The SA validated by record review and staff interview an in-service by the DON on Neglect and Abuse definitions, the Seven Components of Abuse, Resident Rights and Vulnerable Adult was initiated. Staff members were called and instructed they would not be able to work until the training was completed.

Complaint Investigation #MS Based on facility record review, staff interview and facility policy review, the facility failed to ensure a resident was free of neglect for one (1) of eight (8) residents reviewed, Resident #8; as evidenced by the facility staff dropped Resident #8 during a transfer from Geri-chair to bed that caused a skull fracture and [MEDICAL CONDITION] which led to the residents death. The facility failed to ensure Resident #8 was free on neglect on [DATE] when she was transferred from Geri-chair to bed with a lift pad that was not the assessed size and failed to ensure the pad was placed under the resident in the appropriate manner. The resident fell , sustained a skull fracture and intracranial bleeding, and expired at the hospital. This placed other residents in a situation that was likely to cause serious harm, injury, impairment, or death. The SA determined the facility was not in compliance with the requirements for participation in Medicare and Medicaid. The State Agency (SA) substantiated MS Complaint # with Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) identified on [DATE] and was determined to exist on [DATE]. On [DATE] at 4:30 PM the SA notified the facility's Administrator of the IJ and SQC existed at 42 CFR 483.12 (a) (1) - (3), F224 - Facility Practices. The facility submitted an acceptable Allegation of Compliance (A(NAME)) on [DATE], in which the facility alleged removal of the IJ on [DATE]. The State Agency validated the facility's A(NAME) on [DATE], and determined the IJ was removed as of [DATE], prior to exit. Based on the facility's corrective actions, initiated [DATE] and completed on [DATE], the SA determined the IJ and SQC to be removed as of [DATE] for 42 CFR 483.12 (a) (1) - (3), F224 - Facility Practices and the scope and severity was lowered to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy entitled Abuse Prevention Program, no date, revealed comprehensive policies and procedures have been developed to aid our facility in preventing abuse/neglect. Review of the facility's document with the title Seven Components of Abuse, no date, revealed neglect is defined as a failure to provide goods and services necessary to avoid physical harm. Review of facility's investigation [DATE], revealed on [DATE] at 6:04 PM, Certified Nursing Assistant (CNA) #1 and #2 dropped Resident #8 during transfer from a Geri-chair to her bed. Resident #8 sustained a head injury. The facility sent Resident #8 to the emergency room (ER) via ambulance. Review of the facility's lift assessment for Resident #8, dated [DATE], revealed resident had been assessed and required total mechanical lift for transfers with a Vander Lift using a Sling/Pad size XL. Review of Resident #8's physician orders revealed an order to transfer per Vander Lift with an extra-large (XL) sling, dated [DATE]. Review of the facility's ADL care plan, dated [DATE], revealed Resident # 8 was to be transferred per Vander Lift (total mechanical lift), with an XL sling per (two) 2 care givers. Review of the facility's assignment sheet for [DATE] for the ,[DATE] shift revealed CNA #1 was assigned to Hall 2A and room [ROOM NUMBER] and CNA #2 was also assigned to Hall 2. Review of the DON's written synopsis of the investigation, dated [DATE], revealed CNA #1 was the primary CNA caring for Resident #8. CNA #2 assisted CNA #1 to transfer Resident #8 from the chair to the bed. CNA #1 did not use the correct positioning of the lift pad. Neither CNA#1 nor CNA #2 checked placement of the lift pad before beginning the transfer and the wrong size lift pad was used. Resident #8 fell from the lift and sustained a head injury. The facility transferred Resident #8 the emergency roiagnom on [DATE]. The Director of Nurses (DON) began the initial investigation on [DATE] at 6:20 PM. The Certified Nursing Assistants (CNAs) that were involved were questioned by the DON and then sent home and suspended pending the completion of the investigation. Both CNA's were terminated on [DATE]. Review of the Computerized Axial Tomography (CT) scan of Resident #8's brain revealed acute [MEDICAL CONDITION] including blood in frontal regions, a subdural bleed, and blood within the fourth ventricle. There was also bleeding within the right occipital lobe underlying a nondisplaced right occipital bone fracture. Interview with Registered Nurse (RN) #2 on [DATE] at 2:10 PM revealed failure use the X-Large lift pad and ensure placement of the pad per manufacturer's recommendations is considered neglect. Interview with RN #3, Staff Development Nurse, on [DATE] at 4:00 PM revealed she along with the DON provided in-service training on [DATE] related to abuse and Neglect. Review of the facility schedule for mandatory in-service training for 2017 revealed training on resident's rights was provided on [DATE] at 2:00 PM and on [DATE] at 2:00 PM training on abuse. Review of the training documentation for the in-service given on [DATE] revealed the definition of Neglect is failing to do something you should have done. Neglect may also be considered physical abuse and can be intentional or unintentional. Review of CNA #1's personnel files and CNA #2's personnel files revealed both CNAs had signed documents verifying they were trained on using the Vander lift and training on Abuse and Neglect on [DATE]. Interview with CNA #1 on [DATE] at 1:45 PM, revealed she had been trained on using the lift. She also stated, I used the same lift pad that I have always used with this resident. Interview with CNA #1 on [DATE] she admitted that she didn't check the pad for size or correct placement before lifting the resident and that she took responsibility for the incident because she should have. Interview with CNA #2 on [DATE] at 2:00 PM revealed the she had received training on using the lift during orientation and that she didn't pay any attention to the sling size or placement before lifting the resident because she was already sitting in it. She further stated that resident just slipped out of the sling. Review of the facility's face sheet revealed the facility admitted Resident #8 on [DATE]. The resident's [DIAGNOSES REDACTED]., and unspecified convulsions. Review of the resident's most recent Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) Score of five (5) indicating severe cognitive impairment. The facility provided an acceptable Allegation of Compliance (A(NAME)) on [DATE] for the Immediate Jeopardy (IJ). Review of the facility's A(NAME) revealed the facility took the following actions to remove the Immediate Jeopardy. 1. [DATE] 6:04 PM - Resident #1(IJ Resident #8) involved in an incident/accident, she fell out of a Vander Lift sling during a transport form Geri-chair to the bed. resident sustained [REDACTED]. 2. [DATE] 6:05 PM - RN #1 administered first aid to the resident 3. [DATE] 6:05 PM - RN #2 phoned ambulance service and reported the emergency and requested ambulance be sent. 4. [DATE] 6:12 PM - RN #2 phoned and notified the DON 5. [DATE] 6:14 PM - Licensed Particle Nurse (LPN) #2 phoned Responsible Person (RP) of the incident, no answer to phone call and left message to call facility. 6. [DATE] 6:15 PM - The ambulance arrived at the facility and proceeded to room [ROOM NUMBER]. 7. [DATE] 6:20 PM - The DON arrived at the facility and immediately went to room [ROOM NUMBER]. 8. [DATE] 6:30 PM - The DON notified the Administrator of the incident. 9. [DATE] 6:40 PM - The Ambulance personnel left the facility with resident and transferred her to the ER 10. [DATE] 6:40 PM - RN #2 called report to the ER and called and left message for the MD on call to call facility. 11. [DATE] 6:45 PM - The Administrator arrived at the facility and began reviewing the surveillance video/cameras to establish a time line for the employee actions. 12. [DATE] 6:45 PM - The DON removed CNA #1 and CNA #2 from their duties, obtained their written statements and conducted the initial interviews. CNA's were then informed they were both suspended from work until the investigation of this incident was completed. 13. [DATE] 6:50 PM - The RP returned phone call to the facility and she was notified of the incident and that the resident was at the ER. 14. [DATE] 7:00 PM - The DON inspected the Vander Lift and the lift sling that was used in the transfer and both were removed from use. 15. [DATE] 7:25 PM - The MD on call returned a phone call to the facility and he was notified of the incident and the injury which had occurred to the resident. 16. [DATE] 8:45 PM - The DON spoke with the RP regarding the incident. She was informed that an investigation had been started and the two (2) CNA's that were involved in the incident had been suspended. Also that the Administrator would notify the Mississippi State Department of Health (MSDH) and Attorney General's office. 17. [DATE] 9:42 PM The Administrator notified the Corporate President 18. [DATE] 8:00 AM - The Administrator instructed the maintenance supervisor to inspect all Vander Lifts and to report any problems. There were no problems identified. 19. [DATE] 8:00 AM - The DON began an in-service with the CNA's who were on duty at that time on the proper use of the Vander Lift, utilizing the proper size of sling, where to look for the information regarding transfers for a specific resident, the Activities of Daily Living (ADL) Care Plan and following the resident ADL care plan. 20. [DATE] 8:20 AM - The Administrator notified the MSDH of the incident via phone call. 21. [DATE] 8:46 AM - The Administrator then notified the Attorney General's Office of the incident via an on line report. 22. [DATE] 9:20 AM - The DON began and completed the inspection of all the Vander Lift slings in the building and examined slings for any problems. Four (4) unused slings were removed from the lift sling inventory. 23. [DATE] 11:20 AM - The Administrator held a meeting with the DON, Corporate President, Minimal Data Set (MDS) Coordinator, Staff Development/Infection Control Nurse, Social Services Designee, Patient Activity Coordinator and Dietary Manager to discuss the incident and the plan of action to include staff in-service, following the resident specific ADL Care Plans for transfer instructions, auditing of all the residents with the potential to be affected by this incident. 24. [DATE] 2:00 PM - A Directed in-in-service was initiated for all the direst care staff (Nurses and CNA's) and was conducted by a Loss Control & Prevention Manager along with the Staff Development Nurse. This in-service was titled; The use of the Vander Lift II which included Lift techniques, safety procedures, the resident assessment for the transfers, proper sling selection. Proper placement of lift sling and following the resident specific ADL care plan. No direct care employee will be allowed to work, (regular employee, contract or agency staff) until this in-service is completed 25. [DATE] 10:40 AM - The DON called CNA #1 and asked the CNA to come to the facility to discuss the investigation findings which included; CNA#1 did not use the correct size of the lift sling for the resident, and the lift sling was placed improperly underneath the resident(placed inside out). She did not verify with the resident specific ADL care plan the correct size of the lift sling to be used nor did she verify the correct placement of the lift sling before beginning the transfer. DON informed CNA #1 that these actions directly impacted the transfer of Resident #1 and caused the resident to fall out of the sling and suffer injuries. DON informed CNA #1 that due to the findings of the investigation her employment with the facility was terminated and was effective immediately. 26. [DATE] 12:45 PM - The DON called CNA #2 and requested she came to the facility. DON then discussed the findings of the investigation which included that the incorrect size of lift sling was used; the lift sling was not properly placed underneath the resident by CNA#1. Also CNA #2 did not verify the correct size of the lift sling to be used in the transfer nor did she verify or check the correct placement of the lift sling underneath the resident before the transfer was initiated. DON informed CNA#2 that due to the failure to follow the resident specific ADL care plan and the failure verify and check the size of the sling, the proper placement of the lift sling directly impacted the transfer of resident and caused the resident to fall out of the lift sling and suffer injuries. The DON informed CNA #2 that due to these findings of the investigation her employment with the facility was and was terminated and was effective immediately 27. [DATE] 1:00 PM The facility Medical Director came into the facility for her monthly rounds. The DON discussed with the Medical Director the incident, the findings of the investigation which revealed two (2) CNA's failure to follow the policy and procedure for the operation of the Vander Lift, and failure to follow the resident specific ADL care plan by using the improper lift sling and the improper placement of the lift sling which directly resulted in the incident that occurred and the eventual death of the resident. The DON discussed the plan of action and the interventions that had already been put in place and the on-going in-servicing that is to be completed. 28. [DATE] 8:30 AM - The Administrator and the DON met with the resident's family and discussed the incident and the investigation findings. 29. [DATE] 5:20 PM - The QA meeting was held, present in the meeting was the Administrator, DON, Corporate Nurse Consultant, MDS Coordinator, Staff Development/Infection Control Nurse, Patient Activities Coordinator, Social Services Designee, and Dietary Manager. The Medical Director attended the meeting via teleconference. A review of the QA policy and procedures was completed. Discussion in the meeting also included the Immediate Jeopardy Status, new policy updates required and revised (Lifting Machine, Using a Portable) and was verbally approved by the Medical Director. Re-auditing all the residents who have the potential to be affected by this incident. The re-in-service of all the direct care staff on the new policy updated, following the resident specific ADL care plan for the transfer requirements of each resident. 30. [DATE] 8:00 PM - The DON initiated audit of all the 16 residents who have potential to be affected by the incident. Audit was complete and updates were made. 31. [DATE] 10:45 PM - The Vander Lift II and updated policy for Lifting Machine, Using a Portable, following the residents specific ADL care plans for instructions for the transfer of a resident. The in-service was initiated for ,[DATE] and 11 - 7 shifts. Handouts were given and a return demonstration of the use of the Vander Lift and the placement of the lift sling was given by the Staff Development Nurse and the Don. Employees were given a post test and were checked off to verify competency after the return demonstration of the use of the Vander Lift II, selecting the proper lift sling and the proper placement of sling. [DATE] 8:00 AM - A titled in-service, Vander Lift II and Updated policy for Lifting machine, using a portable, following the resident specific ADL care plans for the instruction for a transfer of a resident is continued for the direct care staff. No facility employee, contract or agency staff will be allowed to work until this in-service has been completed. 