Every finding on record at Grenada Rehabilitation and Healthcare Center

Based on observation, staff and resident interviews, record review, and facility policy review the facility failed to provide timely incontinence care for a resident, causing the resident embarrassment and humiliation. This also put the resident at risk for skin impairment and discomfort for one (1) of four (4) residents reviewed. Resident #2.Findings Include: Review of the facility policy Activities of Daily Living (ADL), Supporting with revision date of March 2018, revealed .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .An observation and interview with Resident #2 on 04/06/26 at 11:00 AM revealed him lying in bed and there were multiple large smears of a yellowish substance on his bed pad, fitted sheet and on his flat sheet. Resident #2 attempted to cover up the yellowish substance with the clean part of the top flat sheet. Resident #2 revealed that he had had a bowel movement, had been lying in a dirty diaper for over an hour and was waiting for someone to come in and change him. Resident #2 stated, It's hard to get anyone to come in here and clean me up, they don't care. Resident pressed his call light at 11:08 AM.An observation on 04/06/26 at 11:11 AM revealed an unidentified staff member enter Resident #2's room, she deactivated the call light and exited. An observation and interview on 04/06/26 at 12:23 PM with Resident #2 revealed him in the same position, lying in a soiled brief with yellow fecal matter smeared on his bed pad, fitted and flat sheets. He stated, This makes me feel bad and No one else would want to lay here like this either. He revealed that it was embarrassing and he was upset and he wanted to get out of there as soon as he could. Resident #2 confirmed that someone had come in earlier to see what he needed, went back out to get someone to help, and had not returned.An observation and interview on 04/06/26 at 12:30 PM with Resident #2's Resident Representative (RR), revealed her sitting at the table in the dining room that was across the room from Resident #2's room. Resident #2's RR asked how long her brother had to wait before someone cleaned him up and changed him. She revealed that she had been there since 12:00 PM, had gone into his room and found him in a mess and he told her that he was waiting on someone to come in and change him. RR revealed that he had had a large bowel movement and it was all over him and his bed. She also revealed that when Resident #2 saw her enter his room, he was embarrassed and tried to cover it up with the clean part of his sheet. She revealed that she walked up to the nursing desk, told them he needed help and still no one came and she stated, Nobody should be treated like this. RR revealed that she saw a nurse go into his room earlier and she came back out into the hall and text someone with her phone. She revealed that he's been at the facility for 6-7 days after being in the hospital for over a month, he had to have one of his legs amputated, and he depended on the staff there to take care of him. An observation and interview on 04/06/26 at 12:35 PM with Certified Nursing Assistant (CNA) #1, revealed her out in the hall taking a lunch tray to the cart. She revealed that Licensed Practical Nurse (LPN) #1, notified her about Resident #2 needing to be changed a while ago, and her next stop was to take care of him. She revealed that she was very busy, that she went out to get supplies to change him and saw that the lunch trays had been delivered to the floor. CNA #1 revealed that she went and passed out trays and had to feed another resident before her food got cold. She again stated, I was going to change Resident #2 as soon as I finished feeding the resident. CNA #1 was tearful and confirmed that she would not want to be in a soiled brief for a long time and neither should he have to be. She also agreed that lying in a soiled brief for a long time could cause skin breakdown and that they were supposed to keep residents clean and dry. She agreed that she should have changed Resident #2 sooner and if she couldn't get to him timely, she should have asked for help.An interview on 04/06/26 at 12:42 PM with LPN #1, revealed that Resident #2's sister came to her and asked for someone to change him. She revealed that she went into the room and told Resident #2 that she was getting him some help, and then texted CNA #1, who said she was coming on in there to take care of him. LPN #1 confirmed that she had not followed up and did not know that CNA #1 had not changed him. She revealed that it was not acceptable to leave a resident in a soiled diaper or brief for long periods of time and confirmed that this could cause skin breakdown. She revealed that they were supposed to make rounds every two hours and if residents called to be changed, they were supposed to change them and not allow them to remain wet or soiled. During an observation and interview on 04/06/26 at 12:46 PM with the Administrator (ADM) and the Director of Nursing (DON) in Resident #2's room, they confirmed that he was lying in a soiled brief and confirmed the yellow fecal matter smeared on the outside of his bed pad and both sheets. The Director of Nursing stated that Resident #2 could not do for himself and depended on staff to meet his needs and this was not acceptable. She revealed that after CNA #1 saw him in this shape, she should have immediately gone back in and cleaned him up and not put him off. The DON revealed that leaving a resident in a soiled brief could result in skin breakdown, pressure ulcers and could be a dignity issue. The Administrator revealed that they expected their staff to answer call lights promptly and provide the care needed and not allow residents to be in this condition. The DON further revealed that if CNA #1 was busy, she could and should have asked someone for help. The ADM revealed that CNA #1 should have asked someone to help pass the trays or assist in getting Resident #2 changed. She revealed that these residents were everyone's responsibility and it takes teamwork to get the job done. ADM revealed that communication was the key and if she voiced that she needed help, someone would have helped. She revealed that no one would want to sit in a soiled brief and that Resident #2 should not have had to sit there embarrassed, having to wait that long to be changed.An observation on 04/06/26 at 12:50 PM revealed that CNA #1 entered Resident #2's room with her supplies to provide care, an hour and fifty minutes later than the first observation.Record review of Resident #2's admission Record revealed an admission date of 03/25/26 and that his diagnoses included Traumatic Subarachnoid Hemorrhage with Loss of Consciousness, Multiple Fractures of Ribs, Left Side. Record review of Resident #2's Progress Note dated 03/26/26 revealed .Resident has a Right BKA (Below the Knee Amputation) .Dependent on staff for all needs at this time with ADLs, transfers, turning and repositioning .Record review of Resident #2's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 03/30/26 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 13 which indicated that he was cognitively intact.

Based on observation, resident, resident representative, and staff interviews, and record reviews, the facility failed to ensure a resident's right to be treated with dignity and respect as evidenced by failure to respond in a timely manner to the resident's requests for assistance causing the resident embarrassment and humiliation for one (1) of four (4) residents reviewed, Resident #2. Findings include:On 04/06/26 at 11:00 AM an observation and interview with Resident #2 revealed him lying in bed and there were multiple large smears of a yellowish substance on his bed pad, fitted sheet and on his flat sheet. Resident #2 attempted to cover up the yellowish substance with the clean part of the top flat sheet. Resident #2 revealed that he had had a bowel movement, had been lying in a dirty diaper for over an hour and was waiting for someone to come in and change him. Resident #2 stated, It's hard to get anyone to come in here and clean me up, they don't care. Resident pressed his call light at 11:08 AM.On 04/06/26 at 12:23 PM an observation and interview with Resident #2 revealed him in the same position, lying in a soiled brief with yellow fecal matter smeared on his bed pad, fitted and flat sheets. He stated, This makes me feel bad and No one else would want to lay here like this either. He revealed that it was embarrassing and he was upset and he wanted to get out of there as soon as he could. Resident #2 confirmed that someone had come in earlier to see what he needed, went back out to get someone to help, and had not returned.On 04/06/26 at 12:30 PM during an observation and interview with Resident #2's Resident Representative (RR), she asked how long her brother had to wait before someone cleaned him up and changed him. She revealed that she had been there since 12:00 PM, had gone into his room and found him in a mess and he told her that he was waiting on someone to come in and change him. RR revealed that he had had a large bowel movement and it was all over him and his bed. She also revealed that when Resident #2 saw her enter his room, he was embarrassed and tried to cover it up with the clean part of his sheet. She revealed that she walked up to the nursing desk, told them he needed help and still no one came and she stated, Nobody should be treated like this. The RR revealed that she saw a nurse go into his room earlier and she came back out into the hall and text someone with her phone. She revealed that he's been at the facility for 6-7 days after being in the hospital for over a month, he had to have one of his legs amputated, and he depended on the staff there to take care of him. On 04/06/26 at 12:46 PM during an observation and interview with the Administrator (ADM) and the Director of Nursing (DON) in Resident #2's room, they confirmed that he was lying in a soiled brief and confirmed the yellow fecal matter smeared on the outside of his bed pad and both sheets. The Director of Nursing stated that Resident #2 could not do for himself and depended on staff to meet his needs and this was not acceptable. The DON revealed that leaving a resident in a soiled brief could result in skin breakdown, pressure ulcers and could be a dignity issue. The Administrator revealed that they expected their staff to answer call lights promptly and provide the care needed and not allow residents to be in this condition. The DON revealed that these residents were everyone's responsibility and it takes teamwork to get the job done. The ADM revealed that no one would want to sit in a soiled brief and that Resident #2 should not have had to sit there embarrassed, having to wait that long to be changed.Record review of Resident #2's admission Record revealed an admission date of 03/25/26 and that his diagnoses included Traumatic Subarachnoid Hemorrhage with Loss of Consciousness, Multiple Fractures of Ribs, Left Side. Record review of Resident #2's Progress Note dated 03/26/26 revealed .Resident has a Right BKA (Below the Knee Amputation) .Dependent on staff for all needs at this time with ADLs, transfers, turning and repositioning .Record review of Resident #2's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 03/30/26 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 13 which indicated that he was cognitively intact.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical abuse by a Certified Nurse Assistant (CNA) for one (1) of three (3) residents reviewed for abuse (Resident #7). This deficient practice resulted in the resident being forcefully pushed down onto the bed by a staff member, creating potential for physical injury and psychological harm. Findings include: Review of the facility policy titled Abuse Prohibition Policy, last reviewed 5/17/25, revealed the following: Intent: Each resident has the right to be free from abuse .Definitions: Physical Abuse includes hitting, slapping, kicking, shoving, pinching, and controlling behavior through corporal punishment . The policy further directed that all staff are responsible for immediately reporting any witnessed or suspected abuse and that any employee accused of abuse will be removed from resident care duties pending investigation. During an interview with the Administrator (ADM) on 10/28/25 at 2:55 PM, related to the facility-reported allegation of physical abuse involving Resident #7 and CNA #4, she confirmed that the facility did substantiate abuse occurred. She stated that CNA #1 came to her office that morning and reported witnessing CNA #4 abuse Resident #7. CNA #1 stated that she had asked for help to get Resident #7 dressed and that he was standing up beside his bed when CNA #4 had entered the room and pushed Resident #7 so hard that he fell on the bed. The ADM stated she immediately began an internal investigation, interviewed all parties involved, and assessed the resident. She stated the resident confirmed that CNA #4 had pushed him down from a standing position. The ADM reported that CNA #4 was immediately placed on administrative leave pending investigation and was terminated on 10/10/25 after the facility substantiated that the abuse did occur. An interview with Resident #7 on 10/28/25 at 2:50 PM revealed the resident was alert and oriented. When asked if he was okay, the resident stated, I'm fine. When asked specifically about CNA #4 pushing him onto the bed, the resident turned his head away and made no further comments and did not want to discuss it any further and appeared to withdraw from the conversation. Record review of the facility investigation dated 10/09/25 revealed that an interview was conducted with Resident #7 at the time of the incident and he confirmed that CNA #4 had pushed him down and stated, Nothing will be done to her. Peer reviews were conducted with seven employees and two of the employees revealed that they had heard CNA #4 talk rough to residents in the facility. During an interview with CNA #1 on 10/28/25 at 1:00 PM, she stated that on 10/9/25 she had been reassigned to A Wing for the day and was unfamiliar with that hall. She stated she observed Resident #7 standing in his room with his brief off and refusing assistance from staff. CNA #1 stated she asked CNA #4 to assist her with the resident because she was unfamiliar with him. She stated CNA #4 then entered the room and said in a rough voice, I can't do what I want to because B Wing is over here. CNA #1 stated that Resident #7 balled his fists but did not attempt to strike CNA #4 at all. She stated CNA #4 then pushed the resident very hard, causing him to fall backward onto the bed from a standing position. CNA #1 stated she immediately reported what she witnessed to the nurse and the administrator. During a phone interview with CNA #4 on 10/29/25 at 8:30 AM, she denied pushing Resident #7 down onto the bed. She stated she assisted the resident because he refused care from CNA #1. She stated she had cared for the resident frequently and that he was familiar with her. She confirmed she helped dress the resident and returned him to his chair but maintained that she did not abuse or push the resident. An interview with the Director of Nursing (DON) on 10/29/25 at 10:00 AM, she stated that staff abuse towards a resident could lead to physical harm, make them afraid and affect them mentally. Record review of an Abuse In-Service Attendance Sheet revealed CNA #4 last received abuse-prevention education on 6/10/25. The training included a review of abuse definitions, mandatory reporting, and staff responsibilities to treat all residents with dignity and respect. Record review of CNA #4's time sheet revealed her last day worked was 10/9/25, with documentation confirming she was removed from duty at 10:05 AM pending investigation. Record review of a Personnel Action Form revealed CNA #4 was terminated on 10/10/25. Record review of the admission Record revealed the facility admitted Resident #7 on 8/20/18 with a diagnosis that included cerebral infarction. Record review of Resident #7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/25 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact.