32. [DATE] 5:05 PM - An in-service was initiated by the DON on the Abuse and Neglect policy and procedures which includes the definitions of Abuse and neglect, The 7 components of abuse which include the screening, training, prevention, identification, protection and reporting of suspected abuse of neglect, Resident rights, stress and burn out and Vulnerable Adult were also included in the in-service. No facility staff or agency/contract staff will be allowed until in serviced on Abuse and Neglect. The facility alleges that the IJ has been removed as of [DATE] at which time all areas addressed will be corrected. The State Agency (SA) validated the facility's Allegation of Compliance (A(NAME)) on [DATE]. Interview with the DON on [DATE] at 10:00 AM revealed she along with the Staff Development Nurse performed all in-service training and discussed all aspects of Neglect/Abuse and Resident Rights. The DON stated that she instructed the staff following on requirements to follow all aspects of the resident's care plan. She also stated that she had instructed the CNA's that it is their responsibility to review each resident's ADL care plan for type of lift and size of sling prior to transferring a resident with the Vander Lift. The DON stated that she instructed staff that failure to follow a resident's care plan in providing was considered neglect. She also stated that she instructed staff that failure to ensure proper equipment was used in the correct manner was neglect. The DON stated that she had required all staff to be checked off on using the lifts. 1. The SA verified by record review and interview the incident on [DATE] at 6:04 in which Resident #1 (IJ Resident #8) was dropped out of the lift while being transferred from the Geri-chair. The facility's nurses performed first aid at starting at 6:05 PM and phoned the ambulance service to notify them of the incident and request an ambulance. Staff nurses notified the DON and the on call physician. Staff called the resident's family at 6:14 and there was no answer so a message was left to call the facility. The family returned the call and was informed of the incident and that the resident was being sent to the ER. The DON went directly to the resident's room on her arrival at the facility and also notified the Administrator. The facility called report to the ER, When the administrator arrived at the facility she began reviewing the video/cameras to establish a time line. The administrator notified the Corporate President. 2. The SA validated through interview and record review that the DON removed the CNA's involved from duty, obtained their written statements and conducted initial interviews and suspended them from work. Time card review revealed the CNA's were sent home and did not work again after the incident. The SA also confirmed that the DON spoke with the RP and informing her an investigation had been started and the two (2) CNA's that were involved had been suspended and the Administrator would notify the Attorney General (AG) an the Department of Health (DOH) 3. The SA verified through interview that the DON inspected and took the lift and sling involved out of service on [DATE]. The SA validated through interview and record review the DON inspected all the lift slings in the building and four (4) unused slings were removed from service. The Administrator and DON instructed the maintenance supervisor to inspect the lifts and slings. 4. The SA confirmed through interviews with CNA's, Licensed Practical Nurses (LPN's) and Registered Nurses (RN's) and in-service sign in sheets validated that the DON conducted in-service training on proper use of the Vander Lift, utilizing proper sling size, where to find the information regarding transfers for a specific resident, the ADL care plan and following the resident ADL care plan. The SA validated through interviews and sign in sheets the in-service training for direct care staff, titled The use of the Vander Lift II which included lift techniques, safety procedures, the resident assessment for the transfers, proper sling selection, proper sling placement and following the resident specific ADL care plan was conducted by the staff development nurse and a Loss Control and Prevention Manager and that no direct care staff were allowed to work until this in-service was completed. 5. The SA verified the facility notified the MSDH and AG's Office of the incident. 6. The SA verified through record review and interview with the Administrator, the DON, the Staff Development Nurse and the MDS nurse held a facility meeting to discuss the incident and plan of action. 7. The SA validated through record review and interviews with CNA #1, the facility Administrator and the DON that CNA #1 was terminated as of [DATE] because the investigation had revealed The CNA failed to use the appropriate sling size, failed to check the ADL care plan, placed the sling under the resident wrong side out and failed to check sling placement before starting to lift the resident thereby causing the resident to be dropped from the lift, suffer injuries that subsequently lead to the resident's death. 8. The SA validated through record review and interviews with CNA #2, the facility Administrator and the DON that CNA #2 was terminated as of [DATE] because the investigation revealed the CNA failed to verify the size sling needed by checking the ADL care plan and failed to check the size of sling used and failed to verify correct placement of the sling before the transfer which directly impacted the transfer of the resident and cause the resident to fall out of the lift sling and suffer injuries that led to the resident's death 9. The SA validated through interview with the Administrator and record review that the Facility Medical Director was made aware of the incident and subsequent death of the resident on [DATE]. 10. The SA validated through interview with the Administrator and RP that the Administrator and DON met with the resident's family and discussed the findings of their investigation. 11. The SA validated through interview with the DON and the Administrator and the Quality Assurance (QA) Committee sign sheet that a QA meeting was held on [DATE] in which the QA policies and procedures were reviewed. New policy updates regarding the lift policy were approved by the medical Director who attended by teleconference. 12. The SA validated through interview with the DON and Staff Development Nurse and document review the facility audited all 16 residents who had the potential to be affected. 13. By interviews with CNA's and LPN's, sign in sheets and record review the SA confirmed the DON and the Staff Development nurse began in-service training staff on the updated policy for lifts. This in-service was continued and no staff was allowed to work until this in-service was completed. 14. The SA validated by record review and staff interview an in-service by the DON on Neglect and Abuse definitions, the Seven Components of Abuse, Resident Rights and Vulnerable Adult was initiated. Staff members were called and instructed they would not be able to work until the training was completed.

Based on facility record review, staff interview and facility policy review the facility failed to ensure a resident was free of accidents and injury for one (1) of eight (8) residents reviewed, Resident #8; as evidenced by the facility staff dropped Resident #8 during a transfer from Geri-chair to bed that caused a skull fracture and intracranial hemorrhage which led to the residents death. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when the facility failed to use the appropriated lift pad/sling that Resident #8 as per Facility Lift Assessment, physician's orders [REDACTED]. These failures resulted in Resident #8 being dropped during transfer from chair to bed. The resident sustained [REDACTED]. The facility failed to ensure Resident #8 was free of accidents and injury when she was transferred from Geri-chair to bed with a lift pad that was not the assessed size and failed to ensure the pad was placed under the resident in the appropriate manner, placed this resident and other residents in a situation that was likely to cause serious harm, injury, impairment, or death. On [DATE] at 4:30 PM the SA notified the facility's Administrator of the IJ and SQC existed at 42 CFR 483.25 (d) (1), F323 - Quality of Care. The facility submitted an acceptable Allegation of Compliance (A(NAME)) on [DATE], in which the facility alleged removal of the IJ on [DATE]. The State Agency validated the facility's A(NAME) on [DATE], and determined the IJ was removed as of [DATE], prior to exit. Based on the facility's corrective actions, initiated [DATE] and completed on [DATE], the SA determined the IJ and SQC to be removed as of [DATE] for 42 CFR 483.25 (d) (1), F323 - Quality of Care and the scope and severity was lowered to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy with a title of Safe Lifting and Movement of Resident revealed a policy statement that in order to protect the safety and wellbeing of residents and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. Review of the facility document entitled Using a Portable Lifting Machine, no date, revealed under the first step is to assess the resident's care plan for any specific needs of the resident. Review of the document How to use the Vander Lift II, no date, the first step listed states: Identify correct lift and sling for the resident. Review of the manufacturer's guidance, dated [DATE], revealed each sling size is indicated by a correlating color. X-Large slings are brown and large slings are blue. Observation of all lifts in the facility on [DATE] revealed a color chart on the lifts that indicated color of each size lift pad. Review of facility's investigation dated [DATE], revealed on [DATE] at 6:04 PM, facility Certified Nurse Assistant (CNA) #1 called for help in room 20. Upon entering the room License Practical Nurse (LPN) #1 saw Resident #8 lying on across the lift legs with her head on the floor. LPN #1 called out for help and Registered Nurses (RNs) # 1 and #2 came to assist. CNA#1 stated that she and CNA #2 were transferring Resident #8 from her Geri-chair to her bed when the resident slipped out of the lift and hit her head on the floor. RN #1 held pressure on the resident's head to stop bleeding while RN#1 called an ambulance. RN#1 maintained c-spine alignment while others assisted in rolling the resident's body off the lift legs. Staff brought supplies to the room and applied a pressure dressing to the area that was bleeding. The Emergency Medical Technicians (EMTs) arrived and transported Resident #8 to the local emergency room . Review of the Director of Nursing (DON)'s written synopsis of her investigation of incident with a date of [DATE] revealed CNA #1 was the primary CNA for resident #8 and CNA #2 was assisting her to move the resident from the chair to the bed. CNA # 1 did not use the correct lift pad and placed the lift pad wrong side out. Neither CNA checked placement of the lift pad before beginning the transfer and the wrong size lift pad was used. Review of the Computerized Axial Tomography (CT) scan of Resident #8's brain done at the hospital on [DATE] and electronically signed by the radiologist at 7:45 PM, revealed acute intracranial hemorrhages and an occipital bone fracture. Review of the facility's assignment sheet for [DATE] for the 3 -11 shift revealed that CNA #1 was assigned to Hall 2A and room 20 and CNA #2 was also assigned to that hall. Interview with the resident's granddaughter, on [DATE] at 9:00 AM, revealed the resident was admitted to the hospital after being seen in the ER. She stated that her grandmother had been unresponsive and vomiting when family members arrived at the hospital. She also stated that she had a large hematoma on the back of her head and what appeared to be a dime sized puncture wound in the center of the hematoma. She stated that she had also observed multiple areas of bruising along the resident's spine. She stated that her grandmother had died at the hospital on [DATE] without ever regaining consciousness. Review of Resident #8's Physician order [REDACTED]. Review also revealed an order, dated [DATE], that the resident may be up in Geri-chair as tolerated secondary to poor trunk control. Review of the facility's lift assessment for Resident #8, dated [DATE], revealed Resident #8 required total mechanical lift for transfers with a Vander Lift using a Sling/Pad size XL. Interview with CNA #1, on [DATE] at 1:45 PM, revealed she had been trained on using the lift. She also stated that she had used the same lift pad that she had always used with this resident. Interview with the CNA #1 ON [DATE] at 10:00 AM revealed she stated that she really didn't know the difference between the large and the extra-large lift pads. She stated that the sling/lift pad she used was already in the room the day of the incident. She stated, I really don't know what happened. This contradicted her interview on [DATE]. She further stated that she didn't check the pad for size or correct placement before lifting the resident and that she took responsibility for the incident because she should have. Interview with CNA #2, on [DATE] at 2:00 PM, revealed she did not pay any attention to the sling size or placement before lifting the resident because the resident was already sitting in the sling when she got to the room. She said each CNA hooked their side of the sling. She stated CNA #1 was operating the lift, and the resident just slipped out and hit her head on the floor. She stated she had received training on using the lift during orientation. Review of CNA #1 and CNA #2's personnel files revealed the CNA had signed documents verifying they had been trained on using the Vander lift. Interview on [DATE] at 2:35 PM with RN #1 revealed, she was working the night of Resident #8's fall from the sling. She stated she was at the nurses station and heard someone call for help. She stated she entered Resident #8's room and saw Resident #8 lying on the floor across the base of the lift. She stated she immediately immobilized her cervical spine and then applied pressure to the wound on her head. She stated EMTs arrived and placed a c-collar on Resident #8. She stated Resident #8 complained of neck pain and vomited. Review of a statement written and signed by the Administrator and the DON, dated [DATE], revealed they had reviewed the surveillance video. The video showed CNA#1 going out of the resident's room to the linen cart on the east hall, pulling a sling from the top of the cart and returning to the resident's room. In this statement, it was surmised that the footage disputes CNA #1's claim that she used the sling that was already in the room. Interview with the DON on [DATE] at 5:00 PM revealed, I believe the evidence shows that the CNA's were not paying attention. The lift pad was inside out, and it was the wrong size lift pad. They were at fault and were terminated. They had received in-service training on using the lift just like everyone else. Interview with RN #3 on [DATE] at 2:30 PM revealed staff are taught to use the lift at new hire. RN #3 stated there is a film they watch, and they are paired with a mentor CNA who shows them how to use the lifts. Then once a year we give another in-service on using the lift. Interview with the facility Administrator on [DATE] at 1:50 PM revealed the incident took place on Wednesday night [DATE]. The Administrator stated she and the DON began the investigation immediately after the incident and placed CNA #1 and CNA #2 on suspension. The CNAs were being terminated as of [DATE]. On [DATE] at 2:15 PM, the State Agency (SA) attempted to contact the Medical Director. As of 11:30 AM on [DATE], the Medical Director had not returned the SA call and the SA exited the facility. A review of the facility's face sheet revealed the facility admitted Resident #8 on [DATE]. The resident had [DIAGNOSES REDACTED]., and unspecified convulsions. Review of the resident's most recent Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) Score of five (5) indicating severe cognitive impairment. The facility provided an acceptable Allegation of Compliance (A(NAME)) on [DATE] for the Immediate Jeopardy (IJ). Review of the facility's A(NAME) revealed the facility took the following actions to remove the Immediate Jeopardy. 