Based on interviews, record reviews, and facility policy review, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs. This deficient practice resulted in prolonged call-light response times and delays in assistance with care needs and had the potential to affect all 101 residents residing in the facility. Findings include:Review of the facility policy titled Staffing, Sufficient and Competent Nursing, last reviewed 3/2023, revealed, Policy Statement: Our facility provides sufficient numbers of nursing staff with the appropriate skills necessary to provide nursing and related care and services for all residents in accordance with resident care plans and facility assessment .Resident #1During an interview with Resident #1 during an onsite complaint investigation on 10/28/25 at 10:00 AM, she stated she has to wait too long to go to the bathroom. She stated she is often wet because she has an overactive bladder and cannot hold her urine that long. She stated, I feel like the staff try, but they are stretched so thin with not enough people working. I can put my call light on, and it will be an hour before anyone comes, and even worse on the weekends. It happens too often.Record review of the admission Record revealed Resident #1 was admitted on [DATE] with a diagnosis of overactive bladder.Record review of the Brief Interview for Mental Status (BIMS) dated 9/6/25 revealed a score of 15, indicating the resident was cognitively intact.Resident #2An interview in the room with Resident #2's sitter on 10/28/25 at 9:50 AM revealed she was not trained to provide care, that the family had hired her to help because the resident has a trach and requires extensive help and assistance and to be at the facility to help the staff when he needs to be turned or to notify the staff when he needs help because he can't push the call light. She stated, Sometimes we wait an hour or more for someone to come. He requires two staff for turning and incontinence care, and they have to wait until they can find someone to help. She stated, The staffing is horrible.An interview with the Respiratory Therapist on 10/28/25 at 12:20 PM revealed, It does take a while sometimes for the CNAs to change Resident #2 and he always requires two people because of the trach. Sometimes they have extra residents to care for because someone called in, and we are short-staffed all the time.An interview with Resident #2's representative on 10/28/25 at 3:00 PM revealed she hired private sitters to ensure the staff were taking care of her husband. She stated, You can call and wait hours before they come because he requires two people to care for him. There have been numerous times I call for help and just have to wait and wait. She stated a charge nurse told her, We don't have enough staff. She stated my husband has only been here a few months, but I saw right away that when I wasn't here who would check on him because the staffing is so bad, so I hired sitters and it is costing me so much money, but I feel I don't have a choice right now.Record review of the admission Record revealed Resident #2 was admitted on [DATE] with a diagnosis of anoxic brain damage.An interview with Certified Nurse Assistant (CNA) #2 on 10/28/25 at 1:30 PM revealed, Staffing is terrible. The call-ins are out of control. Sometimes we have 15 to 16 residents per CNA. Yes, call lights go off longer, and residents don't get changed as timely as they should. The workload is too much for the acuity of these bed-bound, total-care residents who often require the assistance of two staff.An interview with Licensed Practical Nurse (LPN) #1 on 10/28/25 at 1:45 PM revealed, We are short-staffed a lot. There are always call-ins, and that causes delays in care, especially if residents require more than one person to assist. The facility has a lot of total-care residents.An interview with CNA #4 on 10/29/25 at 1:55 PM revealed, The weekends is the worst. We have heavy loads and do the best we can to take care of the residents, but it does cause them to have to wait longer for care. We have high-acuity residents like those with tracheostomies and bed-bound residents requiring two staff. An interview with the Ombudsman on 10/28/25 at 2:10 PM revealed she had spoken to the Administrator multiple times about the timeliness of care and answering call lights. She stated there had been multiple family and resident complaints, including from Resident #1 and Resident #2's families. She stated, I have advised the Administrator that I was receiving the same complaints repeatedly and that something had to be done. This has been going on for over three months. She stated she informed the Administrator she would have to report the concerns if they were not corrected.An interview with the Administrator on 10/28/25 at 3:00 PM confirmed the facility had received numerous complaints from families and residents regarding staffing, delayed response to call lights, and timeliness of care. She stated, Administration comes in to help, but call-ins are excessive and staff are leaving. She stated she had reached out to Corporate about halting admissions, but that had not occurred. She confirmed there was a definite staffing concern at the facility and that residents are left waiting for help.During an interview with the Assistant Director of Nursing (ADON) on 10/29/25 at 9:55 AM, she stated she has been handling the schedule because there is no staffing coordinator at this time. She confirmed staffing is a major problem and stated, Call-ins are excessive. Administration tries to cover the shift when someone calls in but there are often just more call-ins, and it is impossible to manage the residents care properly when there is just not enough help. We have lost staff due to changes being made to the schedule.An interview with the Director of Nursing (DON) on 10/29/25 at 10:00 AM revealed there was a concern with staffing. She stated Administration staff help when they can, but there are numerous call-ins and that it can't all be covered to meet the residents needs who require help. She stated they have changed the schedule, and some staff were unhappy and resigned. She confirmed there had been many complaints about staffing and lack of care. She stated her concern about not having enough staff is that it causes delays in care and answering call lights, which could lead to increased falls, accidents and residents left incontinent or needing help with meals.Record review of the staffing grid dated 10/29/25 revealed that on 10/26/25 the facility had four CNAs on the 3PM-11PM shift and the 11PM-7AM shift for 95 residents. On 09/14/25 the facility had four CNAs on the 3PM-11PM shift to care for 91 residents and on 09/20/25 on the 11PM-7AM shift the facility had three CNAs in the building to care for 89 residents.Record review of the facility roster matrix revealed that the facility had four wings in the building: A wing with 30 residents, B wing with 31 residents, C wing with 20 residents and a Tracheostomy unit with 13 residents for a total of 94 residents in the building when the complaints related to staffing were submitted to the state agency.

Based on staff interview, record review and facility policy review, the facility failed to provide written transfer notice to a resident's representative for one (1) of nine (9) residents records reviewed. Resident #1 Findings Include Review of the facility policy, titled “Transfer or Discharge Notice”, revealed, “Policy Interpretation and Implementation…5. The resident and representatives are notified in writing of the following information: a. The specific reason for the transfer or discharge. b. The effective date of the transfer or discharge. c. The location to which the resident is being transferred or discharged …” Review of the online complaint received revealed that Resident #1’s resident representative was not notified by the facility of his transfer to the emergency room on 6/25/25. Record review of a “Progress Note”, dated 6/25/25, revealed that Resident #1 was transferred to the emergency room on 6/25/25 at 3:05 PM. In an interview with the Administrator (ADM) on 8/11/25 at 3:45 PM, she stated that no written Hospital Transfer Notification was sent to the Resident #1’s Resident Representative because he returned to the facility before midnight and was only gone a few hours, so they didn’t think it had to be sent. Record review of the “admission Record” revealed that the facility admitted Resident #1 on 11/11/24 with a diagnosis of Cerebral Infarction.

Based on staff interview and record review the facility failed to submit accurate data into the Payroll-Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. Second quarter 2024. Findings include: Record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 2, 2024 (January 1-March 31), revealed Excessively Low Weekend Staffing-Triggered. Triggered=Submitted Weekend Staffing data is excessively low. During an interview on 07/16/24 at 9:30 AM, the Human Resources/Payroll Coordinator revealed the corporate office submits the payroll-based journal. The Human Resources/Payroll Coordinator stated, If one of the administrative nurses works a weekend shift, they are supposed to submit a form to me so I can manually change their hours. An interview on 07/17/24 at 3:45 PM, the Director of Nurses (DON) revealed regarding the low weekend staffing for the second quarter, I worked a lot of those weekends to cover shifts and revealed she wasn't sure if she had submitted the forms like she was supposed to. An interview on 07/17/24 at 4:05 PM, the Corporate Consultant confirmed the hours worked by the DON and the treatment nurse were not captured correctly on the PBJ report and were done so in error. She revealed the shifts for the second quarter of 2024 were covered, however, the data was entered incorrectly and did not capture the direct care on the PBJ. An interview on 07/18/24 at 8:24 AM, the DON revealed they were adequately staffed for the second quarter weekends, however after auditing revealed there were inconsistencies in reporting to the PBJ.

Based on staff and resident interviews, record review, and facility policy review the facility did not report an allegation of abuse to the State Agency within two (2) hours after the incident reportedly occurred for one (1) of four (4) investigations. Resident #58 Findings include: Record review of the facility policy titled Abuse Prohibition Policy reviewed 5/17/24 revealed 1. Any employee who becomes aware of an allegation of abuse, neglect or misappropriation of resident property, shall report the incident to the Abuse Coordinator immediately. Failure to do so will result in disciplinary action up to and including termination . On 7/16/24 at 8:35 AM, an interview with Nursing Assistant (NA) #1 revealed she and Certified Nursing Assistant (CNA) #1 were providing care to Resident #58 when he reached up and touched her breast. CNA #1 told him not to do that and removed his hand, he then grabbed her breast again and she held his wrist and hit him in the face with his hand. The NA confirmed she did not tell or report to anyone about the incident that day. NA #1 revealed she did tell a nurse the next day, she was aware she should have reported it immediately but did not because CNA #1 was around. On 7/16/24 at 9:00 AM, an interview with Registered Nurse (RN) #1 revealed she was asked by NA #1 to come in the room and help with care for Resident #58. CNA #1 was in the room when RN #1 entered. CNA #1 left the room to get a clean sheet and gown for the resident and then when she returned, she assisted in positioning the resident. RN #1 confirmed NA #1 did not tell her of the incident that allegedly just occurred, while they were alone in the room or any time during that day. RN #1 revealed NA #1 told her of the alleged incident the next day. On 7/17/24 at 8:15 AM, an interview with the Director of Nursing (DON) revealed the facility was not aware of the alleged incident until the day after it reportedly occurred. Record review of the facility Disciplinary Action Record completed by the DON, revealed NA #1 was suspended pending investigation, due to not reporting an allegation of abuse observed by her on 6/4/24 until 6/5/24. The form revealed the expectations were NA #1 should report an allegation of abuse immediately. The Disciplinary Action Record dated 6/5/24 revealed the NA #1's signature.

Based on staff interviews and record review, the facility failed to ensure staff completed competency skills check-off and completed Enhanced Barrier Precautions training prior to caring for residents with a tracheostomy for one (1) of four (4) respiratory staff personnel files reviewed. Respiratory Therapist (RT) #1 Findings include: Record review of a type statement on facility letterhead dated 7/19/24 and signed by the facility Administrator revealed (Facility proper name) does not have a policy for competency skills checkoffs. While observing tracheostomy care for Resident #53 on 7/17/24 at 10:00 AM, revealed an Enhanced Barrier Precaution sign on the resident's outer door. RT #1 performed tracheostomy care without proper Personal Protective Equipment, which included a gown. In an interview on 7/17/24 at 10:35 AM, RT #1 revealed that she wasn't sure if Resident #53 was under the enhanced barrier precautions or not and stated, No, I don't think he is he doesn't have an infection. RT #1 glanced at the resident's door and then stated, Oh yes, he has one of those signs on the door, I was supposed to wear a gown into his room. RT #1 revealed that she had not been trained in enhanced barrier precautions. In an interview on 7/17/24 at 10:50 AM, the Director of Nurses (DON) revealed all nursing staff were to be trained on enhanced barrier precautions and she was not aware that RT #1 was not trained. In an interview on 7/17/24 at 1:40 PM, the Assistant Director of Nurses (ADON) revealed she is the backup Infection Preventionist and confirmed that RT #1 had not been in-serviced on enhanced barrier precautions and confirmed that all staff was to be in-serviced. She revealed it is the responsibility of the Infection Preventionist and Staff development nurse to provide in-service to all staff, and they failed to ensure the in-service was completed for RT #1. In an interview on 7/18/24 at 8:32 AM, the DON confirmed RT #1 had not been trained on Enhanced Barrier Precautions. She revealed they had training in September 2023, with the epidemiologist involved, and that RT #1 was not trained at that time either. In an interview on 7/18/24 at 9:00 AM, the Respiratory Therapist Director revealed he has only been in the role of Director for about a month. He revealed he was unaware that RT #1 was not adequately trained on enhanced barrier precautions. During an interview on 7/18/24 at 9:56 AM, the DON revealed that RT #1 did not have a competency skill checkoff for tracheostomy care. She confirmed the RT had been employed part-time since 2022 and usually worked one day a week.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection, as evidenced by failing to ensure Enhanced Barrier Precautions (EBP) and proper hand hygiene during resident care treatment for one (1) of four (4) resident care treatments observed. Resident #53 Findings include: Record review of the facility policy titled, Enhanced Barrier Precautions dated 4/1/2024 revealed .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove used during high contact resident care activities. Record review of the facility policy titled, Handwashing/Hand Hygiene with a revision date of 3/1/2020 revealed, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections . Record review of the facility policy titled, Tracheostomy Care with a revision date of March 2024 revealed .General Guidelines . 3. Disposable gown must be worn as part of Enhanced Barrier Precautions .Preparation and Assessment . 9. Remove old dressings. Pull soiled glove over dressing and discard into appropriate receptacle. 10. Wash hands. Clean the Removable Inner Cannula.8. Put on sterile gloves .14. Remove and discard gloves into appropriate receptacle .15. Wash hands and put on fresh gloves. Observation of tracheostomy (trach) care for Resident #53 on 7/17/24 at 10:00 AM, revealed an Enhanced Barrier Precaution sign on the resident's outer door. Respiratory Therapist (RT) #1 washed her hands briefly with an antiseptic hand sanitizer, applied gloves, and entered the resident's room without applying a protective gown. The RT cleaned the overbed table and set up her barrier, discarded her gloves, and applied new gloves without washing her hands. She then proceeded to perform tracheostomy care. The RT removed sterile gloves from the suction catheter kit and applied the sterile gloves over her soiled gloves. The RT suctioned the resident and then removed her sterile gloves leaving her soiled gloves intact, failing to wash her hands. The RT opened the tracheostomy care tray with the soiled gloves, removed the sterile gloves, placed them over the non-sterile gloves, and continued tracheostomy care. The RT removed her gloves, packaged up the unclean trach supplies, and placed them in a red biohazard bag, she removed a soiled washcloth that was saturated with fluids that had been placed under Resident #53's trach for any excessive secretions and stated I'm not supposed to put this on the floor, but I don't have anywhere to place it. There should be a container in here. RT #1 then placed the soiled washcloth on the floor and exited the room. She tucked the red biohazard bag under her arm and briskly applied antiseptic hand sanitizer from a bottle on the top of her treatment cart. In an interview on 7/17/24 at 10:35 AM, Respiratory Therapist #1 revealed that she wasn't sure if Resident #53 was under enhanced barrier precautions or not and then stated, No, I don't think he is he doesn't have an infection. The RT glanced at the resident's door and then stated, Oh yes, he has one of those signs on the door, I was supposed to wear a gown into his room. She confirmed she had not worn the proper personal protective equipment into the room to render care to the resident. She revealed that she had not been trained in enhanced barrier precautions. RT #1 revealed that during her tracheostomy care, she was taught in school to keep her gloves on and put the sterile gloves over top of them and wasn't aware that she had to remove the soiled gloves and wash her hands during the dirty and clean process of rendering tracheostomy care. The RT revealed that she understood where it could be an infection control issue and confirmed that she had not used proper hand hygiene while performing tracheostomy care on Resident #53, and by not doing so, it's possible the resident could get an infection. An interview on 7/17/24 at 10:50 AM, the Director of Nurses (DON) confirmed that the respiratory therapist was supposed to wear a gown into the room as part of the enhanced barrier precautions and to change out her gloves and wash her hands between the dirty and clean trach care and revealed that is our standards of practice for tracheostomy care. The DON confirmed the resident could get an infection from the lack of proper hand hygiene and lack of proper personal protective equipment (PPE) during his tracheostomy care. In an interview on 7/18/24 at 9:00 AM, the Respiratory Director confirmed that the standard of tracheostomy care to possibly prevent infections is to wear a gown and perform appropriate hand hygiene. A record review of Resident #53's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Pneumonitis due to inhalation of food and vomit, Cerebral infarction, and Encounter for attention to tracheostomy.