1. [DATE] 6:04 PM - Resident #1(IJ Resident #8) involved in an incident/accident, she fell out of a Vander Lift sling during a transport form Geri-chair to the bed. resident sustained [REDACTED]. 2. [DATE] 6:05 PM - RN #1 administered first aid to the resident 3. [DATE] 6:05 PM - RN #2 phoned ambulance service and reported the emergency and requested ambulance be sent. 4. [DATE] 6:12 PM - RN #2 phoned and notified the DON 5. [DATE] 6:14 PM - Licensed Particle Nurse (LPN) #2 phoned Responsible Person (RP) of the incident, no answer to phone call and left message to call facility. 6. [DATE] 6:15 PM - The ambulance arrived at the facility and proceeded to room 20. 7. [DATE] 6:20 PM - The DON arrived at the facility and immediately went to room 20. 8. [DATE] 6:30 PM - The DON notified the Administrator of the incident. 9. [DATE] 6:40 PM - The Ambulance personnel left the facility with resident and transferred her to the ER 10. [DATE] 6:40 PM - RN #2 called report to the ER and called and left message for the MD on call to call facility. 11. [DATE] 6:45 PM - The Administrator arrived at the facility and began reviewing the surveillance video/cameras to establish a time line for the employee actions. 12. [DATE] 6:45 PM - The DON removed CNA #1 and CNA #2 from their duties, obtained their written statements and conducted the initial interviews. CNA's were then informed they were both suspended from work until the investigation of this incident was completed. 13. [DATE] 6:50 PM - The RP returned phone call to the facility and she was notified of the incident and that the resident was at the ER. 14. [DATE] 7:00 PM - The DON inspected the Vander Lift and the lift sling that was used in the transfer and both were removed from use. 15. [DATE] 7:25 PM - The MD on call returned a phone call to the facility and he was notified of the incident and the injury which had occurred to the resident. 16. [DATE] 8:45 PM - The DON spoke with the RP regarding the incident. She was informed that an investigation had been started and the two (2) CNA's that were involved in the incident had been suspended. Also that the Administrator would notify the Mississippi State Department of Health (MSDH) and Attorney General's office. 17. [DATE] 9:42 PM The Administrator notified the Corporate President 18. [DATE] 8:00 AM - The Administrator instructed the maintenance supervisor to inspect all Vander Lifts and to report any problems. There were no problems identified. 19. [DATE] 8:00 AM - The DON began an in-service with the CNA's who were on duty at that time on the proper use of the Vander Lift, utilizing the proper size of sling, where to look for the information regarding transfers for a specific resident, the Activities of Daily Living (ADL) Care Plan and following the resident ADL care plan. 20. [DATE] 8:20 AM - The Administrator notified the MSDH of the incident via phone call. 21. [DATE] 8:46 AM - The Administrator then notified the Attorney General's Office of the incident via an on line report. 22. [DATE] 9:20 AM - The DON began and completed the inspection of all the Vander Lift slings in the building and examined slings for any problems. Four (4) unused slings were removed from the lift sling inventory. 23. [DATE] 11:20 AM - The Administrator held a meeting with the DON, Corporate President, Minimal Data Set (MDS) Coordinator, Staff Development/Infection Control Nurse, Social Services Designee, Patient Activity Coordinator and Dietary Manager to discuss the incident and the plan of action to include staff in-service, following the resident specific ADL Care Plans for transfer instructions, auditing of all the residents with the potential to be affected by this incident. 24. [DATE] 2:00 PM - A Directed in-in-service was initiated for all the direst care staff (Nurses and CNA's) and was conducted by a Loss Control & Prevention Manager along with the Staff Development Nurse. This in-service was titled; The use of the Vander Lift II which included Lift techniques, safety procedures, the resident assessment for the transfers, proper sling selection. Proper placement of lift sling and following the resident specific ADL care plan. No direct care employee will be allowed to work, (regular employee, contract or agency staff) until this in-service is completed 25. [DATE] 10:40 AM - The DON called CNA #1 and asked the CNA to come to the facility to discuss the investigation findings which included; CNA#1 did not use the correct size of the lift sling for the resident, and the lift sling was placed improperly underneath the resident(placed inside out). She did not verify with the resident specific ADL care plan the correct size of the lift sling to be used nor did she verify the correct placement of the lift sling before beginning the transfer. DON informed CNA #1 that these actions directly impacted the transfer of Resident #1 and caused the resident to fall out of the sling and suffer injuries. DON informed CNA #1 that due to the findings of the investigation her employment with the facility was terminated and was effective immediately. 26. [DATE] 12:45 PM - The DON called CNA #2 and requested she came to the facility. DON then discussed the findings of the investigation which included that the incorrect size of lift sling was used; the lift sling was not properly placed underneath the resident by CNA#1. Also CNA #2 did not verify the correct size of the lift sling to be used in the transfer nor did she verify or check the correct placement of the lift sling underneath the resident before the transfer was initiated. DON informed CNA#2 that due to the failure to follow the resident specific ADL care plan and the failure verify and check the size of the sling, the proper placement of the lift sling directly impacted the transfer of resident and caused the resident to fall out of the lift sling and suffer injuries. The DON informed CNA #2 that due to these findings of the investigation her employment with the facility was and was terminated and was effective immediately 27. [DATE] 1:00 PM The facility Medical Director came into the facility for her monthly rounds. The DON discussed with the Medical Director the incident, the findings of the investigation which revealed two (2) CNA's failure to follow the policy and procedure for the operation of the Vander Lift, and failure to follow the resident specific ADL care plan by using the improper lift sling and the improper placement of the lift sling which directly resulted in the incident that occurred and the eventual death of the resident. The DON discussed the plan of action and the interventions that had already been put in place and the on-going in-servicing that is to be completed. 28. [DATE] 8:30 AM - The Administrator and the DON met with the resident's family and discussed the incident and the investigation findings. 29. [DATE] 5:20 PM - The QA meeting was held, present in the meeting was the Administrator, DON, Corporate Nurse Consultant, MDS Coordinator, Staff Development/Infection Control Nurse, Patient Activities Coordinator, Social Services Designee, and Dietary Manager. The Medical Director attended the meeting via teleconference. A review of the QA policy and procedures was completed. Discussion in the meeting also included the Immediate Jeopardy Status, new policy updates required and revised (Lifting Machine, Using a Portable) and was verbally approved by the Medical Director. Re-auditing all the residents who have the potential to be affected by this incident. The re-in-service of all the direct care staff on the new policy updated, following the resident specific ADL care plan for the transfer requirements of each resident. 30. [DATE] 8:00 PM - The DON initiated audit of all the 16 residents who have potential to be affected by the incident. Audit was complete and updates were made. 31. [DATE] 10:45 PM - The Vander Lift II and updated policy for Lifting Machine, Using a Portable, following the residents specific ADL care plans for instructions for the transfer of a resident. The in-service was initiated for ,[DATE] and 11 - 7 shifts. Handouts were given and a return demonstration of the use of the Vander Lift and the placement of the lift sling was given by the Staff Development Nurse and the Don. Employees were given a post test and were checked off to verify competency after the return demonstration of the use of the Vander Lift II, selecting the proper lift sling and the proper placement of sling. [DATE] 8:00 AM - A titled in-service, Vander Lift II and Updated policy for Lifting machine, using a portable, following the resident specific ADL care plans for the instruction for a transfer of a resident is continued for the direct care staff. No facility employee, contract or agency staff will be allowed to work until this in-service has been completed. 32. [DATE] 5:05 PM - An in-service was initiated by the DON on the Abuse and Neglect policy and procedures which includes the definitions of Abuse and neglect, The 7 components of abuse which include the screening, training, prevention, identification, protection and reporting of suspected abuse of neglect, Resident rights, stress and burn out and Vulnerable Adult were also included in the in-service. No facility staff or agency/contract staff will be allowed until in serviced on Abuse and Neglect. The facility alleges that the IJ has been removed as of [DATE] at which time all areas addressed will be corrected. The State Agency (SA) validated the facility's Allegation of Compliance (A(NAME)) on [DATE]. Interview with the DON on [DATE] at 10:00 AM revealed she along with the Staff Development Nurse performed all in-service training and discussed all aspects of Neglect/Abuse and Resident Rights. The DON stated that she instructed the staff following on requirements to follow all aspects of the resident's care plan. She also stated that she had instructed the CNA's that it is their responsibility to review each resident's ADL care plan for type of lift and size of sling prior to transferring a resident with the Vander Lift. The DON stated that she instructed staff that failure to follow a resident's care plan in providing was considered neglect. She also stated that she instructed staff that failure to ensure proper equipment was used in the correct manner was neglect. The DON stated that she had required all staff to be checked off on using the lifts. 1. The SA verified by record review and interview the incident on [DATE] at 6:04 in which Resident #1 (IJ Resident #8) was dropped out of the lift while being transferred from the Geri-chair. The facility's nurses performed first aid at starting at 6:05 PM and phoned the ambulance service to notify them of the incident and request an ambulance. Staff nurses notified the DON and the on call physician. Staff called the resident's family at 6:14 and there was no answer so a message was left to call the facility. The family returned the call and was informed of the incident and that the resident was being sent to the ER. The DON went directly to the resident's room on her arrival at the facility and also notified the Administrator. The facility called report to the ER, When the administrator arrived at the facility she began reviewing the video/cameras to establish a time line. The administrator notified the Corporate President. 2. The SA validated through interview and record review that the DON removed the CNA's involved from duty, obtained their written statements and conducted initial interviews and suspended them from work. Time card review revealed the CNA's were sent home and did not work again after the incident. The SA also confirmed that the DON spoke with the RP and informing her an investigation had been started and the two (2) CNA's that were involved had been suspended and the Administrator would notify the Attorney General (AG) an the Department of Health (DOH) 3. The SA verified through interview that the DON inspected and took the lift and sling involved out of service on [DATE]. The SA validated through interview and record review the DON inspected all the lift slings in the building and four (4) unused slings were removed from service. The Administrator and DON instructed the maintenance supervisor to inspect the lifts and slings. 4. The SA confirmed through interviews with CNA's, Licensed Practical Nurses (LPN's) and Registered Nurses (RN's) and in-service sign in sheets validated that the DON conducted in-service training on proper use of the Vander Lift, utilizing proper sling size, where to find the information regarding transfers for a specific resident, the ADL care plan and following the resident ADL care plan. The SA validated through interviews and sign in sheets the in-service training for direct care staff, titled The use of the Vander Lift II which included lift techniques, safety procedures, the resident assessment for the transfers, proper sling selection, proper sling placement and following the resident specific ADL care plan was conducted by the staff development nurse and a Loss Control and Prevention Manager and that no direct care staff were allowed to work until this in-service was completed. 5. The SA verified the facility notified the MSDH and AG's Office of the incident. 6. The SA verified through record review and interview with the Administrator, the DON, the Staff Development Nurse and the MDS nurse held a facility meeting to discuss the incident and plan of action. 7. The SA validated through record review and interviews with CNA #1, the facility Administrator and the DON that CNA #1 was terminated as of [DATE] because the investigation had revealed The CNA failed to use the appropriate sling size, failed to check the ADL care plan, placed the sling under the resident wrong side out and failed to check sling placement before starting to lift the resident thereby causing the resident to be dropped from the lift, suffer injuries that subsequently lead to the resident's death. 8. The SA validated through record review and interviews with CNA #2, the facility Administrator and the DON that CNA #2 was terminated as of [DATE] because the investigation revealed the CNA failed to verify the size sling needed by checking the ADL care plan and failed to check the size of sling used and failed to verify correct placement of the sling before the transfer which directly impacted the transfer of the resident and cause the resident to fall out of the lift sling and suffer injuries that led to the resident's death 9. The SA validated through interview with the Administrator and record review that the Facility Medical Director was made aware of the incident and subsequent death of the resident on [DATE]. 10. The SA validated through interview with the Administrator and RP that the Administrator and DON met with the resident's family and discussed the findings of their investigation. 11. The SA validated through interview with the DON and the Administrator and the Quality Assurance (QA) Committee sign sheet that a QA meeting was held on [DATE] in which the QA policies and procedures were reviewed. New policy updates regarding the lift policy were approved by the medical Director who attended by teleconference. 12. The SA validated through interview with the DON and Staff Development Nurse and document review the facility audited all 16 residents who had the potential to be affected. 13. By interviews with CNA's and LPN's, sign in sheets and record review the SA confirmed the DON and the Staff Development nurse began in-service training staff on the updated policy for lifts. This in-service was continued and no staff was allowed to work until this in-service was completed. 14. The SA validated by record review and staff interview an in-service by the DON on Neglect and Abuse definitions, the Seven Components of Abuse, Resident Rights and Vulnerable Adult was initiated. Staff members were called and instructed they would not be able to work until the training was completed.

Based on observation, record review, policy review, staff interviews and facility investigation review, the facility failed to provide adequate supervision to prevent a resident from leaving the facility unsupervised for one (1) of four (4) residents reviewed as evidenced by Resident #1, who was assessed and for an elopement risk, left the facility through an unlocked exit door and unlocked exit gate after the facility's Maintenance Director propped the door and gate open for a local contractor to bring in supplies. When driving to work on 2/16/17 at 9:12 AM, a facility employee discovered Resident #1 walking down the street. Resident #1 was approximately 237 steps from the facility when the employee saw the resident. Resident #1 was returned to the facility with no apparent injury. Based on camera footage, the facility determined the resident was out of the facility unassisted approximately three (3) minutes. The lack of supervision for Resident #1, with a history of wandering and exit-seeking behaviors, placed the resident and other residents with exit seeking behaviors in a situation that was likely to cause serious harm, injury, impairment or death. Based on the facility's implementation of corrective actions completed 2/17/17, prior to the State Agency (SA) entrance on 2/27/17, the SA determined the Immediate Jeopardy to be Past Non-Compliance and removed as of 2/17/17. Findings include: Review of the facility policy entitled Safety and Supervision of Residents , undated, revealed, Resident safety and supervision, and assistance to prevent accidents, are facility-wide priorities. Review of the Wandering/Elopement/Resident's at Risk policy, updated on 7/31/07, revealed, the purpose of this policy is to implement appropriate protective measures to help guard against a resident wandering from the facility. Record review of the facility's written investigative report, dated 2/18/17, revealed Resident #1 walked out of the propped open Chapel exit door and out of the unlocked Chapel exit gate, then down the street 237 steps unattended on 2/16/17. The Chapel exit door had been propped open by the Maintenance Director to allow a vendor to come and go to bring in tools and supplies while working at the facility, but failed to report to any other staff to monitor the open door which allowed Resident #1 to walk out the door and out of the gate. Resident #1 was observed walking down the street when a facility worker, Certified Occupational Therapy Assistant (COTA) #1, while driving to work, noticed him and stopped the car to assist him back to the facility. Observation, on 2/28/17 at 9:50 AM, with the Facility's Administrator revealed it was 56 steps from the Chapel exit to the Chapel exit gate, 62 steps on the sidewalk to a circular drive/front parking area of the facility, then 47 steps to the street, then crossing the street 20 steps to the next street, then 144 steps to the local Hospice/Home Health office. The COTA saw Resident #1 approximately half way down the last street 72 steps. This is a total of 237 steps from the Chapel exit door to place where the COTA #1 observed Resident #1 walking down the street. During the observation, the surveyor saw a total of three (3) cars passing on the street from 9:50 AM to 10:15 AM. Review of Resident #1's clinical record revealed elopement assessments dated 11/7/16 and 12/7/16, which indicated Resident #1 was assessed at risk for elopement and scored greater than eight (8) on both the assessments indicating Resident #1 was at risk for elopement. Interview post exit on 3/9/17 at 1:50 PM, with Certified Nurses Assistant (CNA) #1, revealed she was aware Resident #1 was assessed and care planned for wandering. She stated she was the CNA assigned to Resident #1 on 2/16/17, and had got him dressed and ready for the day. She stated that he had wanted a shave, so she assisted him with his shave using his electric razor. She stated Resident #1 had exhibited exit seeking behaviors about two (2) to three (3) weeks prior to the elopement on 2/16/17, but he did not exhibit exit seeking behaviors that morning. Interview with the Director of Nursing (DON) on 2/28/17 at 11:10 AM, revealed Resident #1 was assessed at risk for elopement but had not attempted to leave the building. The DON stated on review of the video, Resident #1 was walking down the East Hall towards the chapel at 9:09 AM. The DON stated at approximately 9:13 AM, COTA #1 called to notify the facility that Resident #1 was out of the building. The DON explained Resident #1 was placed on one to one (1:1) observation and remained on one to one (1:1) observation until he was transferred on 2/17/17, to a sister facility with a locked Alzheimer's Unit for his safety. The DON stated the facility notified the local Area Ombudsman to discuss the transfer to assure they protected the rights of Resident #1. During a post exit interview on 3/9/17 at 1:40 PM, the DON stated the facility does not routinely document visual checks on residents assessed as at risk for elopement unless a resident exhibits exit seeking behaviors, then the facility would place the resident on every 15 minute checks or one on one (1:1) observation. She stated these are determined on a case by case bases. Review of Resident #1's Visual Checks: Resident sheets, revealed the facility did not initiate visual checks until after the resident's elopement on 2/16/17. Interview with the Maintenance Director on 2/28/17 at 2:20 PM, revealed on 2/16/17, he propped the Chapel Exit Door open and unlocked the Chapel Exit Gate for the vendor to take supplies in and out of the facility while doing carpenter work. The Maintenance Director stated he did not realize that a facility staff member should have been at the door while it was unlocked. The Maintenance Director stated after the incident, the facility suspended him from work for three (3) days and in-serviced him on residents at risk for elopement. The Maintenance Director stated all vendors now have to sign a statement prior to working acknowledging not to prop or leave exit doors open for any reason without a staff member standing at the door. Interview on 2/28/17 at 2:00 PM, with the Certified Occupational Therapy Assistant (COTA) #1, revealed she was driving to work on the morning of 2/26/17, at around 9:00 AM, when she observed Resident #1 down the street walking toward the local Hospice/Home Health building. COTA #1 stated Resident #1 was dressed in a long sleeve shirt, pants, shoes, and was wearing a belt. COTA #1 stated the weather was nice and warm. COTA #1 stated she stopped her car and got out to walk with Resident #1. She stated she tried to get him to walk back to the facility but he continued walking away from the facility. COTA #1 stated she called the facility and notified them and continued to walk with Resident #1 to the local drugstore. She stated the local Hospice/Home Health staff walked with them to the drugstore in case she required assistance until the facility staff and van returned him to the facility unharmed. Interview on 2/28/17 at 3:40 PM, with the Administrative Assistant (AA), confirmed she received a phone call from COTA #1 on 2/26/17 at about 9:00 AM, informing the facility Resident #1 was out of the facility and walking down the street. The AA stated she, the Activities Director, and a Certified Nursing Assistant (CNA) took the facility van and picked up Resident #1 at the local drugstore and returned him to the facility unharmed. Interview, on 2/28/17 at 3:00 PM, with Registered Nurse (RN) #1, revealed, RN #1 confirmed taking her car with Licensed Practical Nurse (LPN) #2 on 2/16/17, and joining the other staff in the van to get Resident #1 at the local drugstore and bring him back to the facility. RN #1 confirmed on return to the facility a head to toe assessment was completed for Resident #1. RN #1 stated the facility initiated a Code W and staff checked all the other residents to assure they were also in the building. RN #1 stated immediately all exit doors were checked to confirm they were secure and locked. RN #1 stated LPN #2 interviewed the vendor/contractor and verified the Chapel Exit Door had been propped open by the Maintenance Director. The contractor stated he saw Resident #1 leave through the door but did not realize he was a resident. RN #1 stated she notified Resident #1's Responsible Party (RP) and the Primary Care Physician (PCP). Interview, on 2/27/16 at 10:10 AM, with the facility Administrator, confirmed Resident #1 left the facility unsupervised, and COTA #1 discovered the resident and alerted the facility. The Administrator stated the Maintenance Director should have placed a staff member at the unlocked door until it was locked again for the safety of the residents. Interview with the Primary Care Provider (PCP) on 2/27/17 at 3:35 PM, confirmed the facility notified him on 1/16/17. of Resident #1's elopement from the facility. The PCP confirmed the transfer of Resident #1 to a higher level of care for his safety and protection. Interview with the facility's Medical Director, on 2/27/17 at 3:30 PM, confirmed she had been notified of Resident #1's elopement from the facility. The Medical Director also confirmed she participated by phone in the Quality Assurance (QA) meeting and policies discussed to include the Elopement Plan and the Care Plan. The Medical Director confirmed during the QA process, the facility discussed the notification of the local vendors regarding door safety and would not be able to work until they signed a statement. Interview with the Responsible Party (RP), on 2/27/17 at 3:00 PM, confirmed she had been notified of Resident #1's elopement when the facility left the door open for a carpenter to bring supplies in and out of the building. The SA attempted to call Vendor #1 on 2/27/17 at 10:20 AM, and 2/28/17 at 2:30 PM, but was unable to reach the Vendor. Interview with the Area Ombudsman, on 2/27/17 at 2:45 PM, confirmed the facility had contacted her regarding Resident #1's elopement from the facility and to discuss with her steps to assure the resident's rights were protected for proper transfer to sister facility where the resident could receive a higher level of care. The Ombudsman stated the facility is proactive and had no concerns from the families or residents regarding care at the facility. Review of the Face Sheet revealed the facility admitted Resident #1 on 11/7/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/17, revealed a Brief Interview for Mental Status (BIMS) score was unable to be completed because the resident was severely impaired cognitively. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 2/27/17: 1. On 2/16/17, at approximately 9:09 AM, revealed Resident #1 had been seen by the local vendor walking out of the building and out of the gate but did not realize he was a resident at the facility. On 2/16/17 at 9:12 AM, a Certified Occupational Therapy Assistant (COTA) #1, was driving in to work and noticed Resident #1 walking down the street towards the local Hospice/Home Health office and stopped to assist him. At the same time workers from the Hospice/Home Health office came out to assist her. COTA #1 called and alerted the facility and the facility's staff and van came and picked them up and brought them back to the facility unharmed. The resident was assessed and placed on every fifteen (15) minute visual checks until staff could arrive for one to one (1:1) observation until he was discharged to a higher level of care in a local Alzheimer's unit on 2/17/17 at 3:00 PM. The result of the head to toe assessment by Registered Nurse (RN) #1 revealed no injuries. Resident #1 was dressed in a button down long sleeve shirt, pants, belt, and shoes when he exited the building and it was a warm sunny day. 2. On 2/16/17 at 9:30 AM, all staff on duty met at the nurses' station and duties were assigned. All exit doors were checked and now locked by the Maintenance Director. 3. On 2/16/17 at 9:30 AM, a head count of all of the remaining 49 residents of the facility were present and accounted for by the facility staff. The other three (3) residents previously assessed as an elopement risk were visually observed by Licensed Practical Nurse (LPN) #1. 4. On 2/16/17 at 9:30 AM, the Staff Development Nurse initiated in-service to all staff for elopement prevention, how to respond to a missing person, exit doors are not to be propped open and following the resident's plan of care for residents at risk for elopement. All staff was in-serviced prior to being allowed to return to work and was completed on 2/25/17. 5. On 2/16/17, a Quality Assurance Committee Meeting was held with the following staff in attendance: DON, Administrator, Staff Development Nurse, Social Service Director, Dietary Manager, LPN #1 and the facility's Medical Director by phone. During this meeting the Code W Elopement Policy, Wandering, Unsafe Resident Policy, Wandering/Elopement/Resident's at Risk Policy, Wandering Resident Drill Policy, Visual Checks Policy, Elopement Policy, Care Plan Policy. The QA Committee reviewed the current investigation and the root cause analysis. This QA Committee made recommendations and implemented the Door Code Procedure for Vendors that required all facility vendors to sign acknowledgement prior to being allowed to provide services to the facility. Recommendations made to discontinue the use of the green bracelets and to transfer Resident #1 to a higher level of care and a more secure Alzheimer's unit for his safety. Recommendations made to continue 1:1 observation until Resident #1 was transferred safely to an Alzheimer's unit. 6. Resident #1's Care Plan and assessment were audited for elopement prevention by the DON on 2/16/17, and was found to be comprehensive and accurate. On 2/16/17, the DON reviewed three (3) other residents, previously found to be at risk for elopement, Care Plans and assessments and found them to be comprehensive and removed Resident #4 from the list of at risk for elopement due to adjustment to the facility with no attempts at elopement. 7. On 2/16/17, the facility Administrator verified the signage at the exit doors on 2/16/17. 8. At 9:30 AM on 2/16/17, the Director of Nursing (DON) and the facility Administrator was notified that Resident #1 was notified of the elopement. On 2/16/17 at 10:15 AM, Resident #1's Responsible Party (RP) was notified. On 2/16/17 at 10:40 AM, Resident #1's Primary Care Physician was notified. On 2/17/17 at 9:00 AM, the Mississippi State Department of Health was notified via fax of the elopement. The facility alleged the Corrective Action Plan (CAP) was completed by 2/17/17. 9. On 2/17/17, the facility Administrator gave a written warning to the Maintenance Director with suspension for three (3) days for propping the Chapel Exit Door and Chapel Exit Gate open to allow the vendor to bring supplies in without notifying any other staff to provide security of the unlocked door and gate. The State Agency (SA) validated the facility's corrective action on 2/28/17. 1. The SA validated the facility's investigation of Resident #1's elopement and return to the facility uninjured on 2/16/17. The SA verified this by record review, interviews/written statements of staff and vendors and written report to the SA. 2. The SA validated by staff interviews, review of the facility's investigation, review of statements that on 2/16/17, all of the remaining 49 residents of the facility were accounted for. The three (3) remaining residents residing in the facility that had previously been identified as an elopement risk were visually observed. 3. The SA validated by, staff interviews, review of the facility's investigation and review of statements that on 2/16/17, exit doors were checked to ensure they were secured and locked. Observation of exit doors during survey revealed they were locked, secured and functioning with a sign on each door warning visitors to not let residents out and to make sure door closes securely. The Elopement Book at the Nurses Station was reviewed and all three (3) current identified residents at risk for elopement were present. Review of Resident #1's care plan revealed an update on 2/16/17. 4. The SA verified through review of the Quality Assurance attendance record and agenda, and staff interviews, that on 2/16/17, a Quality Assurance Committee Meeting was held, with the following staff in attendance: DON, Administrator, Staff Development Nurse, Social Service Director, Dietary Manager, LPN #1 and the facility's Medical Director by phone. During this meeting the Code W Elopement Policy, Wandering, Unsafe Resident Policy, Wandering/Elopement/Resident's at Risk Policy, Wandering Resident Drill Policy, Visual Checks Policy, Elopement Policy, Care Plan Policy. The QA Committee reviewed the current investigation and the root cause analysis. This QA Committee made recommendations and implemented the Door Code Procedure for Vendors that required all facility vendors to sign acknowledgement prior to being allowed to provide services to the facility. This QA Committee recommended the green bracelets not be used and Resident #1 be transferred to a more secure Alzheimer's unit for his safety with 1:1 observation until Resident #1 was transferred safely to an Alzheimer's unit. 5. The SA verified through review of in-service records signed by staff, and staff interviews that on 2/16/17, beginning at 9:30 AM, the following policies were reviewed by the Staff Development Nurse with the staff on duty at the time and continued until the last employee was in-serviced on 2/25/17. No staff was allowed to work until the in-service was complete. 6. The SA verified through record review, review of the facility's investigation and audits, staff interviews, that Resident #1's Care Plan and risk assessment were reviewed and updated to include elopement and every 15 minute check then changed to one (1) to one (1) observation until he was transferred to a higher level of care on 2/17/17. The three (3) other residents previously found to be at risk for elopement had reviews of the Care Plan and assessments and were updated. Resident #4 was removed from being at risk for elopement during this review. 7. The SA verified through record review and interviews the facility implemented the Door Code Procedure for Vendors on 2/17/17. Beginning on 2/17/17, all vendors must sign acknowledgement of the Door Code Procedure for Vendors to verify understanding to keep doors locked for the safety of the residents. The Vendors also verified they are never to allow anyone out of the door unless approved with a staff member and to never prop a door open for any reason. The posted sign on the exit doors reads, Attention We thank you for visiting (facility name) Nursing Center. We all must work together to keep our residents safe. PLEASE DO NOT OPEN THE DOOR FOR ANY RESIDENT OR LET THEM OUT. WE ASK THAT YOU GET THE NURSE IF THIS OCCURS. PLEASE BE SURE THE DOOR CLOSES SECURELY WHEN YOU EXIT. WE ARE DEPENDING ON EVERYONE'S HELP TO KEEP OUR RESIDENTS SAFE. THANK YOU Residents with exit seeking behaviors are discussed daily in the Morning Meetings per staff interviews. There have been no new residents identified since 2/16/17. 8. The SA verified through record review, review of the facility investigation and report, staff interview and the Medical Director interview, that on 2/16/17, the Director of Nursing (DON) was notified Resident #1 was missing from the facility and brought back when COTA #1 observed him walking down the street and called the facility to come and pick them up. On 2/16/17 at 10:15 AM, Resident #1's responsible party was notified of his elopement and returned without injury. On 2/17/17 at 9:00 AM, the Mississippi Department of Health was notified via fax by the facility Administrator of the elopement. 9. The State Agency reviewed the Employee Warning Report that confirmed on 2/17/17, the facility Administrator gave a written warning to the Maintenance Director with suspension for three (3) days for propping the Chapel Exit Door and Chapel Exit Gate open to allow the vendor to bring supplies in without notifying any other staff to provide security of the unlocked door and gate.