Based on record review, staff interview, and facility policy review, the facility failed to complete a Quarterly Minimum Data Set (MDS) no later than 14 days of the Assessment Reference Date (ARD) for one (1) of 19 assessments reviewed. Resident # 49 Findings include Record review of the facility policy CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) . Chapter 5: Submission and Correction of the MDS Assessment, dated October 2023, revealed .5.2 Completion Timing: For all non-Admission OBRA (Omnibus Budget Reconciliation ACT) and PPS (Prospective Payment System) discharge assessments, the MDS Completion Date (Z0500B) must be no later than 14 days after the Assessment Reference date (ARD) (A2300) . Review of the CMS Submission Final Validation Report revealed Resident #49 ' s Quarterly assessment was completed more than 14 days after the assessment reference date. Record review of the quarterly Minimum Data Set for Resident #49 revealed in Section A2300- the Assessment Reference Date was documented as 6/07/2024. Section Z0500-Assessment Completion was documented as 7/03/24. During an interview with the MDS Coordinator on 7/17/24 at 10:53 AM, she confirmed after review of the CMS submission final validation report that Resident #49's MDS was completed late. She revealed she was aware that the facility has previously had late assessments and the MDS department has been placed on an action plan for about a year to address the problems, but confirmed the problems still exist. She stated she felt time management was part of the reason for the assessments were late. During a phone interview with the MDS Consultant on 7/17/24 at 11:08 AM, she confirmed she was aware the facility was having issues with the MDS's being completed and submitted. She stated the facility had put a plan of action in place a few months ago to stop the late completion of the assessments, but confirmed the plan needed to be altered. She revealed the purpose of completing and transmitting the MDS timely is to ensure billing is correct, and the correct resident information is submitted to complete the resident's plan of care. Record review of the Admission Record revealed the facility admitted Resident #49 to the facility on [DATE] with diagnoses that included Cerebral Palsy.

Based on record review, staff interview, and facility policy review, the facility failed to complete an Annual Minimum Data Set (MDS) no later than 14 days of the Assessment Reference Date (ARD) for one (1) of 19 assessments reviewed. Resident # 24 Findings include Record review of the facility policy CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) . Chapter 5: Submission and Correction of the MDS Assessment, dated October 2023, revealed .5.2 Completion Timing: For all non-Admission OBRA (Omnibus Budget Reconciliation ACT) and PPS (Prospective Payment System) discharge assessments, the MDS Completion Date (Z0500B) must be no later than 14 days after the Assessment Reference date (ARD) (A2300) . Review of the Centers for Medicare & Medicaid Services (CMS) Submission Final Validation Report revealed Resident #24 's Annual assessment was completed more than 14 days after the assessment reference date. Record review of the annual Minimum Data Set for Resident #24 revealed in Section A2300- the Assessment Reference Date was documented as 6/06/2024. Section Z0500-Assessment Completion was documented as 7/01/24. In an interview with the MDS Coordinator on 7/17/24 at 10:53 AM, she confirmed after review of the CMS submission final validation report, Resident #24 's MDS was completed late. She revealed she was aware that the facility has previously had late assessments and revealed the MDS department has been placed on an action plan for about a year to address the problems, but confirmed the problems still exist. She stated she felt time management was part of the reason the assessments were late. In a phone interview with the MDS Consultant on 7/17/24 at 11:08 AM, she confirmed she was aware the facility was having issues with the MDS's being completed and submitted. She stated the facility had put a plan of action in place a few months ago to stop the late completion of the assessments, but confirmed the plan needed to be altered. She revealed the purpose of completing and transmitting the MDS timely is to ensure billing is correct and ensure the correct resident information is submitted to complete the residents' plan of care. Record review of the Admission Record revealed the facility admitted Resident #24 to the facility on [DATE] with current diagnoses that included Transient Cerebral Ischemic Attack.

Based on observations, staff interviews and facility policy review, the facility failed to properly label and store food items in a cooler in the kitchen according to professional standards for food service safety, failed to properly label food items stored in the resident nourishment refrigerators, failed to maintain a temperature log for the resident nourishment refrigerators, and failed to maintain a cleaning schedule for the resident nourishment refrigerators located on A-Hall and C-Hall nursing units of the nursing facility for one (1) of two (2) tours. Findings include: Review of the facility policy titled, Receiving, with a revised date of ,d+[DATE], revealed Policy Statement: Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. Procedures . 6. All food items will be stored in a manner hat ensure appropriate and timely utilization based on the principles of first in - first out (FIFO) inventory management. Review attempted for facility policy for resident nourishment refrigerators revealed the nursing facility did not have a policy. The Administrator provided a letter on the nursing facility's letterhead that revealed The facility does not have a policy on Resident Nourishment Refrigerators in regard to cleaning schedules and general maintenance. An observation during the initial kitchen tour on [DATE] at 03:47 PM, revealed a cooler with food items stored that were not disposed of by the date indicated on the containers. The observation revealed an opened and partially used white plastic container of pimento cheese with a Date Prepared/Opened of [DATE] and no Use By Date was indicated; revealed a clear plastic storage container of leftover brown gravy with a Shelf Life date of [DATE]; revealed an unopened white plastic container of beef base with a Shelf Life date of [DATE], revealed an opened and partially used white plastic container of beef base with a Shelf Life date of [DATE]; revealed a clear plastic zip lock bag that contained a leftover portion of a ham with a date of [DATE]; revealed a clear plastic storage container of leftover egg salad with a Shelf Life date of [DATE]; revealed a clear plastic pitcher of V8 vegetable juice drink with a Date Prepared/Opened of [DATE]; revealed a clear plastic storage container of leftover tomato soup with a Date Prepared/Opened date of [DATE]; and revealed a clear plastic zip lock bag that contained sliced bologna with a Date Prepared/Opened of [DATE]. An observation and interview on [DATE] at 03:52 PM, with the Dietary Aide was observed to remove the items from the cooler, revealed the stored food items were expired, and should be thrown away after being in the cooler for six (6) days. She noted she was responsible to store leftovers and unused portions of food items in the cooler on her shift and was supposed to watch the dates to throw the leftovers and unused food items away by the expiration dates. She noted if any of the food items had been fed to a resident, the resident could have possibly gotten sick. An interview on [DATE] at 11:30 AM with the Dietary Manager revealed all other food items listed should have been discarded after 7 days of the date on the containers. She revealed she usually checked the coolers for expired food each week but did not check this cooler before she left on Friday, [DATE]. She confirmed that if a resident had been served the expired food items there was the possibility of them getting a food borne illness. An interview on [DATE] at 12:00 PM with the Administrator, he confirmed the items should have been labeled properly for storage and to enable the dietary staff to discard the food items by the expiration date of 7 days. He also confirmed that if a resident had been served the expired food items there was the possibility of them getting a food borne illness. An observation and interview with the Director of Nursing (DON), on [DATE] at 10:30 AM, confirmed the resident nourishment refrigerators' freezers on the A Hall and the B Hall nursing units had a thick layer of ice. The buildup of ice in the freezer protruded outward causing the A-Hall refrigerator's door not to close and seal. The DON observed and revealed that the thermometer in the refrigerator on the A Hall nursing unit registered 60 degrees for the internal temperature. The A Hall refrigerator was observed to have two (2) unlabeled clear plastic zip lock bags of cut up cantaloupe, a small bottle of milk, and a clear plastic storage container, of outside food, that was not properly labeled. The B Hall Refrigerator was observed to have a thick layer of ice in the freezer section of the resident nourishment refrigerator and had 1 quarter sized and 2 nickel sized brown spots of a thick appearing liquid substance on the bottom floor of the refrigerator. DON confirmed there was a temperature log that indicated the refrigerator was last inspected and cleaned on [DATE] and had been inspected and cleaned ,d+[DATE]-,d+[DATE]. She confirmed the resident nourishment refrigerators had not been inspected and cleaned regularly on the A-Hall and B-Hall nursing units. She confirmed that both resident nourishment refrigerators needed to be cleaned, should have been kept clean, and the temperatures should have been monitored on a regular schedule, and confirmed the food items in the refrigerator should have been labeled properly to avoid the possibility of food borne illnesses for residents and to allow food items to be discarded in a timely manner. She revealed the unlabeled food items in the refrigerator and the refrigerators not being cleaned regularly have the possibility to cause a resident the possibility of food borne illnesses. Record review of the nursing facility's dietary manager and the dietary department staff in-services revealed Associate In-Service Record . (Dietary Manager's Name Removed) . [DATE] . Topic: Labeling, Dating, and Expired Foods Procedures: Once a product is opened, it must be dated, and if necessary, labeled. There cannot be any expired food in the kitchen. As an Account Manager, it is your responsibility that all food items are in date. All food items must be checked during your daily morning walk through. If a food item has expired, throw it away. Every food item, in your kitchen must be seen and touched daily to ensure it has not expired/fallen out of date. Associate In-Service Record . [DATE] . Topic: Labeling and Dating Procedures and Expired Food Items: Once a product is opened, it must be dated, and if necessary, labeled. Record review of the log for the B-Hall resident nourishment refrigerator revealed REFRIGERATOR-NON-Medication TEMPERATURE no greater than 38 degrees; Monitored for temperature and appropriate contents. The refrigerator should be clean. MONTH [DATE]; DAILY INSPECTION [DATE]; DAILY TEMP 36 degrees; REFRIGERATOR CLEANED? (check mark) . MONTH ,d+[DATE]; DAILY INSPECTION ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE]; REFRIGERATOR CLEANED? (check mark for all dates noted).

Based on resident interviews, staff interviews, record review, and facility policy review the facility failed to provide activities on the weekends, as evidenced by, independent activities only listed on the activity calendar for Saturday's and no scheduled activities on Sunday's for three (3) of 29 sampled residents. Resident #26, Resident #67, Resident #178. Findings include: Review of the facility policy titled, Activity Program, dated 2001, with no review/revised date, revealed Policy Statement: An ongoing program of activities is designed to meet the needs of residents. Policy Interpretation and Implementation: 1. Our activity program is designed to encourage restoration to self care and maintenance of normal activity which is geared to the individual resident's needs. 2. Activities are scheduled daily .3. Our activity program consist of individual, and small and large group activities .6. Individualized and group activities are provided that .b. Are offered .including weekends . Record review of the activities calendar from February 2023 - April 2023 revealed independent activities for residents on Saturday Saturday 10:30 Independent Activities: Coloring Sheets, Board Games, Puzzles, and Table Games in South Dining Room. The record review revealed there were no activities scheduled on the activities calendar for Sundays. Resident #26 An interview on 5/1/23 at 03:50 PM, with Resident #26 during the Resident Council Meeting, revealed she wanted guided activities on the weekends. She revealed that no staff helped the residents with activities on the weekends. She noted she would like staff to be there to assist with organizing the activities and have group activities. Record review of Section C of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/01/2023, for Resident #26, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #26 is cognitively intact. Resident #67 An interview on 5/1/23 at 03:50 PM, with Resident #67, during the Resident Council Meeting, revealed there were no activities on the weekends and the Activities Coordinator had set up a room to have residents go to for independent activities on their own. She noted no staff assisted with activities on the weekend. She also noted she attempted to go and tell other residents to come to the weekend activities room and could only ask those residents that are able to get to the room on their own. Record review of Section C of the Quarterly MDS Assessment, with an ARD of 02/23/2023, for Resident #67, revealed a BIMS score of 14, indicating Resident #67 is cognitively intact. Resident #178 An interview on 05/01/23 at 08:15 AM, Resident #178 revealed there were no activities on the weekend. He revealed he was admitted to the nursing facility on Friday, 4/28/23 and there was nothing offered to him to occupy his time over the weekend. He revealed there was nothing going on in the building and he was bored just sitting in his room. He noted he would like kind of activity on the weekend to help him stay busy and he suffers from total blindness. Record review of Section C of the MDS dated [DATE] revealed a BIMS score of 13 indicating Resident #178 was cognitively intact. An interview on 5/1/23 at 03:00 PM, with the Activities Director revealed she nor the Assistant Activities Director worked the weekends. She confirmed there were no staff assigned to the weekends to assist with activities. She stated that there was an activities room set up for the residents attend on their own on Saturday and Sunday. She stated she would remind residents about the activities room on Fridays. An interview on 5/2/23 at 04:30 PM, with the Administrator confirmed he did not have staff scheduled to assist the residents with activities on the weekends.