Based on record review, policy review, staff interviews and facility investigation review, the facility failed to follow the Plan of Care to include interventions of supervision of residents at risk for elopement for one (1) of four (4) residents reviewed, Resident #1. Resident #1 walked out of an unlocked exit door and unlocked exit gate when the facility's Maintenance Director propped the door and gate open for the local contractor to bring supplies in the facility. The facility failed to provide supervision while the door and gate remained unlocked. The failure to follow the care plan for increased supervision resulted in Resident #1 leaving the building unattended and put Resident #1 and other residents at risk for elopement in a situation that was likely to cause serious harm, injury, impairment or death. Based on the facility's implementation of corrective actions as of 2/17/17, initiated prior to the State Agency (SA) entrance on 2/27/17, the SA determined the Immediate Jeopardy to be Past Non-Compliance and removed as of 2/17/17. Findings include: Review of the facility policy entitled Care Planning-Interdisciplinary Team, revised December 2008, revealed, care plans shall incorporate goals and objectives are defined as the desired outcome for a specific resident problem. Review of Resident #1's Care Plan revealed a Problem, dated 11/7/16, for elopement risk. The goal for this care plan was Resident will be safe in the facility. Interventions included: Maintain a current census list with residents who are elopement risk. Perform every one (1) hours visual checks and document in these checks in the flow-sheets as needed (such as if a resident attempts to exit the building). This care plan was updated 2/16/17. Review of the facility's written report, dated 2/18/17, revealed on 2/16/17 Resident #1 walked out of the propped open Chapel exit door and out of the unlocked Chapel exit gate, then down the street 237 steps unattended. A facility worker, Certified Occupational Therapy Assistant (COTA ) #1, while driving to work, noticed Resident #1 walking down the street and stopped the car to assist him back to the facility. The facility's report revealed Resident #1 had a written Care Plan for elopement but the facility failed to follow the Care Plan as evidenced by failure to provide supervision of the resident while the facility had an exit door and gate unlocked. Interview, on 2/27/16 at 10:10 AM, with the facility Administrator revealed the Administrator confirmed Resident #1 had a written Care Plan for elopement but the facility failed to provide supervision of the unlocked exit door and unlocked gate per the Care Plan. The Administrator stated the Maintenance Director should have placed a staff member at the unlocked door until it was locked again for the safety of the residents. Interview with the Director of Nursing (DON) on 2/28/17 at 11:10 AM, revealed Resident #1 was assessed and at risk for elopement and had a Care Plan for elopement but had no prior attempts to leave the building. The DON confirmed Resident #1 had a Care Plan developed and reviewed for at risk for elopement. Review of the Face Sheet revealed the facility admitted Resident #1 on 11/7/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/17 revealed a Brief Interview for Mental Status (BIMS) score was unable to be completed because resident was severely impaired cognitively. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 2/27/17: 1. On 2/16/17 at approximately 9:09 AM, a local vendor saw Resident #1 walking out of the facility building and out of the facility gate but did not realize he was a resident at the facility. On 2/16/17 at 9:12 AM Certified Occupational Therapy Assistant (COTA) #1 was driving in to work and noticed Resident #1 walking down the street towards the local Hospice/Home Health office and stopped to assist him. COTA #1 called and alerted the facility and the facility's staff and van came and picked them up and brought them back to the facility unharmed. The resident was assessed and placed on one to one (1:1) observation until he was discharged to a higher level of care in a local Alzheimer's unit on 2/17/17 at 3:00 PM. The result of the head to toe assessment by Registered Nurse (RN) #1 revealed no injuries. Resident #1 was dressed in a button down long sleeve shirt, pants, belt, and shoes when he exited the building and it was a warm sunny day. 2. On 2/16/17 at 9:30 AM, all staff on duty met at the nurses' station and duties were assigned. All exit doors were checked and now locked by the Maintenance Director. 3. On 2/16/17 at 9:30 AM, a head count of all of the remaining 49 residents of the facility revealed all residents were present and accounted for by the facility staff. The other three (3) residents previously assessed as an elopement risk were visually observed by Licensed Practical Nurse (LPN) #1. 4. On 2/16/17 at 9:30 AM, the Staff Development Nurse initiated in-service to all staff for elopement prevention, how to respond to a missing person, exit doors are not to be propped open and following the resident's plan of care for residents at risk for elopement. All staff was in-serviced prior to being allowed to return to work and was completed on 2/25/17. 5. On 2/16/17, a Quality Assurance Committee Meeting was held with the following staff in attendance: Director of Nursing, Administrator, Staff Development Nurse, Social Service Director, Dietary Manager, Licensed Practical Nurse (LPN) #1 and the facility's Medical Director by phone. During this meeting the Code W Elopement Policy, Wandering, Unsafe Resident Policy, Wandering/Elopement/Resident's at Risk Policy, Wandering Resident Drill Policy, Visual Checks Policy, Elopement Policy, Care Plan Policy. The QA Committee reviewed the current investigation and the root cause analysis. This QA Committee made recommendations and implemented the Door Code Procedure for Vendors that required all facility vendors to sign acknowledgement prior to being allowed to provide services to the facility. Recommendations made to discontinue the use of the green bracelets because residents could pull them off and the bracelets were not effective. Recommendations made to transfer Resident #1 to a sister facility with an Alzheimer's unit for his safety. Recommendations made to continue 1:1 observation until Resident #1 was transferred safely to an Alzheimer's unit. 6. Resident #1's Care Plan and assessment were audited for elopement prevention by the DON on 2/16/17 and was found to be comprehensive and accurate. On 2/16/17, the DON reviewed three (3) other residents, previously found to be at risk for elopement, Care Plans and assessments and found them to be comprehensive and removed Resident #4 from the list of at risk for elopement due to adjustment to the facility with no attempts at elopement. 7. On 2/16/17, the facility Administrator verified the signage at the exit doors on 2/16/17. 8. At 9:30 AM on 2/16/17, the Director of Nursing (DON) and the facility Administrator was notified that Resident #1 was notified of the elopement. On 2/16/17 at 10:15 AM, Resident #1's Responsible Party (RP) was notified. On 2/16/17 at 10:40 AM, Resident #1's Primary Care Physician was notified. On 2/17/17 at 9:00 AM, the Mississippi State Department of Health was notified via fax of the elopement. The facility alleged the Corrective Action Plan (CAP) was completed on 2/17/17. The State Agency (SA) validated the facility's corrective action on 2/28/17. 1. The SA validated the facility's investigation of Resident #1's elopement and return to the facility uninjured on 2/16/17. The SA verified this by record review, interviews/written statements of staff and vendors and written report to the SA. 2. The SA validated by staff interviews, review of the facility's investigation, review of statements that on 2/16/17 all of the remaining 49 residents of the facility were accounted for. The three (3) remaining residents residing in the facility that had previously been identified as an elopement risk were visually observed. 3. The SA validated by, staff interviews, review of the facility's investigation and review of statements that on 2/16/17 exit doors were checked to ensure they were secured and locked. Observation of exit doors during survey revealed they were locked, secured and functioning with a sign on each door warning visitors to not let residents out and to make sure door closes securely. The Elopement Book at the Nurses Station was reviewed and all three (3) current identified residents at risk for elopement were present. Review of Resident #1's care plan revealed an update on 2/16/17. 4. The SA verified through review of the Quality Assurance attendance record and agenda, and staff interviews, that on 2/16/17, a Quality Assurance Committee Meeting was held, with the following staff in attendance: DON, Administrator, Staff Development Nurse, Social Service Director, Dietary Manager, LPN #1 and the facility's Medical Director by phone. During this meeting the Code W Elopement Policy, Wandering, Unsafe Resident Policy, Wandering/Elopement/Resident's at Risk Policy, Wandering Resident Drill Policy, Visual Checks Policy, Elopement Policy, Care Plan Policy. The QA Committee reviewed the current investigation and the root cause analysis. This QA Committee made recommendations and implemented the Door Code Procedure for Vendors that required all facility vendors to sign acknowledgement prior to being allowed to provide services to the facility. This QA Committee recommended the Green bracelets not be used and transfer of Resident #1 to a more secure Alzheimer's unit for his safety with continued 1:1 observation until Resident #1 was transferred to an Alzheimer's unit. 5. The SA verified through review of in-service records signed by staff, and staff interviews that on 2/16/17, beginning at 9:30 AM, the following policies were reviewed by the Staff Development Nurse with the staff on duty at the time and continued until the last employee was in-serviced on 2/25/17. No staff was allowed to work until the in-service was complete. 6. The SA verified through record review, review of the facility's investigation and audits, staff interviews, that Resident #1's Care Plan and risk assessment were reviewed and updated to include elopement and every 15 minute check then changed to one (1) to one (1) observation until he was transferred to a higher level of care on 2/17/17. The three (3) other residents previously found to be at risk for elopement had reviews of the Care Plan and assessments and were updated. Resident #4 was removed from being at risk for elopement during this review. 7. The SA verified through record review and interviews the facility implemented the Door Code Procedure for Vendors on 2/17/17. Beginning on 2/17/17, all vendors must sign acknowledgement of the Door Code Procedure for Vendors to verify understanding to keep doors locked for the safety of the residents. The Vendors also verified they are never to allow anyone out of the door unless approved with a staff member and to never prop a door open for any reason. The posted sign on the exit doors reads, Attention We thank you for visiting (facility name) Nursing Center. We all must work together to keep our residents safe. PLEASE DO NOT OPEN THE DOOR FOR ANY RESIDENT OR LET THEM OUT. WE ASK THAT YOU GET THE NURSE IF THIS OCCURS. PLEASE BE SURE THE DOOR CLOSES SECURELY WHEN YOU EXIT. WE ARE DEPENDING ON EVERYONE'S HELP TO KEEP OUR RESIDENTS SAFE. THANK YOU Residents with exit seeking behaviors are discussed daily in the Morning Meetings per staff interviews. There have been no new residents identified since 2/16/17. 8. The SA verified through record review, review of the facility investigation and report, staff interview and the Medical Director interview, that on 2/16/17, the Director of Nursing (DON) was notified Resident #1 was missing from the facility and brought back when COTA #1 observed him walking down the street and called the facility to come and pick them up. The SA verified through record review and RP interview that on 2/16/17 at 10:15 AM, Resident #1's responsible party was notified of his elopement and return without injury. On 2/17/17 at 9:00 AM, The SA verified through record review that the Mississippi Department of Health was notified via fax by the facility Administrator of the elopement.

Based on observation, staff interview, and facility policy review, the facility failed to maintain the metal door frame casing, and wooden baseboards in good repair to one (1) of two (2) bathing areas observed. Findings include: A review of the facility's policy titled, Maintenance Service, (no date) stated the function of the maintenance personnel included maintaining the building in good repair. An observation on 11/29/2016 at 3:00 PM, of the shower room on the North Hall, revealed the metal door casing had a corrosive area seven (7) inches wide, and seven (7) inches long, containing a corrosive hole that measured three (3) inches in diameter. Located at the base of the metal door casing was an attached, loose, dampened, and disintegrated baseboard measuring three (3) inches in width, and twenty four (24) inches in length. An interview on 11/30/2016 at 11:20 AM, with the Administrator revealed she was aware of the corrosive area located on the door casing in the North Hall bathing room. An interview on 12/01/2016 at 10:30 AM, with the Maintenance Director confirmed the area in the bathing room on the North Hall had a corrosive area at the base of the door casing with a corrosive hole. He also confirmed the attached wooden baseboard was loose, damp, and disintegrated. He stated the baseboard needed to be replaced, and the door casing needed to be repaired. He stated the baseboard was loose because the wall behind the baseboard had disintegrated, and there was nothing to hold it in place.

Based on staff interview, record review, and facility policy review, the facility failed to complete reference checks for one (1) of five (5) new hires reviewed during the survey, for Licensed Practical Nurse (LPN) #1. Findings include: Review of the facility's policy titled, Background Screening Investigations, without a date, revealed reference checks would be initiated within two days of employment, or offer of employment. A review of the facility's Personnel Record for Licensed Practical Nurse (LPN) #1 revealed no reference checks for a hire date of 10/13/2016. (LPN #1 had been previously employed at the facility, and quit working at the facility in June 2016). The Personnel Record's check-off list was dated 08/27/2013, with the word, need written by the title, Confidential Telephone Reference. An interview on 11/30/2016 at 11:30 AM, with the Administrator confirmed she could not find current reference checks for LPN #1 in the personnel file. The Administrator said the policy used for collecting reference checks was within the Abuse/Neglect policy, but was not specific on re-hires that were hired back within a year of leaving work. An interview on 11/30/2016 at 3:30 PM, with the Staff Development Nurse revealed she had been working with the facility almost a year. The Staff Development Nurse said she normally did two (2) reference checks for all new hires. She confirmed she did not do any reference checks for LPN #1 because she was a re-hire. An interview on 11/30/2016 at 3:30 PM, with the Director of Nursing (DON) revealed LPN #1 was a re-hire within a year, and the facility policy was the facility could use her work history at the facility. The DON said only in-house recommendations were used for the re-hire for LPN #1.

Based on record review, staff interview, and facility policy review, the facility failed to complete criminal background checks for two (2) of five (5) new employees hired in the previous four (4) months, Employee #2, and #4. Findings include: A review of the facility's policy entitled, Abuse Prevention Program, revised April 2014, documented: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting or mistreating individuals. Review of the list of employees provided by the facility on 02/03/16, identified five (5) new employees hired in the past four (4) months. Records were reviewed for five (5) new hires. There was no evidence the Mississippi Nurse Aide Registry was checked for the history of potential abuse prior to employment on the following employees: Employee #2 -a Licensed Practical Nurse, hired 12/18/15, and Employee #4 - a Nurse Aide Trainee, hired 11/23/15. During an interview on 02/04/16 at 11:45 PM, the Assistant Administrator acknowledged the Mississippi Nurse Aide Registry had not been checked on the new hires. During an interview on 02/04/16 at 3:06 PM, the Administrator affirmed the Mississippi Nurse Aide Registry was not checked for history of abuse for the two (2) of five (5) new hires.

Based on record review, staff interview, and facility policy review, the facility failed to ensure Registered Nurse (RN) coverage eight (8) hours daily for seven (7) days per week, for two (2) of 15 facility staffing days reviewed. This had the potential to affect all residents in the facility. Findings include: A review of the facility's policy entitled, Staffing, dated April 2007, documented: Our facility provides adequate staffing to meet needed care and services for our resident population. 1. Our facility maintains adequate staffing on each shift to ensure that our resident ' s needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care. Review of the schedule from 01/29/2016 - 02/03/16, revealed the following dates did not have eight (8) hours of RN coverage: 01/23/16 (Saturday) Total of three (3) hours worked. 01/24/16 (Sunday) Total of three (3) hours worked. During an interview on 2/4/16 at 11:45 AM, the Director of Nurses (DON) confirmed there were not eight (8) hours of Registered Nurse coverage on the day shift for 1/23/16 (Saturday) and 1/24/16 (Sunday). An interview on 02/04/2016 at 3:06 PM with the Administrator confirmed the facility did not provide eight (8) hours of registered nursing care on January 23, 2016 and January 24, 2016.

Based on observation, staff interview and facility policy review, the facility failed to provide care in a manner to prevent the possible spread of infection and cross contamination by failing to disinfect multi-resident use items and exercise proper hand hygiene during med pass for one (1) of three (3) medication passes and one (1) of four (4) nurses observed, and during incontinent care for one (1) of three (3) incontinent care observations. Findings include: Review of the facility's policy titled, Handwashing/Hand Hygiene (Revised 4/2012), revealed hand hygiene as the primary means to prevent the spread of infections. Hands are to be washed before and after direct resident contact or performing any invasive procedure (fingerstick blood sampling). If hands are not visibly soiled, an alcohol-based hand rub can be used before preparing or handling medications and is to be used after removing gloves. Review of the facility's policy titled Cleaning and Disinfection of Resident-Care Items and Equipment (Revised 10/2009), revealed reusable items are to be cleaned and disinfected between residents (stethoscopes, durable medical equipment). Review of the facility's policy titled Subcutaneous Injections (no date), revealed nursing staff is to perform hand antisepsis and put on gloves before administering an injection. Medication pass on 2/3/16 at 4:02 PM, revealed RN #1 failed to: wash hands during the entire observed medication pass, disinfect the pulse oximeter after use and prior to placing back into the medication cart, wear gloves while obtaining a finger stick blood glucose sample and administering two (2) insulin injections. During an interview on 2/4/16 at 4:40 PM, RN #1 acknowledged he did not wash or sanitize his hands at all during medication pass, wear gloves while obtaining a fingerstick blood glucose sample or while administering insulin injections, and disinfect the pulse oximeter after use. He further stated that germs could be passed back and forth between residents if hands are not washed or sanitized. He said he usually washes them more than he did during this particular medication pass. During an interview on 2/5/16 at 12:15 PM, the Director of Nurses (DON) confirmed the Staff Development Nurse witnessed RN #1 not washing his hands during medication pass. She also stated that it is important for nurses to wash and sanitize hands before procedures and to disinfect and clean reusable medical equipment. She further stated that hand washing is the most effective way to prevent infections and gloves should be worn when performing fingersticks and injections. An observation on 2/3/16 at 3:20 PM revealed failure of Nursing Assistant (NA) #1 to change gloves and wash hands after gloves became visibly soiled during incontinent care of Resident #8. With soiled gloves, she (NA #1) continued to perform incontinent care, wiping back to front (dirty to clean) and was observed touching the following items: reached back into the clean pack of wipes, the periwash bottle, clean sheets, Resident #8's right side, and a clean bed pad. Upon completion of incontinent care, NA #1 removed the gloves but failed to wash her hands. With bare hands, NA #1 picked up the bottle of peri-wash and disposable wipes that had been touched with soiled gloves and placed them back in Resident #8's wardrobe cabinet. During an interview on 2/4/16 at 4:30 PM, NA #1 confirmed she did not change gloves or wash her hands during perineal care for Resident #8 and acknowledged this practice could spread germs. During an interview on 2/5/16 at 12:01 PM, the Director of Nurses (DON) stated it was the Staff Development Nurse's responsibility to ensure the Nursing Assistants and Certified Nursing Assistants were monitored for correctly performing perineal care. She also stated the Staff Development Nurse was recently hired and that no perineal care skills check-offs had been performed since 2014. She further stated wiping back to front (dirty to clean) could potentially introduce bacteria into the urinary tract.

Based on observation, staff interview and facility policy review, the facility failed to ensure the procedural steps of incontinent care were followed as evidenced by failure to change soiled gloves and wash hands and wipe perineum front to back for one (1) of three (3) incontinent care observations. Resident #8. Findings include: Review of the facility's policy Perineal Care (Revised 3/2015), revealed perineal care should be provided in a matter to promote cleanliness and to prevent infections and skin irritation. Steps in the procedure should include washing and wiping the perineal from front to back and hands are to be washed and dried thoroughly. An observation on 2/3/16 at 3:20 PM of incontinent perineal care for Resident #8, revealed Nursing Assistant (NA) #1 wiping the resident in a back-to-front fashion, rather than front-to-back. In an interview on 2/4/16 at 4:13 PM, Certified Nursing Assistant (CNA) #2 confirmed Nursing Assistant (NA) #1 wiped improperly during incontinent care for Resident #8. In an interview on 2/5/16 at 12:01 PM, the Director of Nursing (DON) said it was the Staff Development Nurse's responsibility to ensure the NA's and CNA's were monitored for correctly performing perineal care. She stated the Staff Development Nurse had just recently been hired and there had been no perineal care skills check-offs since 2014. She also stated wiping from back to front (dirty to clean) during perineal care could introduce bacteria into the urinary tract. Review of the facility's face sheet revealed Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/29/16, revealed long and short term memory deficits and moderately impaired cognitive skills. The MDS also assessed Resident #8 as requiring extensive assistance with toileting, bed mobility, and transfers; being totally incontinent of bowel and bladder.

Based on observation, interview, record review and facility policy review, the facility failed to implement written policies and procedures that prohibit neglect/adequate supervision of residents to prevent one (1) of six (6) sampled residents reviewed, Resident #1, from exiting the building (time undetermined) unsupervised and without staff knowledge. Resident #1 exited the building unsupervised and without staff knowledge on 12/24/10. Resident #1 was last seen in her room by Certified Nurse Assistant (CNA) #2 at approximately 11:10 a.m. on 12/24/10. Resident #1 was observed outside of the facility by staff who were on break and was returned to the facility by staff on 12/24/10 at approximately 11:15 a.m. To exit the facility a keypad code is required to open the exit doors. Facility supervision measures consisted of placing/monitoring a green arm bracelet on residents, who were identified to be at risk for wandering and monitoring doors for closure. The green bracelet was checked once a week by the Social Service Director (SSD). As of 1/25/11, there had been no additional supervision measures implemented by the facility to ensure the safety of residents who were identified to be at risk for wandering. The lack of the implementation of safety measures to ensure that Resident #1, who was assessed as exhibiting wandering behaviors, did not exit the building without staff supervision or staff knowledge was deemed as an Immediate Jeopardy (IJ) on 1/26/11 at 3:00 p.m. The IJ began on 12/24/10 and was determined to be removed on 1/28/11. The Administrator was notified of the Immediate Jeopardy on 1/26/11 at 3:20 p.m. The facility provided a credible Allegation of Compliance (AoC) on 1/28/11. Based on the facility's implementation of corrective actions the Immediate Jeopardy was removed and the scope and severity was lowered on 1/28/11 to a "D" level which constitutes no actual harm with potential for more than minimal harm. Findings Include: Cross Refer to F-323 for the facilities failure to ensure that Resident #1 did not leave the building without staff knowledge and supervision. "Credible Allegation of Compliance" "Resident #1 was observed in her room sitting on her bed by CNA #2 at 11:10 a.m. on December 24, 2010. Resident #1 was observed standing on the front lawn outside the dayroom window by 4 (four) staff members on break in the day room on December 24, 2010 at approximately 11:15 a.m. by CNA #1, Housekeeper, #1, Maintenance Director and Laundry #1. Resident #1 ambulated back into the facility escorted by CNA #1, Laundry #1 and Housekeeper #1 via the front door at approximately 11:17 a.m. on December 24, 2010. On December 24, 2010 Resident #1 was assessed by the RN Charge Nurse #1 at approximately 11:20 a.m. no evidence of physical, mental or emotional trauma was identified. LPN #1 notified MD at 11:20 a.m. on December 24, 2010 and MD called back at 11:30 a.m. Resident #1 responsible party was notified of the incident on December 24, 2010 at 11:25 a.m. At approximately 12:00 p.m. on December 24, 2010 the administrator changed the front door code, checked all exit doors to ensure all doors secure and in working order and alerted on duty staff that the new code was not to be given to any non-staff persons. On December 24, 2010 at approximately 12:10 p.m. the administrator posted a note above the time clock and at the nurse's station alerting staff that only they could open the door and the front door code could no longer be given out to any non-staff person. All exit doors used by the public have signs posted instructing visitors not to let anyone out without consulting with staff and these signs have been in place since 2007. Resident #1 was placed on 1-1 observation at 11:20 a.m. on 12/24/10 while awake. 1-1 continued during waking hours (7:00 a.m. until 11:00 p.m.) until she was transferred and discharged to Senior Care at 9:00 a.m. on 12/27/10. Resident was placed on q (every) 15 minute visual checks during hours of sleep (11:00 p.m. until 7:00 a.m.) on 12/24/10 and q 15 minute checks were discontinued and routine q 2 hour rounds/checks during night hours were implemented as resident had made no further attempts to leave the facility. Night hours are considered 11:00 p.m. until 7:00 a.m. Resident remained on 1 on 1 observation during day hours until her discharge and admission to Senior Care on 12/27/10 at 9:00 a.m. per MD order. On 12/24/10 at 11:20 a.m. 1 on 1 was initiated by Activity Assistant #1 and continued until 4:15 p.m. which was documented in the nurses note. 12/24/10 CNA #3 was assigned from 4:15 p.m. until 4:45 p.m. 12/24/10 RN charge nurse #2 was assigned to 1 on 1 observation from 4:45 p.m. until 10:00 p.m. 12/24/10 LPN #3 began visual checks at 11:10 p.m. and continued until 6:00 a.m. on 12/25/10. 12/25/10 at 6:00 a.m. CNA #5 was assigned to perform 1 on 1 observation until 2:00 p.m. 12/25/10 at 2:00 p.m. CNA #3 was assigned to perform 1 on 1 observation until 3:00 p.m. 12/25/10 at 3:00 p.m. CNA #6 until 4:00 p.m. and documented in the nurses notes. 12/25/10 RN charge nurse #2 from 4:00 p.m. to 8:00 p.m. 12/25/10 CNA #6 8:00 p.m. to 11:00 p.m. 12/25/10 from 11:00 p.m. to 7:00 a.m. on 12/26/10 LPN #3. 12/26/10 CNA #4 from 6:00 a.m. to 2:00 p.m. 12/26/10 CNA #3 from 2:00 p.m. to 3:00 p.m. 12/26/10 CNA #6 from 3:00 p.m. to 4:00 p.m. 12/26/10 RN charge nurse #2 from 4:00 p.m. to 10:00 p.m. 12/26/10 CNA #6 from 10:00 p.m. to 11:00 p.m. 12/26/10 11:00 p.m. to 12/27/10 at 7:00 a.m. CNA #7. 12/27/10 6:00 a.m. to 9:00 a.m. CNA #4. At approximately 9:00 a.m. on 12/27/10 resident was transferred to Senior Care and admitted per physician's orders [REDACTED]. An in-service was initiated on 12/28/10 at 2:00 p.m. for all staff by Staff Development Nurse regarding confidentiality of front door codes to ensure resident's did not exit facility without supervision. Staff Development Nurse conducted a mandatory in-service on 1/10/11 at 2:00 p.m. for all staff regarding established policies and procedures for: (a) abuse and neglect b) wandering and elopement protocols and the change of the door codes. No staff will be allowed to work prior to completing this in-service. Resident #2 was identified to be at risk for elopement on 12/24/10. Resident #2 has made no attempts to exit the facility. On 12/24/10 at approximately 12:30 p.m. RN charge nurse #1 reviewed Resident #2 clinical record and verified that Resident #2 had a current elopement assessment and care plan in place and no changes were necessary. RN charge nurse #1 reviewed the elopement book for Resident #1 and Resident #2 to ensure information was current and accurate. No changes were necessary. Resident #4 was identified as an elopement risk on January 5, 2011 and care plan for Resident #4 was developed and implemented with no problems. Resident #4 was discharged to the hospital January 15, 2011. Resident #3 was identified as an elopement risk on January 13, 2011 and a care plan for Resident #3 was developed and implemented with no problems. Resident #3 was discharged to the hospital on January 13, 2011. Resident #3 and Resident #4 will be reassessed upon return to the facility and care plans will be developed and implemented as indicated to ensure needs are met. Quality Improvement Committee met on 12/28/10 at 9:00 a.m. and discussed the elopement incident that occurred on 12/24/10 and interventions put in place. a) front door code had been changed. b) notes had been posted to inform staff on change and that only staff would have access to front door codes and staff would need to let visitors out. c) reviewed care plan and elopement book for all residents identified at risk for elopement. The administrator will change all door codes monthly or more frequently if needed. The facility staff will continue to check all doors each shift per policy and procedure to ensure that doors are secure. Resident #2 care plan will be revised as of January 28, 2011 at 4:00 p.m. to reflect the assigned medication nurse will perform a visual check q shift to ensure the green elopement bracelet is in place and document accordingly on the Medication Administration Record. Policy and procedure for wandering/elopement has been revised as of January 28, 2011 @ (at) 4:15 p.m. to reflect changes in monitoring and documentation of green elopement bracelets for residents identified at risk for elopement. Nurse #5 in-serviced nurses on duty January 28, 2011 at 3:15 p.m. regarding changes in monitoring of green elopement bracelet q shift and documenting on Medication Administration Record. DON and or Designee will ensure all nurses are in-serviced on this change prior to being allowed to work. DON or designee will conduct shift to shift in-services to ensure all nurse are aware of changes related to the monitoring green elopement bracelets. DON and or Designee will check all residents at risk for elopement to ensure green bracelet is in place and documented on the Medication Administration Record daily for 1 week then 3 x week for 2 weeks beginning January 28, 2011 @ 4:00 p.m. DON will report the findings to the Quality Assurance Committee. The Quality Assurance Committee which meets quarterly and QA committee will review all interventions, determine effectiveness and make changes based upon results achieved." Verification of the AoC: Random interviews with Maintenance/Housekeeping, Laundry, Social Services, Dietary, Nursing Staff (LPNs and RNs), and CNAs were conducted from 1/27/11 at 3:50 p.m. to 1/28/11 at 4:42 p.m. On 1/28/11 at 11:40 a.m., it was verified through random interviews, written staff statements and employee timecards, that the monitoring of visual checks on Resident #1 were conducted until Resident #1 was discharged to Senior Care on 12/27/10 at 9:00 a.m. Observation of door codes and exit doors were checked on 1/28/11 at 4:10 p.m. to 4:42 p.m. and were found to be in working order. Also, all exit doors have signs posted instructing visitors not to let anyone out without consulting with staff. Observation and interview with the Administrator on 1/28/11 at 5:20 p.m. verified that all door codes had been changed and not to be given to any non-staff person. The Inservice records were verified with Staff Development on 1/28/11 at 1:15 p.m., against the staff roster, to ensure all employees had been inserviced on confidentiality of door codes, abuse and neglect, wandering and elopement protocols, and monitoring of green elopement bracelets. Review of the Wandering/Elopement/Resident's At Risk Policy and Procedure was verified to be updated on 1/28/11 at 4:15 p.m. The policy updated that green elopement bracelets will be checked by the medication nurse each shift and the results documented on the Medication Administration Record (MAR). Review of the Quality Improvement committee sign in sheet on 1/27/11 at 12:25 p.m. verified that the committee met. Review of the MAR on 1/28/11 at 5:05 p.m., verified that there was one (1) resident (Resident #2) that required visual checks every (q) shift to ensure the green elopement bracelet was in place and documented on the MAR. Resident #3 and Resident #4 were not observed during the complaint survey prior to exit on 1/28/11 at 6:30 p.m. because they were in the hospital. Resident #3 was discharged to the hospital on [DATE]. Review of the "Bed Reservation Agreement" revealed that a fifteen (15) day hospital length of stay is allowed. Review of Resident #3's "Bed Reservation Agreement" revealed that the Responsible Party did not agree to pay for non-covered days. Resident #4 was discharged to the hospital on [DATE]. Review of Resident #4's "Bed Reservation Agreement" revealed that the Responsible Party agreed to pay for the non-covered days. Resident #3 and Resident #4 were assessed and addressed as at risk wanderers. The facility noted them in the AoC and that the residents would be re-assessed upon return to the facility from the hospital. Care plans will be developed and implemented to ensure needs are met. After verification of the facility's corrective action through observations, staff interviews and inservice reviews, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 1/28/11 to a "D" level which is no actual harm with the potential for more than minimal harm. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated for effectiveness by the facility's Quality Assurance (QA) committee.