Based on staff and resident interview, record review and facility policy review the facility failed to respect the right of a resident as evidenced by the facility applying a lap tray to a cognitively intact resident against her wishes for one (1) of 29 residents sampled. Resident # 45. Findings Include Record review of the facility policy titled, Resident's Rights with no revision date revealed under #3. Is assured of adequate and appropriate medical care is fully informed by a physician, of his medical condition unless medically contraindicated (as documentation by a physician, in his medical record) is afforded the opportunity to participate in the planning of his medical treatment to refuse to participate in experiment research and to refuse medication and treatment after being fully informed of and understanding the consequences of such actions. An observation on 4/30/23 at 4:08 PM revealed Resident #45 was self-propelling her wheelchair down the hall with a lap tray attached. An observation and interview on 5/1/23 at 9:15 AM revealed that Resident #45 was self-propelling in her wheelchair with a lap tray attached. An interview at this time with the resident revealed she did not like the lap tray, did not want it and cannot remove it herself. Record review of Resident #45 Minimum Data Set with an Assessment Reference Date of 2/6/23 revealed in Section C a Brief Interview for Mental Status of 14, which indicates the resident is cognitively intact. An interview on 5/2/23 at 2:36 PM with the Corporate Clinical Nurse revealed she realized that the resident did not like the lap tray and did not want it. She confirmed that putting the lap tray on the resident's wheelchair was going against her wishes. She revealed that they did not mean to infringe on her rights. An interview on 5/2/23 at 4:21 PM with Resident #45's representative revealed he was aware that his sister had a lap tray on her wheelchair now and he knew she did not like it. He revealed the facility did not ask for his consent prior to applying the lap tray, he was notified by the facility after the lap tray was applied, he did not get educated on the risk of the lap tray and he did not have to sign anything giving consent. Observation and interview on 5/15/23 at 11:30 AM with Resident #45 revealed she was up in a wheelchair with a high back in her room. Resident has a soft pink helmet on her head. She does not have a lap tray or seat belt on. Her speech can be difficult to understand but she is able to say yeah, no and complete simple sentences. When asked if she knew there would be a lap tray used before the staff used one on her wheelchair, she stated yeah. When asked why she didn't want the lap tray on her wheelchair, she stated couldn't move like I wanted. State Agency (SA) asked if the facility staff had explained to her that she could be harmed/hurt if she falls out of the wheelchair, she stated yes. It is noted that she does display the jerking, sudden movements from her extremities that accompany Huntington's disease. Interview with the Director of Nurses on 5/15/23 at 11:45 AM revealed that the consent for the lap tray was verbally over the phone due to the Resident Representative (RR) living 3.5 hours away. She stated that Resident #45 had a fall this morning, but had no injuries from this fall. She said that Resident #45 is glad she doesn't have to use the lap tray anymore. The RR is aware the lap tray has been discontinued (dc'd). Care plan meeting with the RR are done over the phone due to the distance of his home to the facility. The DON explained the risks of falls and possible injury have been explained to both the RP and resident by the DON and the clinical nurse consultant. The DON confirmed the lap tray was dc'd 5/11/23. Record review of Resident #45's physician's orders revealed an order dated 4/10/23- Apply lap tray when up in wheelchair, check every 30 minutes and release every 2 hours for toileting and repositioning every shift for involuntary movement of trunk and extremities related to Huntington's Disease. Record review of Resident #45's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Huntington's Disease.

Based on observation, staff interviews, and facility policy review the facility failed to assure that services being provided meet professional standards of quality as evidenced by staff failed to sign off medications as administered for one (1) of four (4) residents reviewed( Resident #60) and failed to check the 5 rights of medication prior to the administration for one (1) of four (4) residents reviewed. (Resident #181) Findings include: Review of the facility's policy titled, Administering Medications, Revised April 2019 revealed, Policy heading: Medications are to be administered in a safe and timely manner, and as prescribed .Interpretation and Implementation: 4.) Medications are to be administered in accordance with prescribed orders .10.) The individual administering the medication checks the label three times to verify the right resident, right medication, right dose, right time, and right route of administration before giving the medication .22.) The individual administering the medication initials the resident's MAR (Medication Record) after giving each medication and before administering the next ones . Resident #60 An observation of medication administration with Licensed Practical Nurse (LPN) #2 on 5/2/23 at 8:00 AM, revealed LPN #2 set up and administered medication to Resident # 60. LPN #2 returned to her cart and began to set up another resident's medications with no observation by the State Agency (SA) of LPN #2 signing off medications as administered. During an interview on 5/2/23 at 8:20 AM, with LPN #2, confirmed she was finished giving medication to Resident #60. LPN #2 confirmed she did not sign off the medications as given after administration, but she should have done so and would correct that now. A review of the Medication Administration Audit Report for Resident #60 dated 5/2/23 revealed administration time of 8:20 AM and documented time of 8:21 AM. Record review of the Admission Record revealed that the facility admitted Resident # 60 to the facility on [DATE] with diagnoses of Myotonic Muscular Dystrophy and Unspecified protein calorie malnutrition. Resident # 181 An observation of a room called the Charge Nurse/Storage Office with the Assistant Director of Nursing (ADON) on 5/2/23 at 8:50 AM, revealed the Assistant Director of Nursing (ADON) pick up a small bag of intravenous fluids (IV) off a shelf with multiple other bags of IV fluids. She verbalized she was ready to hang Resident #181's antibiotics. The ADON administered Vancomycin HCl in NaCl (Sodium Chloride) Intravenous Solution 1.25-0.9 GM/250ML% (grams/milliliter)to Resident #181. The ADON failed to review the E-MAR (Electronic Medication Administration Record) with the medication label and check the five (5) rights of medication before administering the intravenous medication. The SA asked the ADON about how she knew she had the correct medication for Resident #181. The ADON revealed she had reviewed the order early in the morning and knew the resident got the medication. The SA asked the ADON about possible concerns of not checking the five rights of medication and the ADON remained silent. A review of the Medication Administration Audit Report for Resident #181 dated 5/2/23 revealed administration time of 8:57 AM and documented time of 8:57 AM. An interview with Registered Nurse (RN) #1 on 5/2/23 at 9:40 AM, revealed that not checking the 5 rights of medications when preparing a medication using E-MAR /medication label could possibly result in the wrong medication being given because there may have been a new change to the order, or discontinued. RN #1 confirmed a number of concerns could be possible from failing to check the 5 rights like adverse reactions and possibly death. An interview with the Infection Control (IC) nurse on 5/2/23 at 1:00 PM, revealed all nurses have been educated on medication administration and know they must check the medication label with the E-MAR prior to administering medications because a medication may have been changed or discontinued. The IC nurse confirmed medications should be signed immediately after administration to the resident. An interview with the Director of Nursing (DON) on 5/03/23 at 8:10 AM, she confirmed the nursing staff should use the medication record with the medication label and check the five (5) rights to ensure they give the correct medication to a resident. She confirmed the nurses should sign off the medications after every resident. A record review of in-services titled Safe Handling of Drugs /Administration dated 1/12/23, revealed in-service topics: Documentation of Medication Administration and Administering Medications with signatures for LPN #2 and the ADON as attended. Record review of the Admission Record revealed that the facility admitted Resident # 181 to the facility on [DATE] with diagnoses of Infection following a procedure, superficial incision surgical site and Methicillin Resistant Staphylococcus Aureus infection.

Based on staff and resident interview, record review and facility policy review the facility failed to include a resident in the development of their plan of care for one (1) of 18 resident care plans reviewed. Resident # 52. Findings Include Record review of the facility policy titled, Care Plans, Comprehensive Person Centered with a revision date of January 2023 revealed Policy Interpretation and Implementation .#1. The Interdisciplinary Team (IDT) , in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. An interview on 5/1/23 at 4:10 PM, with Resident #52 revealed no one from the facility had asked him to attend a care plan meeting. An interview on 5/3/23 at 09:30 AM, with Social Services revealed that Resident #52 could understand you when you spoke with him and make his wishes known. She confirmed that the resident had never attended a care plan meeting and no follow up was documented regarding speaking with the resident to verify he agrees with the plan of care that was decided upon. Record review of Resident #52's Progress Notes revealed the following care plan meetings documentation. 3/7/23 was not attended by either the resident or the resident representative. There was no documentation that Resident #52 attended care plan meetings on 12/13/22, 09/20/22, 06/23/22, or 03/24/22. The documentation indicated the facility had care plan conferences with Resident #52's Resident Representative by phone. Documentation did not include that Resident #52 had attended the phone conference or had attend in person. Record review of Resident #52's history of Minimum Data Sets with Brief Interviews for Mental Status (BIMS) scores revealed Resident #52 had BIMS scores on 1/2/22 of 14 indicating Resident #52 was cognitively intact and on 3/13/23 a score of 11 indicating Resident #52 had moderate cognitive impairment. Record review of Resident #52's Admission Record revealed he was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction Unspecified.

Based on staff interview, record review and policy review the facility failed to develop a care plan for the application of an Aspen collar, splint, and a Wrist-Hand-Finger Orthosis (WHFO) for Resident # 17 and implement a care plan for monitoring of side effects and behaviors for psychotropic medication (Resident # 229) for two (2) of 20 residents care plans reviewed. Findings include: A review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated 10-2022; Reviewed [DATE] Policy Statement: A comprehensive, person-centered care plan . is developed and implemented for each resident. Policy Interpretation and Implementation, 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Resident #17 Record review of the care plans, for Resident #17, revealed he did not have a comprehensive person-centered care plan developed to ensure proper implementation of care for his Aspen Collar, proper implementation of care for his right-hand Wrist-Hand-Finger Orthosis (WHFO), and proper implementation of care for his left knee extension splint. An observation and interview on 5/3/23 at 9:15 AM, with the Care Plan Nurse confirmed the Aspen Collar, the right-hand WHFO and the left knee extension splints were not care planned for Resident #17 and confirmed there should have been a care plan developed for these areas. She revealed she was aware that a comprehensive person-centered care plan was to be developed for residents from physician's orders with goals and interventions related to care needed to carry out that plan of care for the residents. An interview on 5/3/23 at 11:00 AM, with the Administrator, confirmed Resident #17 did not have a comprehensive person-centered care plan developed for the Aspen Collar, for the right-hand WHFO, and for the left knee extension splint. He confirmed Resident #17 could possibly have a decline in positioning due staff being unaware of the full plan of care, for Resident #17, related to a care plan was not developed for implementation of care. Record review of the active physician's orders on the Order Summary Report, for Resident #17, revealed Order Date: 03/10/2023; Start Date: 03/10/2023 . Pt to have Aspen Collar to neck at all times until follow up with Neurosurgeon. Every shift related to SUBLUXATION OF C1/C2 CERVICAL VERTEBRAE, SUBSEQUENT ENCOUNTER . Order Date: 03/08/2023 . Pt to have L knee extension splint for contracture management. Splint to be worn up to 6 hours/day per pt tolerance and applied by therapy . Order Date: 03/08/2023 . Pt to have R WHFO to be worn up to 6 hrs/day per patient tolerance to be applied by nsg to manage contractures. Record review of the Admission Record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses that included SUBLAXATION OF C1/C2 CERVICAL VERTEBRAE, SUBSEQUENT ENCOUNTER, UNSPECIFIED FRACTURE OF UNSPECIFIED THORACIC VERTEBRA, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING, AND ENCOUNTER FOR OTHER ORTHOPEDIC AFTERCARE. Record review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/20/23, for Resident #17, revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating Resident #17 is severely cognitively impaired. 47157 Resident #229 A record review of Resident # 229's care plan, date initiated 4/21/23 revealed, Focus The resident uses antidepressant medication (Mirtazapine) r/t (related to) Depression .Goal The resident will be free from discomfort or adverse reactions related to antidepressant therapy .Interventions, Monitor/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT THERAPY . Record review of Resident #229's care plan, date initiated 4/20/23, revealed, Focus The resident uses anti-anxiety medications (Lorazepam) r/t Anxiety disorder.Goal The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy .Interventions Monitor/document/report PRN adverse reactions to ANTI-ANXIETY THERAPY . Record review of the care plan dated 4/24/23 revealed, Focus The resident has a behavior problem . Goal The resident will have fewer episodes of behavior .Interventions .Monitor behavior episodes and attempt to determine underlying cause . Record review the Medication Administration Record dated 4/1/23 through 4/30/23 revealed no documentation of behavior monitoring. An interview with the DON on 05/01/13 at 3:00 PM, revealed that Resident # 229 had a care plan for monitoring for side effects and behavior monitoring for psychotropic drugs and confirmed the care plans were not being followed. Concerns related to failure to follow the care plan were over sedation, falls, and drowsiness. An interview and record review with LPN # 4 on 05/01/23 at 3:35 PM, she confirmed they were not following the plan of care. Record review of the Admission Record revealed Resident # 229 was admitted to the facility on [DATE] with diagnoses which included Anxiety, Alcohol Abuse, and Major Depressive Disorder. Record Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/27/2023 revealed a Brief Interview for Mental Status (BIMS) score of eight (8) indicating Resident #229 had moderate cognitive impairment.