Based on observation, interview, record review and facility policy review, the facility failed to provide adequate supervision to prevent one (1) of six (6) sampled residents reviewed, Resident #1, from exiting the building (time undetermined) unsupervised and without staff knowledge. Resident #1 exited the building unsupervised and without staff knowledge on 12/24/10. Resident #1 was last seen in her room by Certified Nurse Assistant (CNA) #2 at approximately 11:10 a.m. on 12/24/10. Resident #1 was observed outside of the facility by staff who were on break and was returned to the facility by staff on 12/24/10 at approximately 11:15 a.m. In order to exit the facility a keypad code is required to open the exit doors. Facility supervision measures consisted of placing/monitoring of a green arm bracelet on residents, who were identified to be at risk for wandering and monitoring doors for closure. The green bracelet was checked once a week by the Social Service Director (SSD). As of 1/25/11, there had been no additional supervision measures implemented by the facility to ensure the safety of residents who were identified to be at risk for wandering. The lack of the implementation of safety measures to ensure that Resident #1, who was assessed as exhibiting wandering behaviors, did not exit the building without staff supervision or staff knowledge was deemed as an Immediate Jeopardy (IJ) on 1/26/11 at 3:00 p.m. The IJ began on 12/24/10 and was determined to be removed on 1/28/11. The Administrator was notified of the Immediate Jeopardy (IJ) on 1/26/11 at 3:20 p.m. The facility provided a credible Allegation of Compliance (AoC) on 1/28/11. Based on verification of the facility's implementation of corrective actions the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 1/28/11 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: The facility submitted the following information to the state agency: "Suspected Abuse Investigation Form. Date: 12/29/10. Date/Time of Incident: 12/24/10 approx. 11:20 a.m. Description of Incident: (Name of Resident #1) was observed by several staff members outside of facility on front lawn. (Name of Resident #1) left the bldg (building) on 12/24 @ approximately 11:20 a.m. it is thought behind a male visitor who had been seen heading towards the front exit. She was seen on the lawn in the front yard by several staff members and immediately brought back into the facility. No injuries were sustained. She said she was trying to get back into the bldg. She was placed on 1-1 observation...". The family, Physician and State Agency were notified. Weather history for 12/24/10 at 10:56 a.m. for the facility area was 51.1 degrees Fahrenheit (F). Partly cloudy with 50% humidity. On 1/25/11 there were three (3) resident's in the facility identified with wandering behaviors/elopement risk. Resident #1 Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Observation of Resident #1 was not conducted during the on-site investigation. Resident #1 was discharged from the facility on 12/27/10. Observation on 1/26/11 at 10:20 a.m. of the physical site/front lawn where Resident #1 was found revealed: The area/site was 110 steps from the facility front door and approximately 80 steps from the facility driveway. The site was directly in front of the day room windows of the facility. Walk time from the facility front door to the site were Resident #1 was found took one (1) and one half (1/2) minutes. (Note exit door Resident #1 left the facility from was undetermined). Review of Resident #1's five (5) day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/10 revealed a Brief Interview for Mental Status (BIMS) score of 2 (two) (0-7 = severe cognitive impairment). Wandering behavior occurred 1 (one) to 3 (three) days during the assessment period. Review of Resident #1's medical record revealed: "Psychiatric Evaluation" dated 11/29/10 revealed "History of Present Illness: Over the past couple of weeks the patient has also had some dramatic behavioral problems, worsening cognition and perceptual problems. Specifically, the patient was taken from her home to go spend the night at her sisters house a couple of weeks ago and she became very agitated from that, was not sleeping, not eating well, was constantly roaming and wandering around for about three days following that. This again was rekindled around Thanksgiving." "Nursing Home Psychological Services Initial Evaluation Note" dated 12/16/10 revealed "Reasons for referral: New admission, assess mood, cognition, and efficacy of psychoactive medication due to Dementia with Behavior Disturbance. Occ (occasional) wandering and restless bhx (behavior)." "Physician Orders" dated 12/10 revealed "High Risk for Falls; Sliding Scale Insulin; Seroquel 50 mg (milligram) (1) PO (by mouth) QD (every day) @ (at) 2 p.m. for Alzheimer's Dementia with Behavioral Disturbance/Delusions; Seroquel 100 mg (1) PO Q (every) HS (hour of sleep) for Alzheimer's Dementia with Behavioral Disturbance/Delusions; Remeron 30 mg (1) PO Q HS hour of sleep for Insomnia; and Ativan .5 mg (1) TID (three times a day) for Anxiety." "Total Care Plan" dated 12/17/10 revealed: "Problems or Needs - Resident is wandering @ risk for elopement. Approaches - 1) monitor doors for complete closure; check door alarms for proper working order frequently. 4) Resident's picture et (and) face sheet to be kept in green elopement binder @ nurse's desk. 5) Resident to have on green arm band to indicate to staff that she is @ risk for elopement. 6) Staff to insure that resident is wearing all identification bracelets @ all times. 9) Resident's chart to have green sticker on spine of chart to indicate potential for elopement. 10) Green sticker to be placed on resident's ADL record to indicate potential for elopement. 11) List of resident's names that are @ risk for elopement kept in view of staff @ nurses station." Review of Resident #1's medical record revealed that there was no documentation that the facility had monitored placement of Resident #1's green arm band/bracelet. Review of the "Nurses Notes" revealed: On 12/13/10 at 10:50 a.m. "Res (resident) is oriented but has confusion et (and) requires redirection et verbal cues." 12/13/10 at 8:05 p.m. "She has been confused and trying to locate her husband." 12/14/10 at 8:00 p.m. "She has remained confused and must be frequently re-oriented to room number and location." 12/16/10 at 6:30 p.m. "Res. has been ambulating throughout facility. Res is confused et staff unable to reorient res to place et time. Res left dining rm (room) several x's (times) throughout meal voicing "I have a telephone call @ the concession stand." 12/17/10 at 6:50 p.m. "Has not attempted any elopement this shift but has voiced the need to get home because husband had an accident which she heard about in phone call in her room, continuing to monitor." 12/24/10 at 11:20 a.m. "Staff member observed resident to be walking outside alone near day room. Staff immediately assisted resident back into facility. Resident states, "I was only trying to find the front door to get back in the facility. Resident placed on one on one c (with) staff member @ this time." "Social Progress Notes" dated 12/15/10 revealed "Resident seen per SSD (social service director) this day ambulating throughout facility. Resident is an elopement risk and is observed/re-oriented as indicated." Interview on 1/28/11 at 10:25 a.m. with the Social Service Director (SSD) revealed; "She (Resident #1) required redirection and is very confused. I wrote a note on 12/15/10. That day she was a busy body. You would see her at the bird cage up front then I'd see her at her room. I believe she was considered an elopement risk on 12/15/10 based on what I saw." "Elopement Risk Assessment" dated 12/17/10 revealed "Instructions: Complete upon admission. Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near exit door?- "yes". Has the family/responsible party voiced concerns that would indicate the resident may have wandering tendencies or try to leave? "yes". Resident is at risk for elopement, as evidenced by: confusion- wandering." Interview on 1/26/11 at 1:25 p.m. with Registered Nurse (RN) #5 revealed: "I don't know why an elopement assessment wasn't done upon admission. I don't do them upon admission, the Medicare Nurse would have been responsible for doing it. I was doing the five (5) day assessment and identified there was an issue based on observation and chart review. She was added to the elopement book on 12/17/10 before 4:00 p.m." Interview on 1/26/11 at 2:00 p.m. with RN #4/Medicare Nurse revealed "I didn't do an elopement assessment on her (Resident #1). That's not an assessment I usually do." "Fall Risk Evaluation" dated 12/17/10 revealed: "Total score-13 (A resident who scores a 10 or higher is at risk)." Review of Resident #1's hospital admission records dated 12/27/10 revealed: "History of Present Illness: The patient is referred back to Senior Care Unit (SCU) from Glen Oaks Nursing Home due to problems with wandering and elopement. Apparently she has been somewhat successful in her attempts to elope on a couple of occasions. Past Psychiatric History: The patient was admitted to Senior Care Unit in November 2010 for similar problems. Admit Note: 12/27/10 1025 (10:25 a.m.) Brought to SCU p (pass) eloping from nursing home. GONH (Glen Oaks Nursing Home) DON (Director of Nursing) states that their facility is not equipped to handle elopement risk pts (patients)." Interview on 1/26/11 at 3:45 p.m. with the Senior Care Unit Physician revealed "She has been to our unit twice. She was here 11/10. She didn't adapt well to changes, had extreme confusion. She is wander risk, no doubt about it. On her first admission she was at risk because she was confused. If you see her you would think she was just fine until you talked to her for about 20 seconds. Makes sense to me that she got out the same day she saw her husband." Review of the facility "Weekly ID Bracelet Check" revealed: "Census List - 12/15/10 - (Name of Resident #1) one (1) check mark was in place." "Census List -12/22/10 (Name of Resident #1) two (2) check marks elopement" Interview on 1/27/11 at 4:10 p.m. with the Social Service Director (SSD) revealed: "I keep a book of ID bracelets for the whole facility. If they are an elopement risk I check to see if they have a green bracelet on. If I have a policy for this book "ID Bracelet Book", I don't know. I keep three (3) months worth of checks and after three (3) months I take the check sheets and shred them. I don't document if residents has on green bracelet in the medical record. I just do a check by the resident name in my ID bracelet book once a week. The ID book stays in my office and no one looks at the book but my consultant." Interview on 1/26/11 at 1:45 p.m. with Registered Nurse (RN) #1 revealed that on 12/24/10 "Her (Resident #1) family had been here that morning about 9:30 a.m. She was more confused that day. You would have to tell her it's breakfast or lunch and she would go with you. She knew she was in a nursing home but was confused to time. She knew her name but five (5) minutes later she would say she was in a hospital about to have surgery. That same day she told me she was at the court house on jury duty. The next time I saw her the aides were taking her to lunch about 11:00 a.m. I don't remember which CNA took her to the dining room." Interview on 1/25/11 at 3:15 p.m. with RN # 4 revealed: "facility does not document any monitoring of residents at risk for wandering until that person actually states wants to leave or goes to the door and seen at the door by staff. Visitors are not supposed to have the door code now." Review of facility submitted statement revealed: "In reference to staff who was assigned to care for resident (Name of Resident #1) on 12/24/10 7/3 shift. LPN assigned - (Name of LPN #3). CNA assigned - (Name of CNA #2.)" Interview on 1/26/11 at 4:40 p.m. with CNA #2 revealed: "She (Resident #1) was in her room sitting on her bed about 11:10 a.m. when I passed by her room going to another residents room. I was in other room about 15 minutes when (Name of Housekeeper #1) came to the door. I assume she got out when we had a lot of visitors that day. I don't know how long she was out there or how she got out. She (Resident #1) had said a couple of times before that day that she wanted to check out the hotel. I don't think she had on a green arm band on 12/24/10." Interview on 1/26/11 at 11:05 a.m. with the Maintenance Supervisor revealed that he worked on 12/24/10. He stated that about 11:10-11:15 a.m. while taking a break, he saw a lady outside the window, and other staff with him noted the lady to be Resident #1. "I don't know how she got out." Interview on 1/26/11 at 9:35 a.m. with Certified Nurse Assistant (CNA) #1 revealed: "I worked 12/24/10 6:00 - 2:00 p.m. We were sitting there in the day room taking a break. I don't know exactly what time it was but it was after 10:00 a.m. A (company) delivery man came to the front door and brought packages. It was normal for the (company) delivery man to leave the door blocked open when he has a lot of packages. About 10:55 a.m. (Name of Maintenance Supervisor) said that there is a lady. She was outside the building passing by the day room window. She was (Name of Resident #1). She was headed away from the front door. We went through the Chapel Door and went around and got her. I asked her where she was going and she said that she was trying to get back in. I didn't check her arm to see if she had a green arm band on." Interview on 1/26/11 at 10:35 a.m. with Laundry #1 revealed: "I worked 12/24/10 and know (Name of Resident #1). About 11:15-11:20 a.m. I was taking my break in the day room. (Name of Maintenance Supervisor) saw (name) Resident #1 first. Nobody else was with her. She was walking outside the building. I don't know how she got out. We went out to her. (Name of Licensed Practical Nurse) LPN #1 was the first one who got to her. When we came in (Name of Administrator) was standing at the front door. She had on a green bracelet on 12/24/10 when we saw her outside." Interview on 1/26/11 at 12:10 p.m. with Housekeeper #1 revealed that on 12/24/10 at a little after 11:00 a.m. she was sitting in the day room on break with other staff. She saw Resident #1 walking outside of the facility by herself. Resident #1 had on a shirt and pants. Housekeeper #1 stated: "I didn't see her come out the front door." Interview on 1/25/11 at 6:05 p.m. with CNA #3 revealed: "If a resident goes up to the door or say they want to go home then it is considered at risk for trying to get out." Interview on 1/26/11 at 8:55 p.m. with LPN #1 revealed: "I was assigned to (Name of Resident #1) on 12/24/10. It was a little after 11:00 a.m. and they said she was out (of the building). We went to her. I was the first person to get to her. She was right outside the day room window next to the chapel area. When I got to her nobody else was outside with her. She didn't have any injuries and we brought her back in through the front door. She said she was "trying to get back into the hospital honey". She was at risk for wandering. I don't remember checking to see if she had on a green arm band the day she got out. She couldn't tell me how long she had been out. I have never documented if a resident has on a green arm band." Interview on 1/26/11 at 2:20 p.m. with the Administrator revealed that LPN #1 and CNA #2 were assigned to Resident #1 on 12/24/10. The Administrator stated: "I was in my office doing deep cleaning on 12/24/10. I had my window open and heard voices. Between 11:00 - 11:30 a.m. I saw several staff members walking (Name of Resident #1) from picnic table toward the front door. They