Based on record review, staff interviews, and facility policy review the facility failed to complete a baseline care plan, within 48 hours, for new admits to the nursing facility as evidenced by observation of incomplete baseline care plans for one (1) of eight (8) resident investigations. Resident #178 Findings include: Review of the facility policy titled Care Plans - Baseline, with a revised date of March 2022, revealed Policy Statement: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission; Policy Interpretation and Implementation: 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: . e. Social Services. Record review of the Baseline Care Plan dated 4/28/23 for Resident #178 revealed the Social Services section of the Baseline Care Plan was not completed. The record review revealed the questions in the Social Services section of the form . 1. Social Services provided; 2. Mental health needs; 3. Behavioral concerns; 4. PASARR (Preadmission Screening and Resident Review) Level II recommendations; 5. Social Services goals; 6. Depression screening. were not answered. An observation and interview on 5/3/23 at 09:15 AM, with the Care Plan Nurse related to the Baseline Care Plan for Resident #178 confirmed the Social Services section of the Baseline Care Plan was not completed. She revealed that a Baseline Care Plan should be developed and discussed with the residents/Resident Representatives within 48 hours of admission. She revealed the Baseline Care Plan for Resident #178 was not developed within 48 hours. An observation and interview on 5/3/23 at 9:30 AM, with Social Services, confirmed the Social Services section of the Baseline Care Plan was not completed. She revealed she was not aware of what a Baseline Care Plan was. An interview on 5/3/23 at 9:45 AM, with the Administrator revealed he was not aware that the Baseline Care Plans were not being completed for all new admits to the nursing facility within 48 hours. He was not aware that Social Services had no knowledge of a Baseline Care Plan and confirmed that Resident #178 did not have an adequate plan of care in place. He confirmed that a Baseline Care plan should have been completed for Resident #178 within 48 hours of admission. Record review of the Admission Record revealed Resident #178 was admitted to the facility on [DATE].

Based on staff and resident interview, record review and facility policy review the facility failed to review and gain consent on a cognitively intact residents Advanced Directives (Resident # 52) and failed to obtain a physician's order and formulate a Do Not Resuscitate (DNR) status in the medical record (Resident #181) for two (2) of 29 resident's advance directives reviewed. Resident # 52 and #181 Findings Include: An interview on [DATE] at 3:15 PM, with the Administrator revealed the facility did not have a policy related to the process for ensuring the appropriate code status for DNR for residents. Resident # 52 An interview on [DATE] at 4:10 PM, with Resident #52 revealed no one from the facility had talked to him about his wishes regarding wanting CPR (cardio pulmonary resuscitation) or not. An interview on [DATE] at 4:20 PM, with the Corporate Clinical Nurse revealed that if a resident is admitted and is not cognitively able to sign their own admission paperwork and then becomes cognitive at a later date, they do not redo or go over the resident's advance directive. An interview on [DATE] at 4:30 PM, with Social Services revealed she was unaware that if a resident was not cognitive on admission but became cognitive during their stay at the facility then the resident's advance directive needed to be reviewed and resigned. An interview on [DATE] at 09:30 AM, with Social Services revealed that Resident #52 could understand you when you spoke with him and make his wishes known. She confirmed that the resident had never attended a care plan meeting and no follow up was documented regarding speaking with the resident to verify he agreed with the plan of care that was decided upon. Record review revealed Resident #52 had an Advance Directive signed by the resident's representative on admission [DATE] and a code status change on [DATE]. Record review of Resident #52's history of Minimum Data Sets with Brief Interviews for Mental Status (BIMS) scores revealed a BIMS score on the Admission MDS dated [DATE] of 7 which indicated severely impaired cognitive status. The MDS dated [DATE] revealed a BIMS score of 11 which indicated that the resident had moderately impaired cognitive skills. The MDS dated [DATE] revealed a BIMS score of 11. Record review of Resident #52's Admission Record revealed he was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction Unspecified. 44900 Resident #181 Record review of CONSENT FOR CARDIOPULMONARY RESUSCITATION (CPR) form, for Resident #181, signed by her Resident Representative on [DATE], revealed . This statement will remain in effect as long as the resident remain a resident of this facility . 'x' Decline CPR' I understand that CPR constitutes an extraordinary measure and SHOULD NOT be performed. Date [DATE]. Record review of the Order Summary Report, for Resident #181, revealed she did not have a Do Not Resuscitate (DNR) order in the Electronic Health Record (EHR). Record review of the Admission Record for Resident #181 revealed an admitted [DATE]. An interview on [DATE] at 02:45 PM, with Medical Records confirmed there was not a DNR order in the EHR for Resident #181. She noted old DNR orders are used for residents who readmit to the nursing facility in less than 30 days of discharge and a new order for DNR did not have to be obtained from the physician. She confirmed that Resident #181 was discharged from the nursing facility and readmitted on [DATE] and confirmed that the physician's order for DNR from the previous admission, for Resident #181, was being used for the readmission. An observation and interview on [DATE] at 03:00 PM, with the Director of Nursing (DON), confirmed Resident #181 was recently readmitted to the nursing facility. After being completely discharged from the nursing facility, there was a new Consent For Cardiopulmonary Resuscitation form for the code status request of DNR signed by the Resident Representative. There was not a new code status order obtained related to the new admission to the nursing facility. She revealed she was not aware she needed to have a new physician's order for DNR upon readmission if the resident was not out of the nursing facility for more than 30 days and confirmed that the resident/family choice for plan of care related to Advance Directives was not being honored. She revealed Resident #181 needed to have a signed physician's order in the Electronic Health Record for DNR to ensure Resident #181's choice was honored for her Advanced Directive and to ensure the appropriate level of care was rendered in case of a medical emergency for Resident #181. An interview on [DATE] at 03:15 PM, with the Administrator, revealed the nursing facility did not have a policy related to the process of ensuring the appropriate code status of DNR, for residents, was completed in the EHR. He confirmed the nursing staff should have obtained a signed DNR order for Resident #181 from her admitting physician and confirmed the nursing facility was not honoring the choice of DNR for Resident #181.

Based on observation, staff, resident interview and resident representative interview, record review and facility policy review the facility failed to ensure a resident was assessed for the need of physical restraint as evidenced by no restraint assessment completed prior to applying a lap tray for one (1) of 18 residents reviewed. Resident #45 Findings Include Record review of the facility policy titled, Physical Restraints and Involuntary Seclusion with a revision date of 10/08/20 revealed under Policy .#1. Restraints will not be used unless the facility's Interdisciplinary Team has completed an assessment and evaluation to identify causative medical or environmental factors and considered less restrictive alternatives (except in an emergency). #3 The patient/resident will have the right to refuse or accept the use of restraints. In order for the patient/resident to make an informed choice about the use of restraints, the potential outcomes of restraint use will be explained to the patient/resident. This includes but is not limited to: A. Potential negative outcomes of incontinence, B. Decreased ROM, and ability to ambulate, C. Reduced social contact and D. Possible symptoms of depression. An observation on 4/30/23 at 4:08 PM revealed Resident #45 was self-propelling her wheelchair with a lap tray attached. An observation and interview on 5/1/23 at 9:15 AM revealed Resident #45 was self-propelling her wheelchair with a lap tray attached. An interview at this time with the resident revealed she did not like the lap tray, did not want it and cannot remove it herself. An interview on 5/1/23 at 3:00 PM with the Director of Nurses (DON) revealed that Resident #45 had several falls, and one was with a major injury, so they had a meeting with corporate and therapy and decided that a lap tray was the next step in keeping her in her wheelchair. She revealed the resident should have had an assessment regarding the restraint, but she could not find it or the consent form. An interview on 5/1/23 at 3:15 PM with the Corporate Clinical Nurse confirmed they had a meeting with therapy and decided that Resident #45 needed a lap tray to keep her from falling, because she had fallen so much and had some injuries. She revealed the facility did not have an assessment form that would have been completed for the restraint. She revealed the resident should have had a consent form on her record, but we cannot find it. An interview 5/1/23 at 3:38 PM with the Assistant Director of Nurses (ADON) revealed she went to medical records and found Resident #45's consent for the restraint that was signed by the resident's representative on 4/10/23. An interview on 5/2/23 at 12:15 PM with the Corporate Clinical Nurse confirmed that the facility policy read that an assessment was needed for a restraint but revealed she is unaware of an assessment form. She confirmed that Resident #45 did not have a restraint assessment completed prior to the lap tray being attached to the resident's wheelchair as a restraint. An interview on 5/2/23 at 4:21 PM with Resident #45's representative revealed he was aware that his sister had a lap tray on her wheelchair now and he knew she did not like it. He revealed the facility did not ask for his consent prior to applying the lap tray, he was notified by the facility after the lap tray was applied, he did not get educated on the risk of the lap tray and he did not have to sign anything giving consent. An interview on 5/3/23 at 9:50 AM with the ADON revealed that Resident #45's representative had given consent for the lap tray verbally over the phone but admitted that consent was not obtained prior to applying the lap tray. She revealed the consent for the resident's lap tray should have been obtained prior to applying it because it was not an emergency. Observation and interview on 5/15/23 at 11:30 AM with Resident #45 revealed she was up in a wheelchair with a high back in her room. Resident has a soft pink helmet on her head. She does not have a lap tray or seat belt on. Her speech can be difficult to understand but she is able to say yeah, no and complete simple sentences. When asked if she knew there would be a lap tray used before the staff used one on her wheelchair, she stated yeah. When asked why she didn't want the lap tray on her wheelchair, she stated couldn't move like I wanted. State Agency (SA) asked if the facility staff had explained to her that she could be harmed/hurt if she falls out of the wheelchair, she stated yes. It is noted that she does display the jerking, sudden movements from her extremities that accompany Huntington's disease. Interview with the Director of Nurses on 5/15/23 at 11:45 AM revealed that the consent for the lap tray was verbally over the phone due to the RP living 3.5 hours away. She stated that Resident #45 had a fall this morning, but had no injuries from this fall. She said that Resident #45 is glad she doesn't have to use the lap tray anymore. The Resident Representative (RR) is aware the lap tray has been discontinued (dc'd). Care plan meeting with the RR are done over the phone due to the distance of his home to the facility. The DON explained the risks of falls and possible injury have been explained to both the RR and resident by the DON and the clinical nurse consultant. The DON confirmed the lap tray was discontinued on 5/11/23. Record review of Resident #45's physician's orders revealed an order dated 4/10/23- Apply lap tray when up in wheelchair, check every 30 minutes and release every 2 hours for toileting and repositioning every shift for involuntary movement of trunk and extremities related to Huntington's Disease. Record review of Resident #45's care plans revealed the resident had a care plan created on 4/22/20 and revised on 4/11/23 that read; I am going to fall; I prefer to keep my independence with making coffee from sink. I do not want to have a special cup to prevent spills. She is at high risk for falls with a goal of; I will be free of major injury related to falls through the review date and interventions that include 4/10/23 Restraint would be appropriate at this time due to continuous decline in condition resulting in involuntary movement of trunk and extremities. (Resident #45's proper name) is no longer able to safely maintain position in wheelchair, lap tray applied to wheelchair, staff to check restraint placement every 30 minutes and remove for repositioning and toileting every 2 hours. Record review of Resident #45's record revealed there was no documentation of an assessment for the use of the lap tray or whether the resident could release the lap tray. Record review of Resident #45's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Huntington's Disease. Record review of Resident #45 Minimum Data Set (MDS) an Assessment Reference Date (ARD) of 2/6/23 revealed in Section C a Brief Interview for Mental Status (BIMS) of 14, which indicates the resident is cognitively intact.

Based on observation, interview, record review, and facility policy review, the facility failed to provide supervision to prevent a resident from leaving the facility unsupervised for one (1) of three (3) residents reviewed. Resident #1. The facility failed to provide supervision to prevent elopement for Resident # 1, who was a wandering risk. The resident left the facility through a window unnoticed and unsupervised until the resident was in a community approximately 236.22 feet away from the facility. The Resident was last seen in the facility at 9:00 PM on 2/23/2023. He was not discovered to be missing until 9:53 PM on 2/23/2023 when the facility was notified by the local hospital emergency room (ER) that Resident #1 was in the ER. The facility's failure to provide supervision to a resident who was a wandering risk placed Resident #1 and all residents who were at risk for wandering in a situation that has caused or is likely to cause serious harm, injury, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 1/21/2023 when the facility failed to provide supervision to Resident #1 who was a wandering risk and displayed exit seeking behaviors. Resident #1 left the facility unnoticed and unsupervised on 2/5/2023. The facility Administrator was notified of the IJ on 3/2/2023 at 10:15 AM. The facility provided an acceptable Removal Plan on 3/2/2023, in which the facility alleged all corrective actions were completed to remove the IJ on 3/2/2023. The SA validated the Removal plan on 3/3/2023 and determined the IJ and SQC was removed on 3/3/2023, prior to exit, and the scope and severity for F689 was lowered from a J to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled Wander Management, Monitoring System & Resident Elopement Protocol reviewed 01/2023 revealed Purpose: To monitor safety of residents at risk for elopement. To provide a system to alert staff that a resident may be attempting to leave the facility. Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible . Record review of the facility investigation revealed Resident: (Formal Name of Resident # 1), BIMS(Brief Interview for Mental Status) score of 14, Primary Diagnosis: Malignant Neoplasm of Nasopharynx, Unspecified. On 2/23/2023, (Formal Name of Resident #1), Resident exited the facility via his bedroom window between 21:00 and 21:53. At approximately 21:00 (Formal Name of Certified Nursing Assistant #1 )and (Formal Name of Licensed Practical Nurse #1) witnessed (Formal Name of Resident #1) walk into his private single person bedroom and shut the door, both staff members state that (Formal Name of Resident #1)'s wander guard bracelet was on his ankle when they saw him enter his room. At 21:53 (Formal Name of Local Hospital emergency room ) Charge Nurse called the facility to report (Formal Name of Resident # 1) was at the emergency room . (Formal Name of Resident # 1) exited his bedroom by sliding open the side section of his private room bedroom window and bending the window screen open wide enough for him to crawl out. (Formal Name of Resident # 1)'s wander guard bracelet was in place and functioning properly as were the door wander guard systems prior to the elopement and even after (Formal Name of Resident #1) returned from (Formal Name of Local Hospital) emergency room . Upon his return from (Formal Name of Local Hospital) emergency roiagnom on [DATE], (Formal Name of Resident #1) was placed on one-on-one observation beginning at approximately 01:45 until 06:00, and then 15-minute checks which he remains on it. On 2-24-2023, (Formal Name of Resident # 1) was moved from (Resident #1's previous room) to (Resident # 1's new room) (courtyard room), and a window alarm device were placed on the windows in (Formal Name of Resident #1)'s new room (Resident #1's room).On 2-23-2023 (Formal Name of State Agency) and the AG (Attorney General's) office were notified. Resident's Responsible Party and Physician were notified of the allegation and informed that an investigation was being conducted. Throughout the investigation Employee witness statements were collected, Resident body audit was conducted, one on one resident observation initiated, 100% audit of wandering risk residents conducted, 100% audit residents were assessed for being at risk for elopement, Wander Guard System/Door were checked by Maintenance Department with no areas of concern nor malfunctions noted, and window alarm devices were added to (Formal Name of Resident # 1)'s new courtyard room . Staff members were in-serviced on Abuse/Neglect, Resident Rights, Vulnerable Adults and Elopement policy and procedures. In conclusion, the allegation of abuse or neglect on behalf of the facility is unsubstantiated. I do substantiate that (Formal Name of Resident #1) (BIMS 14) did exit the facility via his bedroom window because he has a strong desire to not be in a Nursing Home and wants to go home . An interview with Registered Nurse (RN) #1 on 2/27/23 at 2:00 PM, revealed that she was on duty as Charge Nurse on 2/23/23 and received a call from the local emergency room (ER) at 9:53 PM notifying her that Resident #1 was in the ER and that he had been picked up by the ambulance in the neighborhood behind the facility. She stated that she and Certified Nursing Assistant (CNA) #2 went to Resident #1's room and noticed that the window was open, and the screen was broken. When she went outside to the back of the building she saw the resident's phone, house shoe, glasses, and jacket. She stated that Resident #1 must have gone through the fence and creek because his clothing was wet when he got to the hospital. She stated that she went to the ER to check on Resident #1 and noticed a laceration on his head and abdomen. RN #1 stated that Resident #1 was last seen by the floor nurse and CNA #2 around 9:00 PM going into his room. In an interview with the Administrator on 2/27/23 at 2:08 PM, he revealed that the resident attempted to exit the building last month. Upon interview with the dispatcher for the local ambulance service on 2/27/23 at 2:29 PM, she stated that Emergency Medical Services (EMS) received a call to respond to an address in a local neighborhood at 9:12 PM on 2/23/2023. EMS picked up Resident #1 at 9:18 PM and took him to the local ER. An interview with LPN #1 on 2/27/23 at 3:15 PM, revealed that she was on duty on the 3-11 shift on 2/23/23 and last saw Resident #1 during the night med pass around 9:00 PM. She stated that he was ambulating up and down the hall and went into his room. LPN # 1 also revealed that she witnessed an incident on 2/21/23 in which the resident became agitated and attempted to get out by using the advanced entry check in machine to try to break a window near one of the exits. She stated that it was obvious that the resident was going to get out any way he could but did not think that he would go out the window. A telephone interview with CNA #1 on 2/27/23 at 3:57 PM, revealed the resident likes to wander and they try to keep him out of the room and in visual site as much as possible. She revealed that on the night of the 2/23/23 Resident #1 went into his room around 9:00 PM. She stated that Resident #1 really needs one on one (1:1) care. CNA #1 stated that if Resident #1 had 1:1 and maybe take him outside to a safe spot so he didn't feel like he was trapped, that maybe they could have talked him out of going out the window. An interview with LPN #3 on 2/28/23 at 11:20 AM, revealed that she is familiar with the resident and that he wanders through the facility and is exit seeking. She states that they give him snacks and try to monitor and redirect him. She states that at times the resident becomes obsessed with things until he gets them. An interview with Resident #1 on 2/28/23 at 11:30 AM, revealed that he did not recall how he obtained the laceration to his head or leaving the building to go home. Resident #1 stated he had $100,000 in the bank and needed some dry clothing and began propelling himself down the hall in the wheelchair. An interview with CNA # 2 on 2/28/23 at 4:00 PM, she revealed that she was the CNA assigned to Resident #1 on the 3-11 shift on 2/23/23. She stated that Resident #1 does wander, and they have to monitor him and redirect him. CNA # 2 stated that she did not look at her watch but that she thinks it was around 9:00 PM when she saw Resident #1 go into his room and shut the door while she was on the way to care for another resident. She stated the resident will usually take a nap for a couple of hours and then get up again. On 3/1/23 at 1:45 PM, an interview and observation with the Maintenance Supervisor revealed that the side window would open at the top and the resident bent the top half of the screen down enough to climb out. On the outside of the building, the window was directly over a concrete drain. The Maintenance Supervisor revealed there was blood found on the concrete drain the morning after the resident eloped. Directly across from his window and the building there was a chain link fence that still had a torn piece of the black T-shirt the resident was wearing the night he eloped and approximately 5 feet down the bank was a house shoe. The bank was very steep and had fallen tree debris and large broken pieces of concrete on both sides. At the bottom of the bank was a creek approximately 5 (five) feet wide and the bank on the other side of the creek was just like the one closest to the building. At the top of the bank were backyards to houses in a subdivision. The Maintenance Supervisor stated the resident climbed out of the window, climbed over the chain link fence, across the creek, up the bank on the other side of the creek and into the backyards of those houses. The Maintenance Supervisor stated they moved the resident to a room that opens onto the courtyard of the facility and has alarms on the window. On 3/2/23 at 3:00 PM, an interview with RN # 1, revealed that when the resident returned from theER on [DATE] he was wearing a black T-shirt that was torn, wet, and muddy, a pair of black slacks that were wet and muddy, and one house shoe. He had a laceration on his head with staples and about 4 scratches on his abdomen. An interview with Officer #1 on 3/1/23 at 7:15 PM, who responded to the initial 911 call on 2/23/2023 revealed, he was unsure of the exact time of the call or time of his arrival. He indicated it was after 9:00 PM. He stated that Resident #1 had been knocking on doors in the neighborhood looking for help. Officer #1 stated that the resident was confused, agitated, and difficult to understand. He stated the resident's clothing was wet and he had blood on his hands that was coming from his head. Officer #1 stated Resident #1 was released to EMS when they arrived. A record review of the local Emergency Medical Services (EMS) report titled Patient Care Report, revealed local EMS responded to a 911 call, arrived at the given address at 9:18 PM and noted that Resident #1 was sitting on the ground on the roadside. The Local Police Department was present. Resident # 1 had dried blood to the left side of his head and abrasions to the abdomen. Resident # 1 had walked up to someone's door and tried to enter the house and they called 911. A record review of the local Hospital Emergency Department (ED) report titled ED Notes revealed on 2/23/2023 at 9:49 PM Resident #1 arrived at the ED via EMS after police responded to him being found in a stranger's yard. Resident #1 had a 3 centimeter (cm) laceration to his scalp, requiring 4 staples, and lacerations down and across his abdomen. The ED notified the facility that Resident #1 was at the ED. The facility was unaware that Resident #1 was not present in the facility. Record review of Past Weather in Grenada dated 2/23/2023 revealed that 9:00 PM to 9:53 PM the temperature was 68 degrees Fahrenheit (F) with no precipitation. Record review of Google Maps revealed that the address where Resident #1 was located was 236.22 feet from the window in Resident #1's room. Record review of the Admission Record for Resident #1 revealed that the resident was admitted on [DATE]. Admitting diagnosis included Malignant Neoplasm of Nasopharynx, Unspecified, Secondary Malignant Neoplasm of Brain, Unspecified Psychosis not due to substance or known physiological condition, Major Depressive Disorder, Recurrent, Unspecified, Unspecified Mood (Affective) Disorder, and Unspecified Glaucoma. A record review of NEX-Wander Data Collection -V1 , with an effective date of 1/21/2023 revealed Resident #1 as High Risk for Wandering with a score of 28, and indicated that Resident #1 was cognitively impaired with poor decision making skills, has wandered, .wandering places the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility), .resident has visual, auditory or communication deficits, .ambulate/perform locomotion independently .,verbally expresses desire to go home .,receives medications that may increase restlessness or agitation, .new behavior, or change in functional status/routine Signed date 2/6/2023. A record review of NEX-Wander Data Collection -V1 , with an effective date of 2/6/2023 revealed Resident #1 as High Risk for Wandering with a score of 28, and indicated that Resident #1 was cognitively impaired with poor decision making skills, has wandered, .wandering places the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility), .ambulate/perform locomotion independently .,verbally expresses desire to go home , .new behavior, or change in functional status/routine Signed date 2/6/2023. Record review of the Physician Orders for Resident #1 revealed that an order for Wandergaurd-check for functioning Daily every shift was started on 02/06/2023. Record review of a Physician Order for Resident #1 dated 2/27/23 revealed the wander guard bracelet was placed on Resident #1 for wandering/exit seeking behaviors secondary to diagnosis of Malignant neoplasm of the brain. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date of 1/16/2023,Section C, revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #1 was cognitively intact. Removal Plan The facility failed to develop/implement a wandering/elopement risk care plan for Resident #1. The facility failed to provide supervision to prevent the elopement of Resident #1, who had exhibited exit seeking behavior. This failure allowed Resident #1 to be away from the facility unnoticed and unsupervised on 2-23-2023 until a nearby hospital alerted the facility at 9:53 PM that the resident was at the hospital. This was approximately 53 minutes after Resident #1 was last observed in the facility. On 3-2-2023 at 10:15 AM an immediate jeopardy (IJ) template was provided to the Nursing Home Administrator (NHA) by the State Agency (SA). Immediate Action started on 2-23-2023 at approximately 9:50 PM 1. On 2-23-2023 at approximately 9:53 PM, Local Hospital emergency room (ER) called charge nurse phone to inform facility that Resident #1 was in the ER and looked beat up with lacerations and bruising. Local Hospital Emergency nurse said he still has his wander guard bracelet on. The Certified Nursing Assistant (CNAs) and Assistant Director of Nursing (ADON) looked into Resident #1's room and noticed that his window was open, and the screen had been bent/broken out and up to allow him to get out of the facility. 2. On 2-23-2023 at approximately 9:58 PM, the Nursing Home Administrator (NHA) notified Mississippi Department of Health and Attorney General Office. 3. On 2-23-2023 at approximately 9:58 PM an investigation was initiated and concluded on 3-1-2023 in which employee witness statements were collected. 4. On 2-23-2023 at approximately 9:58 PM, Assistant Director of Nursing conducted 100% resident audit and ensured all residents were accounted for and ensured two (2) residents with wander guard bracelets were in place and functioning properly. 5. On 2-23-2023 at approximately 10:23 PM, Assistant Director of Nursing notified Resident #1's Physician and Responsible Party. 6. On 2-23-2023 at approximately 10:40 PM, ADON went to the ER to interview Resident #1 and to assess Resident #1. 7. On 2-23-2023 at approximately 11:50 PM, the ADON initiated all staff members in-services on Abuse/Neglect, Resident Rights, Vulnerable Adults and Elopement policy and procedures which included, but does not limit to: Identification & Prevention of elopement, interventions, and documentation, at risk for elopement; monitoring, interdisciplinary interventions, door alarm sounds, procedure for missing residents/elopement, what to do when resident is found, and actions post elopement. No employee will be allowed to return to work without the training. 8. On 2-24-2023 at approximately 1:45 AM, upon return from to the facility Resident #1 was assessed and immediately placed on 1 on 1 observation. He was placed in room with 1 on 1 observation until resident was asleep and then every (Q)15 minute checks were initiated. 9. On 2-24-2023 at approximately 12:00 PM, Wander Guard System/Door were checked by Maintenance Department with no areas of concern nor malfunctions noted and, window alarm devices were added to Resident #1's new courtyard room. 10. On 2-24-2023 between 8:00 AM and 4:30 PM, the Director of Nursing (DON) conducted a 100% audit for the risk of wandering for all 88 residents to include three residents already at risk for wandering. 11. On 2-24-2023 between 8:00 AM and 4:30 PM, the DON conducted a 100% audit of all wandering/elopement resident care plans. 12. On 2-24-2023 between 8:00 AM and 4:30 PM, the DON reviewed the wandering/elopement binders at each nurse's station and no updates were necessary. 13. On 3-2-2023 between 1:00 PM and 3:30 PM, the Regional Director of Clinical Services (RDCS) completed a 100% audit for all high risk wandering/elopement Residents Care Plans to ensure wandering/elopement care plans include appropriate interventions; Resident #1's and Resident # 3's care plans were updated. 14. On 3-2-2023 between 10:00 AM and 4:00 PM, the Staff Development Nurse (SDC) conducted and completed a 100% all Nursing staff in-service on developing Comprehensive Person Centered Care Plans to include interventions that address wandering and or high risk elopement residents. No employee will be allowed to return to work without the training. 15. On 3-2-2023 at approximately 4:45 PM, the Regional Director of Clinical Services (RDCS) in-serviced the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on identifying residents at risk for wandering/elopement and that they have the appropriate interventions in place. No employee will be allowed to return to work without the training. 16. On 3-2-2023 at approximately 6:30 PM, the Maintenance Department conducted an elopement drill and in-serviced staff members on the policy and procedures of elopement which included but does not limit to: Identification & Prevention of elopement, interventions, and documentation, at risk for elopement; monitoring, interdisciplinary interventions, door alarm sounds, procedure for missing residents/elopement, what to do when resident is found, and actions post elopement. 17. On 3-2-23-2023 at 2:00 PM the Ad-Hoc Emergency Quality Assurance Performance Improvement (QAPI) Committee met to review the immediate jeopardy related to F 689 Free of Accident/Hazards/Supervision/Devices and F 656 Develop/Implement Comprehensive Care Plan and conduct a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the Nursing Home Administrator (NHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist Nurse (IPN) and Regional Director of Clinical Services (RDCS). The Medical Director (MD) attended via phone. No Policy and Procedures changes were made at this time. Facility alleges Immediate Jeopardy was removed as of 3-2-2023. State Agency (SA) Validation on 3-3-2023 1. The State Agency (SA) validated through record review and interview with the Assistant Director of Nursing (ADON) that on 2-23-2023 at 9:53 PM, after they were notified by the local hospital Resident #1 was at the hospital, the ADON and Certified Nursing Assistant (CNA) assessed Resident #1 ' s room and found the window was open and the screen was bent and broken. 2. The SA validated through record review and interview with the Nursing Home Administrator (NHA) and the SA complaint department, the elopement of a resident was reported to the State Department of Health on 2-23-2023 at 9:58 PM by the NHA. 3. The SA validated through record review and interview with the ADON that she initiated the investigation on 2-23-2023 at 9:58 PM and was concluded on 3-1-2023 by obtaining interviews, witness statements and observations. 4. The SA validated through record review and an interview with the ADON, a 100% audit of the residents, was performed on 2-23-2023 and begun at 9:58 PM to ensure they were accounted for and the two (2) residents with wander guard bracelets were in place and functioning properly. 5. The SA validated through record review and an interview with the ADON that on 2-23-2023 at 10:23 PM Resident #1 ' s Physician and Responsible Party were notified. 6. The SA validated through record review and an interview with the ADON on 2-23-2023 at 10:40 PM a visual assessment of Resident #1 was conducted at the local Hospital emergency room (ER) by the ADON. 7. The SA validated through record review and interviews with the ADON and eight (8) staff members on 2-23-2023 from 11:50 AM to 1:00 PM, an in service was initiated and attended on Abuse/Neglect, Resident Rights, Vulnerable Adults and Elopement policy and procedures which included but is not limited to: Identification and Prevention of Elopement: interventions and documentation, At Risk For Elopement:, monitoring, interdisciplinary interventions, door alarm sounds, procedure for missing residents/elopement, what to do when resident is found, and actions post elopement. No employee will be allowed to work without the training. 8. The SA validated through record review and interview with the Director of Nursing, nurses and staff assigned to observations that on 2-24-2023 at approximately 1:45 AM, upon Resident #1 ' s return to the facility, he was assessed, placed on one (1) on 1 observation while awake and every 15-minute checks while asleep. 9. The SA validated through record review and interview with the Maintenance Department Director that on 2-24-2023 at 12:00 PM the Maintenance Director checked all Wander Guard System door alarms with no areas of concern nor malfunctions noted and, the window alarm was added to Resident #1 ' s room. 10. The SA validated through record review, and an interview with the DON that on 2-24-2023 between 8:00 AM and 4:30 PM she initiated a 100 % resident audit, for wandering, to include three (3) at high risk wandering residents. 11. The SA validated through record review and an interview with the DON that on 2-24-2023 at 8:00 AM and 4:30 PM she initiated an audit on all wandering/elopement resident care plans for appropriate interventions. 12. The SA validated through record review and interview with the DON the wander/elopement binders at the nurse 's stations were reviewed on 2-24-2023 at 8:00 AM and 4:30 PM for any needed updating. No issues were identified. 13. The SA validated through record review and an interview with the Regional Director of Clinical Services (RDCS) on 3/2/2023 between 1:00 PM and 3:30 PM she conducted an audit for all high risk wandering/elopement Residents Care Plans to ensure wandering/elopement care plans include appropriate interventions. Resident #1 and Resident #3 care plans were updated. 14. The SA validated through record review and interviews with facility staff that the Staff Development Nurse (SDC) conducted and completed an in service on 3/2/2023 at 10:00 AM and 4:00 PM with all nursing staff on developing Comprehensive Person Centered Care Plans to include interventions that address wandering and or high risk elopement resident. 15. The SA validated through record review and an interview with the RDCS that on 3-2-2023 at 4:45 PM she in serviced the NHA and the DON on identifying residents at risk for wandering/elopement and that they have the appropriate interventions in place. 16. The SA validated through record review and an interviews with staff that the Maintenance Department on 3-2-2023 at 6:30 PM conducted a facility wide elopement drill and in service to the staff on the policy and procedures of elopement which included but does not limit to: Identification and Prevention of elopement interventions, door alarm sounds, procedure for a missing resident, what to do when a resident is found and actions post elopement. 17. The SA validated through record review and an interview with the Administrator on 3-2-2023 at 6:30 PM the Quality Assurance Performance Improvement (QAPI) committee met to review the immediate jeopardy related to elopement, elopement interventions and care plans related to elopement. The meeting was attended by the Nursing Home Administrator (NHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Control Preventionist Nurse (IPN), and the Regional Director of Clinical Services (RDCS). The Medical Director attended by phone. No policies were changed. The SA validated that all corrective actions to remove the IJ had been completed as of 3/2/2023, and the IJ was removed on 3/3/23, prior to exit.