said that she was seen in the front yard. She was fine, no marks on her body, not in distress. I could see she had on pants, a top and shoes. The weather was mild. We put her one (1) on one (1) observation and changed the door code on 12/24/10. It was the first of the week of 12/27/10 when I told staff no non-staff or visitors would have or could have the front door code. They accepted her (Resident #1) to Senior Care that Monday (12/27/10) morning." Review of facility documentation dated 12/24/10 revealed: "Attention Staff. Front door code has been changed for resident safety. Do not give this code out to anyone other than staff. Staff members are to let visitors out. No exceptions!!" Review of facility documentation dated 1/25/11 revealed: "Glenoaks Nursing Center does not use any sort of electronic monitoring device for wandering residents." Review of additional documentation submitted by the facility dated 1/28/11 revealed: "Prior to the elopement incident on 12/24/10, Glenoaks Nursing Center staff were allowed to give out the door codes to family members with the understanding that they would not give the code to anyone and that they would observe the signs posted on exits doors stating that no one would be let out of the facility without consulting with staff." The facility provided no documentation that family members signed documentation regarding the understanding of not giving the door code out to anyone. Review of the facility policy "Elopement" dated 7/07 revealed: "All residents will be monitored and evaluated routinely for demonstration of elopement risk. In the event that a resident attempts to leave the facility unescorted or is found to be missing, the following steps should be followed: (1). A list of all residents identified as a potential for elopement will be kept current at the nurses station. A census list of all residents will be kept current at the nurses station and residents who are at risk for elopement will be highlighted. (6). All residents are to have proper identification on their person, i.e., arm band, unless documented as refused. A picture of all residents should be maintained on the medical record and updated annually." Review of the facility policy "Abuse/Neglect Reporting - Resident" dated 6/01 revealed: "(1). Each resident residing in this facility has the right to be free from verbal, sexual, mental, physical abuse, including corporal punishment, involuntary seclusion and/or misappropriation of property. (2). All potential new employees and volunteers will be screened for a history of abuse, neglect, or mistreatment of [REDACTED]. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well being. Neglect: a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." Review of the facility policy "Wandering Resident Drill" dated 7/07 revealed: "Policy: It is the policy of this facility to have in place a system by which all resident's within the facility can be accounted for in an efficient organized manner. Procedure: (9). This drill will be held quarterly. There shall be a written record kept of all wandering resident's drill and retained in notebook in the DON office. (6). A check of all doors and keypads will be conducted every shift to ascertain that they are in proper working order and doors are securely latched. The nurse on duty will perform this. A record of the checks will be kept in the front of the MAR (form door alarm check)." Review of the facility policy "Visual Checks- Resident" dated 6/94 revealed: "It is the policy of this facility to complete visual checks of residents that are attempting to leave the facility, or have left the facility without staff/family assistance, unless they have been authorized to do so. The visual checks will be done if the resident attempts to leave the facility or on return of the resident to the facility after an unauthorized exit. Visual checks will be done every 15 minutes X 4 hours; every 30 minutes X 4 hours; then hourly X 8 hours. This time frame will be followed unless the resident is still exhibiting signs/symptoms of restlessness and attempting to leave. If the resident's behavior continues or resumes, the 15 minute visual checks will be continued or restarted until such time as the behavior subsides and then complete the above process. Documentation is to be completed regarding the resident's activity, behavior and interventions tried by the facility. This documentation should be in the nurse's notes. The resident must be placed in acute charting and remain in acute charting throughout the visual check process." Review of the facility "Door Alarm Check List" dated 10/23/10 to 1/10/11 revealed no documentation as to which door alarms were actually monitored. Review of the facility policy "Identification of Patients - Armbands/Photos" dated 6/94 revealed: "1. A photo of each resident will be maintained on the Medication Administration Record, as a means of a Resident Identification System. 2. A name identification bracelet will be administered to each resident upon admission. These bracelets will contain the resident's name and room number, facility name, and facility telephone number. A red ID band will be used to note that a resident has a No Code order. All other bands will be white. A designated facility employee will be responsible for maintaining the identification bracelets on an ongoing basis. (3).The Social Service Director or other designated staff will be responsible for checking residents at least weekly to insure that ID bracelets are still in place and replace any missing bracelets. A roster of residents will be maintained noting all residents and ID bracelet status." Review of the facility policy "Wandering/Elopement/Resident's at Risk" dated 7/07 revealed "Purpose: To identify residents who have a potential to wander from the facility. To implement the appropriate protective measures to help guard against a resident wandering from the facility. Policy and Procedure: 1. On admission, quarterly and when a resident has a significant change in condition, the nursing staff will assess each resident for potential for elopement risk using the "Elopement Risk Assessment Form." After completing the Assessment Form, the nursing staff will determine if the resident is at risk for wandering/elopement. 2. A resident determined to be at risk for wander/elopement will be identified on the resident's comprehensive plan of care. 3. The nurse and other appropriate team members will document the resident's responses and reactions to the approaches used to curtail wandering/elopement. 4. All wandering episodes will be documented in the resident's medical record. An incident report will be completed for an incident of elopement. 5. The following items will be used to increase staff awareness of resident's at risk for wander/elopement. (a).A current list of all residents who have been identified at risk for wandering will be maintained in a "Green" notebook at the nurse's station along with a current Census list of all residents in the facility. The residents who have been identified as a potential for wandering/elopement will be highlighted on the census list.(b). Each resident who has been identified as a potential for Wandering/elopement will have a current photograph and current face sheet in a protective sheet in the "Green" notebook. (c). The notebook will be labeled on the outside covering "Resident's at risk for wandering/elopement". (d). Each resident identified at risk for wandering/elopement will be identified on the resident's individual ADL sheet and on the outside of the resident's chart with a "Green dot". e. A "Green" bracelet will also be placed on each resident identified to be at risk for wandering/elopement for easy identification on sight." "Credible Allegation of Compliance" "Resident #1 was observed in her room sitting on her bed by CNA #2 at 11:10 a.m. on December 24, 2010. Resident #1 was observed standing on the front lawn outside the dayroom window by 4 (four) staff members on break in the day room on December 24, 2010 at approximately 11:15 a.m. by CNA #1, Housekeeper, #1, Maintenance Director and Laundry #1. Resident #1 ambulated back into the facility escorted by CNA #1, Laundry #1 and Housekeeper #1 via the front door at approximately 11:17 a.m. on December 24, 2010. On December 24, 2010 Resident #1 was assessed by the RN Charge Nurse #1 at approximately 11:20 a.m. no evidence of physical, mental or emotional trauma was identified. LPN #1 notified MD at 11:20 a.m. on December 24, 2010 and MD called back at 11:30 a.m. Resident #1 responsible party was notified of the incident on December 24, 2010 at 11:25 a.m. At approximately 12:00 p.m. on December 24, 2010 the administrator changed the front door code, checked all exit doors to ensure all doors secure and in working order and alerted on duty staff that the new code was not to be given to any non-staff persons. On December 24, 2010 at approximately 12:10 p.m. the administrator posted a note above the time clock and at the nurse's station alerting staff that only they could open the door and the front door code could no longer be given out to any non-staff person. All exit doors used by the public have signs posted instructing visitors not to let anyone out without consulting with staff and these signs have been in place since 2007. Resident #1 was placed on 1-1 observation at 11:20 a.m. on 12/24/10 while awake. 1-1 continued during waking hours (7:00 a.m. until 11:00 p.m.) until she was transferred and discharged to Senior Care at 9:00 a.m. on 12/27/10. Resident was placed on q (every) 15 minute visual checks during hours of sleep (11:00 p.m. until 7:00 a.m.) on 12/24/10 and q 15 minute checks were discontinued and routine q 2 hour rounds/checks during night hours were implemented as resident had made no further attempts to leave the facility. Night hours are considered 11:00 p.m. until 7:00 a.m. Resident remained on 1 on 1 observation during day hours until her discharge and admission to Senior Care on 12/27/10 at 9:00 a.m. per MD order. On 12/24/10 at 11:20 a.m. 1 on 1 was initiated by Activity Assistant #1 and continued until 4:15 p.m. which was documented in the nurses note. 12/24/10 CNA #3 was assigned from 4:15 p.m. until 4:45 p.m. 12/24/10 RN charge nurse #2 was assigned to 1 on 1 observation from 4:45 p.m. until 10:00 p.m. 12/24/10 LPN #3 began visual checks at 11:10 p.m. and continued until 6:00 a.m. on 12/25/10. 12/25/10 at 6:00 a.m. CNA #5 was assigned to perform 1 on 1 observation until 2:00 p.m. 12/25/10 at 2:00 p.m. CNA #3 was assigned to perform 1 on 1 observation until 3:00 p.m. 12/25/10 at 3:00 p.m. CNA #6 until 4:00 p.m. and documented in the nurses notes. 12/25/10 RN charge nurse #2 from 4:00 p.m. to 8:00 p.m. 12/25/10 CNA #6 8:00 p.m. to 11:00 p.m. 12/25/10 from 11:00 p.m. to 7:00 a.m. on 12/26/10 LPN #3. 12/26/10 CNA #4 from 6:00 a.m. to 2:00 p.m. 12/26/10 CNA #3 from 2:00 p.m. to 3:00 p.m. 12/26/10 CNA #6 from 3:00 p.m. to 4:00 p.m. 12/26/10 RN charge nurse #2 from 4:00 p.m. to 10:00 p.m. 12/26/10 CNA #6 from 10:00 p.m. to 11:00 p.m. 12/26/10 11:00 p.m. to 12/27/10 at 7:00 a.m. CNA #7. 12/27/10 6:00 a.m. to 9:00 a.m. CNA #4. At approximately 9:00 a.m. on 12/27/10 resident was transferred to Senior Care and admitted per physician's order. An in-service was initiated on 12/28/10 at 2:00 p.m. for all staff by Staff Development Nurse regarding confidentiality of front door codes to ensure resident's did not exit facility without supervision. Staff Development Nurse conducted a mandatory in-service on 1/10/11 at 2:00 p.m. for all staff regarding established policies and procedures for: (a) abuse and neglect b) wandering and elopement protocols and the change of the door codes. No staff will be allowed to work prior to completing this in-service. Resident #2 was identified to be at risk for elopement on 12/24/10. Resident #2 has made no attempts to exit the facility. On 12/24/10 at approximately 12:30 p.m. RN charge nurse #1 reviewed Resident #2 clinical record and verified that Resident #2 had a current elopement assessment and care plan in place and no changes were necessary. RN charge nurse #1 reviewed the elopement book for Resident #1 and Resident #2 to ensure information was current and accurate. No changes were necessary. Resident #4 was identified as an elopement risk on January 5, 2011 and care plan for Resident #4 was developed and implemented with no problems. Resident #4 was discharged to the hospital January 15, 2011. Resident #3 was identified as an elopement risk on January 13, 2011 and a care plan for Resident #3 was developed and implemented with no problems. Resident #3 was discharged to the hospital on January 13, 2011. Resident #3 and Resident #4 will be reassessed upon return to the facility and care plans will be developed and implemented as indicated to ensure needs are met. Quality Improvement Committee met on 12/28/10 at 9:00 a.m. and discussed the elopement incident that occurred on 12/24/10 and interventions put in place. a) front door code had been changed. b) notes had been posted to inform staff on change and that only staff would have access to front door codes and staff would need to let visitors out. c) reviewed care plan and elopement book for all residents identified at risk for elopement. The administrator will change all door codes monthly or more frequently if needed. The facility staff will continue to check all doors each shift per policy and procedure to ensure that doors are secure. Resident #2 care plan will be revised as of January 28, 2011 at 4:00 p.m. to reflect the assigned medication nurse will perform a visual check q shift to ensure the green elopement bracelet is in place and document accordingly on the Medication Administration Record. Policy and procedure for wandering/elopement has been revised as of January 28, 2011 @ (at) 4:15 p.m. to reflect changes in monitoring and documentation of green elopement bracelets for residents identified at risk for elopement. Nurse #5 in-serviced nurses on duty January 28, 2011 at 3:15 p.m. regarding changes in monitoring of green elopement bracelet q shift and documenting on Medication Administration Record. DON and or Designee will ensure all nurses are in-serviced on this change prior to being allowed to work. DON or designee will conduct shift to shift in-services to ensure all nurse are aware of changes related to the monitoring green elopement bracelets. DON and or Designee will check all residents at risk for elopement to ensure green bracelet is in place and documented on the Medication Administration Record daily for 1 week then 3 x week for 2 weeks beginning January 28, 2011 @ 4:00 p.m. DON will report the findings to the Quality Assurance Committee. The Quality Assurance Committee which meets quarterly and QA committee will review all interventions, determine effectiveness and make changes based upon results achieved." Verification of the AoC: Random interviews with Maintenance/Housekeeping, Laundry, Social Services, Dietary, Nursing Staff (LPNs and RNs), and CNAs were conducted from 1/27/11 at 3:50 p.m. to 1/28/11 at 4:42 p.m. On 1/28/11 at 11:40 a.m., it was verified through random interviews, written staff statements and employee timecards, that the monitoring of visual checks on Resident #1 were conducted until Resident #1 was discharged to Senior Care on 12/27/10 at 9:00 a.m. Observation of door codes and exit doors were checked on 1/28/11 at 4:10 p.m. to 4:42 p.m. and were found to be in working order. Also, all exit doors have signs posted instructing visitors not to let anyone out without consulting with staff. Observation and interview with the Administrator on 1/28/11 at 5:20 p.m. verified that all door codes had been changed and not t