Based on staff interview, record review, and facility policy review, the facility failed to develop and implement care plan interventions for a resident who displayed exit seeking behaviors and eloped from the facility for one (1) of three (3) residents reviewed. Resident #1. The facility failed to provide supervision to prevent elopement for Resident # 1, who was a wandering risk. Resident #1 began exhibiting exit seeking behaviors on 1/21/23. The facility failed to develop a care plan for these behaviors until 2/8/23. On 2/23/23, the resident left the facility through a window unnoticed and unsupervised until the resident was in a community approximately 236.22 feet away from the facility. The Resident was last seen in the facility at 9:00 PM on 2/23/23. He was not discovered to be missing until 9:53 PM on 2/23/23 when the facility was notified by the local Hospital emergency room (ER) that Resident #1 was in the ER. The facility's failure to develop the comprehensive care plan to provide supervision to a resident who was a wandering risk placed Resident #1 and all residents who were at risk for wandering in a situation that has caused or is likely to cause serious harm, injury, impairment, or death. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 1/21/2023 when the facility failed to provide supervision to Resident #1 who, was a wandering risk and displayed exit seeking behaviors. Resident #1 left the facility unnoticed and unsupervised on 2/5/2023. The facility Administrator was notified of the IJ on 3/2/2023 at 10:15 AM. The facility provided an acceptable Removal Plan on 3/2/2023, in which the facility alleged all corrective actions were completed to remove the IJ on 3/2/2023, and the IJ removed on 3/2/2023. The State Agency (SA) determined the IJ was removed on 3/2/2023, prior to exit, and the scope and severity for F 656 was lowered to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered Reviewed [DATE] revealed, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Policy Interpretation and Implementation . :8. g. incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; . 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change . Review of the facility policy titled Wander Management, Monitoring System & Resident Elopement Protocol. Reviewed 01/2023. Purpose: To monitor safety of residents at risk for elopement. To provide a system to alert staff that a resident may be attempting to leave the facility. Policy .All residents, so identified, will have these issues addressed in their individual care plans. Procedures: A. Identification & Prevention of Elopement . 3. All interventions should be documented on the individual plan of care, with periodic reassessments as warranted .4.Residents identified at risk for elopement shall be provided one of the following: .b. A personal safety device that alerts staff of resident effort to leave the facility. C. Signaling device to the arm or ankle or as permitted by the manufacturer. B. Interdisciplinary interventions: Residents identified at risk for elopement will be reviewed by the interdisciplinary team to identify if the causative factors can be eliminated .F. Procedures for Missing Residents/Elopement, 3. Post Elopement: The interdisciplinary team must review the resident's plan of care to determine that changes may be warranted. Record review of the Care Plan for Resident #1 revealed, Focus: Date Initiated 2/8/2023 I HAVE BEEN EVALUATED AS A WANDERING RISK R/T (related to) Exit seeking behaviors r/t Malignant Neoplasm of Brain. 2/23/23: Received a call from the ER that (Formal Name of Resident #1) was in the ER with several lacerations and bruising .Goal: I WILL REMAIN FREE OF INJURIES ASSOCIATED WITH WANDERING BEHAVIORS .Interventions: Date Initiated 2/24/23 Alarm window and door to alert staff for elopement attempts. Date Initiated 2/8/23: CHECK MY LOCATION FREQUENTLY .ENCOURAGE ME TO PARTICIPATE IN ACTIVITIES .ENGAGE ME IN DIVISIONAL ACTIVITIES .EVALUATE THE NEED FOR ME TO UTILIZE A WANDERING BRACELET .OBSERVE ME FOR S/S OF AGITATION .PROVIDE ME RE-ORIENTATION . A record review of Resident #1's Progress Notes, Gen Nurses Notes-narrative for 1/21/2023 at 12:42 PM revealed, .He then started running down the hallway to the door outside of the beauty shop. When he got to the door, he slammed into it trying to open it. He then started hitting the door and code keypad . Resident would not cooperate and remained combative and exit seeking. A record review of Resident #1's Progress Notes, Gen Nurses Notes-narrative for 1/21/2023 at 14:27 revealed, .resident made phone calls to family members stating for them to come get him and took off down the hall running up by the beauty shop exit seeking .Resident continued pushing door and hitting on glass wanting to get out . A record review of Resident #1's Progress Notes, Gen Nurses Notes-narrative for 1/22/23 11:16 AM . resident ran down hallway then got against the wall and slid himself down to the floor .He is hollering out that he wants to go home . A record review of Resident #1's Progress Notes, Gen Nurses Notes-narrative on 2/8/2023, late entry for 2/5/2023 1800 .the door alarm was sounding . double door exit near therapy dept. and the right one was cracked open., (Formal Name of Respiratory Therapist) was pulling into the parking lot and called out to me that (Formal Name of Resident # 1) was at the front door. Resident brought back into facility. A record review of Resident #1's Progress Notes, Gen Nurses Notes-narrative on 2/14/2023 at 06:35 revealed .Resident wandering and exit seeking as well. Resident was redirected multiple times and would become aggressive again shortly after. A record review of Resident #1' Progress Notes, Gen Nurses Notes-narrative on 2/21/2023 at 21:12 revealed, . Exit seeking. Resident became aggressive with staff. Resident began beating on the external glass door to parking lot first with hands then with check in device and shattered the glass, remains in place approximately 15 minutes later resident was back up with same behaviors. All redirecting attempts not successful. DON, NP, Administrator notified. RP made aware @8:37pm of resident current behaviors and agreed that resident was a danger to himself and agreed for resident to be sent to ER. A record review of Resident #1' Progress Notes, Gen Nurses Notes-narrative 2/23/2023 21:53 revealed, Received a call from the ER that (Formal Name of Resident #1) was in the ER with several lacerations and bruising. Went to check his room and found his window open and the screen broken and pushed up. DON and ADM informed. RP informed. Went to ER to see resident and interview him. He is confused with abrasions to abdomen and hands and lacerations to head and face. ER MD stated that they would send him back once CT was clear with sutures to his head. A record review of NEX-Wander Data Collection -V1 , with an effective date of 1/21/2023 revealed Resident #1 as High Risk for Wandering with a score of 28, and indicated that Resident #1 was cognitively impaired with poor decision making skills, has wandered, .wandering places the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility), .resident has visual, auditory or communication deficits, .ambulate/perform locomotion independently .,verbally expresses desire to go home .,receives medications that may increase restlessness or agitation, .new behavior, or change in functional status/routine Signed date 2/6/2023. Record review of the Physician Orders for Resident #1 revealed that on an order for Wandergaurd-check for functioning Daily every shift was started on 02/06/2023. An order for Wander Bracelet r/t wandering/exit seeking behaviors 2nd DX Malignant neoplasm of the brain . was started on 02/27/2023. An interview with the Activity Director (AD) on 2/27/23 at 1:00 PM, revealed that Activities had not left any kind of activities for staff to use in the evening as a diversion for the resident. In an interview with the Administrator on 2/27/23 at 2:00 PM, he revealed that he did not know if any interventions were put in place after Resident's # 1 attempt to exit the building on 1/21/23. During an interview with the Director of Nursing (DON) on 2/28/23 at 11:50 AM, she revealed that following Resident #1's attempt to exit the facility on 2/5/23, he was placed every 15 min monitoring for 24 hours. She stated that a wandergaurd was applied. The DON stated that following Resident # 1's attempt to exit the facility on 2/5/2023 he was sent to the emergency room for evaluation and placed on antibiotic for a urinary tract infection (UTI) and his medications were reviewed, but no other interventions were put in place. On 3/1/23 at 3:57 PM, an additional interview with the DON revealed that the wandergaurd was not ordered until the incident where Resident #1 was out in the parking lot on 2/6/23. When he attempted to go out the door and became very upset on 1/21/23 the DON revealed she tried to find a wandergaurd at that time and does not know what happened but he did not get one ordered at that time. The DON said they sent him to theER on [DATE] for behavior to get some help; the ER gave him some meds to calm him down and he returned to the facility that night. She revealed after he returned from the ER she does not know of any interventions that were developed to address his exit seeking. She revealed she looked and felt he did not need any interventions because this was the first time he had attempted to leave. She felt the interventions were adequate for his condition but in hindsight she should have put on wandergaurd on that night. On 3/1/23 at 4:15 PM, an interview with Minimum Data Set Nurse #1 (MDS) and MDS # 2, The MDS Nurses revealed they are the nurses that develop and update care plans. The problem for wandering for Resident #1 was not developed until 2/6/2023 when the resident was found in the parking lot on 2/5/23. The reason they developed the care plan for wandering at that time was because an order was written for the wandergaurd, and they review and look at all orders written. They stated the incident on 1/21/2023 was discussed in the Huddle meeting at that time but felt the interventions were adequate at that time because that was a new behavior. The care plan developed on 2/6/23 had an intervention for frequent monitoring with no specific time schedule and the MDS Nurses stated that meant every shift. No new interventions were added when the resident attempted to exit by busting out the glass to the front of the building by beating it with a metal pole. Record review of the Admission Record for Resident #1 revealed that the resident was admitted on [DATE]. Admitting diagnosis included Malignant Neoplasm of Nasopharynx, Unspecified, Secondary Malignant Neoplasm of Brain, Unspecified Psychosis not due to substance or known physiological condition, Major Depressive Disorder, Recurrent, Unspecified, Unspecified Mood (Affective) Disorder, and Unspecified Glaucoma. Record review of Resident #1's Section C of the Minimum Data Set (MDS) revealed that on 1/16/2023 the Brief Interview for Mental Status (BIMS) score was 14, indicating the resident was cognitively intact. Removal Plan The facility failed to develop/implement a wandering/elopement risk care plan for Resident #1. The facility failed to provide supervision to prevent the elopement of Resident #1, who had exhibited exit seeking behavior. This failure allowed Resident #1 to be away from the facility unnoticed and unsupervised on 2-23-2023 until a nearby hospital alerted the facility at 9:53 PM that the resident was at the hospital. This was approximately 53 minutes after Resident #1 was last observed in the facility. On 3-2-2023 at 10:15 AM an immediate jeopardy (IJ) template was provided to the Nursing Home Administrator (NHA) by the State Agency (SA). Immediate Action started on 2-23-2023 at approximately 9:50 PM 1. On 2-23-2023 at approximately 9:53 PM, Local Hospital emergency room (ER) called charge nurse phone to inform facility that Resident #1 was in the ER and looked beat up with lacerations and bruising. Local Hospital Emergency nurse said he still has his wander guard bracelet on. The Certified Nursing Assistant (CNAs) and Assistant Director of Nursing (ADON) looked into Resident #1's room and noticed that his window was open, and the screen had been bent/broken out and up to allow him to get out of the facility. 2. On 2-23-2023 at approximately 9:58 PM, the Nursing Home Administrator (NHA) notified Mississippi Department of Health and Attorney General Office. 3. On 2-23-2023 at approximately 9:58 PM an investigation was initiated and concluded on 3-1-2023 in which employee witness statements were collected. 4. On 2-23-2023 at approximately 9:58 PM, Assistant Director of Nursing conducted 100% resident audit and ensured all residents were accounted for and ensured two (2) residents with wander guard bracelets were in place and functioning properly. 5. On 2-23-2023 at approximately 10:23 PM, Assistant Director of Nursing notified Resident #1's Physician and Responsible Party. 6. On 2-23-2023 at approximately 10:40 PM, ADON went to the ER to interview Resident #1 and to assess Resident #1. 7. On 2-23-2023 at approximately 11:50 PM, the ADON initiated all staff members in-services on Abuse/Neglect, Resident Rights, Vulnerable Adults and Elopement policy and procedures which included, but does not limit to: Identification & Prevention of elopement, interventions, and documentation, at risk for elopement; monitoring, interdisciplinary interventions, door alarm sounds, procedure for missing residents/elopement, what to do when resident is found, and actions post elopement. No employee will be allowed to return to work without the training. 8. On 2-24-2023 at approximately 1:45 AM, upon return from to the facility Resident #1 was assessed and immediately placed on 1 on 1 observation. He was placed in room with 1 on 1 observation until resident was asleep and then every (Q)15 minute checks were initiated. 9. On 2-24-2023 at approximately 12:00 PM, Wander Guard System/Door were checked by Maintenance Department with no areas of concern nor malfunctions noted and, window alarm devices were added to Resident #1's new courtyard room. 10. On 2-24-2023 between 8:00 AM and 4:30 PM, the Director of Nursing (DON) conducted a 100% audit for the risk of wandering for all 88 residents to include three residents already at risk for wandering. 11. On 2-24-2023 between 8:00 AM and 4:30 PM, the DON conducted a 100% audit of all wandering/elopement resident care plans. 12. On 2-24-2023 between 8:00 AM and 4:30 PM, the DON reviewed the wandering/elopement binders at each nurse's station and no updates were necessary. 13. On 3-2-2023 between 1:00 PM and 3:30 PM, the Regional Director of Clinical Services (RDCS) completed a 100% audit for all high risk wandering/elopement Residents Care Plans to ensure wandering/elopement care plans include appropriate interventions; Resident #1's and Resident # 3's care plans were updated. 14. On 3-2-2023 between 10:00 AM and 4:00 PM, the Staff Development Nurse (SDC) conducted and completed a 100% all Nursing staff in-service on developing Comprehensive Person Centered Care Plans to include interventions that address wandering and or high risk elopement residents. No employee will be allowed to return to work without the training. 15. On 3-2-2023 at approximately 4:45 PM, the Regional Director of Clinical Services (RDCS) in-serviced the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on identifying residents at risk for wandering/elopement and that they have the appropriate interventions in place. No employee will be allowed to return to work without the training. 16. On 3-2-2023 at approximately 6:30 PM, the Maintenance Department conducted an elopement drill and in-serviced staff members on the policy and procedures of elopement which included but does not limit to: Identification & Prevention of elopement, interventions, and documentation, at risk for elopement; monitoring, interdisciplinary interventions, door alarm sounds, procedure for missing residents/elopement, what to do when resident is found, and actions post elopement. 17. On 3-2-23-2023 at 2:00 PM the Ad-Hoc Emergency Quality Assurance Performance Improvement (QAPI) Committee met to review the immediate jeopardy related to F 689 Free of Accident/Hazards/Supervision/Devices and F 656 Develop/Implement Comprehensive Care Plan and conduct a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the Nursing Home Administrator (NHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist Nurse (IPN) and Regional Director of Clinical Services (RDCS). The Medical Director (MD) attended via phone. No Policy and Procedures changes were made at this time. Facility alleges Immediate Jeopardy was removed as of 3-2-2023. State Agency (SA) Validation on 3-3-2023 1.The State Agency (SA) validated through record review and interview with the Assistant Director of Nursing (ADON) that on 2-23-2023 at 9:53 PM, after they were notified by the local hospital Resident #1 was at the hospital, the ADON and Certified Nursing Assistant (CNA) assessed Resident #1 ' s room and found the window was open and the screen was bent and broken. 2. The SA validated through record review and interview with the Nursing Home Administrator (NHA) and the SA complaint department, the elopement of a resident was reported to the State Department of Health on 2-23-2023 at 9:58 PM by the NHA. 3. The SA validated through record review and interview with the ADON that she initiated the investigation on 2-23-2023 at 9:58 PM and was concluded on 3-1-2023 by obtaining interviews, witness statements and observations. 4. The SA validated through record review and an interview with the ADON, a 100% audit of the residents, was performed on 2-23-2023 and begun at 9:58 PM to ensure they were accounted for and the two (2) residents with wander guard bracelets were in place and functioning properly. 5. The SA validated through record review and an interview with the ADON that on 2-23-2023 at 10:23 PM Resident #1 ' s Physician and Responsible Party were notified. 6. The SA validated through record review and an interview with the ADON on 2-23-2023 at 10:40 PM a visual assessment of Resident #1 was conducted at the local Hospital emergency room (ER) by the ADON. 7. The SA validated through record review and interviews with the ADON and eight (8) staff members on 2-23-2023 from 11:50 AM to 1:00 PM, an in service was initiated and attended on Abuse/Neglect, Resident Rights, Vulnerable Adults and Elopement policy and procedures which included but is not limited to: Identification and Prevention of Elopement: interventions and documentation, At Risk For Elopement:, monitoring, interdisciplinary interventions, door alarm sounds, procedure for missing residents/elopement, what to do when resident is found, and actions post elopement. No employee will be allowed to work without the training. 8. The SA validated through record review and interview with the Director of Nursing, nurses and staff assigned to observations that on 2-24-2023 at approximately 1:45 AM, upon Resident #1 ' s return to the facility, he was assessed, placed on one (1) on 1 observation while awake and every 15-minute checks while asleep. 9. The SA validated through record review and interview with the Maintenance Department Director that on 2-24-2023 at 12:00 PM the Maintenance Director checked all Wander Guard System door alarmswith no areas of concern nor malfunctions noted and, the window alarm was added to Resident #1 ' s room. 10. The SA validated through record review, and an interview with the DON that on 2-24-2023 between 8:00 AM and 4:30 PM she initiated a 100 % resident audit, for wandering, to include three (3) at high risk wandering residents. 11. The SA validated through record review and an interview with the DON that on 2-24-2023 at 8:00 AM and 4:30 PM she initiated an audit on all wandering/elopement resident care plans for appropriate interventions. 12. The SA validated through record review and interview with the DON the wander/elopement binders at the nurse 's stations were reviewed on 2-24-2023 at 8:00 AM and 4:30 PM for any needed updating. No issues were identified. 13. The SA validated through record review and an interview with the Regional Director of Clinical Services (RDCS) on 3/2/2023 between 1:00 PM and 3:30 PM she conducted an audit for all high riskwandering/elopement Residents Care Plans to ensure wandering/elopement care plans include appropriate interventions. Resident #1 and Resident #3 care plans were updated. 14. The SA validated through record review and interviews with facility staff that the Staff Development Nurse (SDC) conducted and completed an in service on 3/2/2023 at 10:00 AM and 4:00 PM with all nursing staff on developing Comprehensive Person Centered Care Plans to include interventions that address wandering and or high risk elopement resident. 15. The SA validated through record review and an interview with the RDCS that on 3-2-2023 at 4:45 PM she in serviced the NHA and the DON on identifying residents at risk for wandering/elopement and that they have the appropriate interventions in place. 16. The SA validated through record review and an interviews with staff that the Maintenance Department on 3-2-2023 at 6:30 PM conducted a facility wide elopement drill and in service to the staff on the policy and procedures of elopement which included but does not limit to: Identification and Prevention of elopement interventions, door alarm sounds, procedure for a missing resident, what to do when a resident is found and actions post elopement. 17. The SA validated through record review and an interview with the Administrator on 3-2-2023 at 6:30 PM the Quality Assurance Performance Improvement (QAPI) committee met to review the immediatejeopardy related to elopement, elopement interventions and care plans related to elopement. The meeting was attended by the Nursing Home Administrator (NHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Control Preventionist Nurse (IPN), and the Regional Director of Clinical Services (RDCS). The Medical Director attended by phone. No policies were changed. The SA validated that all corrective actions to remove the IJ had been completed as of 3/2/2023, and the IJ was removed on 3/3/23, prior to exit.

Complaint Investigation (CI) MS # Based on record review, policy review and staff interview, the facility failed to provide services and effectively monitor a resident with a known history the risk for elopement, as outlined in the care plan, which resulted in the resident leaving the building unsupervised. This affected one (1) of nine (9) residents, Resident #5, evidenced by Resident #5 eloped between 5:10 AM and 5:30 AM on 3/25/18. The facility was not aware of the elopement until notified by the local hospital, at approximately 6:30 AM on 3/25/18. The door alarm was silenced by a staff member, who did not notify the nurse per care plan, or activate the elopement protocol to ensure Resident #5 and other residents at risk for elopement were in the building. Resident #5 was care planned for being at risk for elopement related to (r/t) exit seeking behavior on 3/14/18. The failure to develop/implement the risk for elopement care plan for Resident #5, resulted in Resident #5 leaving the facility unattended and unsupervised, and put Resident #5 and other residents at risk for elopement in a situation that was likely to cause serious harm, injury, impairment or death. This situation was determined to be an Immediate Jeopardy (IJ), which began on 3/25/18. The facility's Administrator was notified of the IJ on 4/17/18 at 2:30 PM. An acceptable credible Allegation of Compliance (AoC) was received on 4/18/18, in which the facility alleged removed of the IJ on 4/18/18. The IJ was removed, prior to exit on 4/20/18. The State Agency validated the AoC and determined the IJ was removed, prior to exit. The scope and severity for the IJ at CFR(s) 438.21(b)(1) F656, Develop/Implement Comprehensive Care Plan, was lowered to a D, while the facility develops a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. FINDINGS INCLUDE: Review of the facility's policy and procedure for Care Plans dated 5/28/13, revealed: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Guidelines included that the care plan team developed and maintained a comprehensive care plan for each resident. Review of Resident #5's elopement risk care plan, initiated 3/14/18, revealed Resident #5 was care planned for the risk of elopement related to exit seeking behavior on 3/14/18. Interventions included, Observe me for signs and symptom (s/s) of agitation, pacing, repetitive verbalizations of wanting to leave, restlessness, report to nurse as needed, and Redirect me away from doorways and engage me in a diversional activities. The goal was for the resident to be free of any injury (related to elopement). Record review of Resident #5's medical record revealed he was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. On admission, he was assessed as an elopement risk and a Wanderguard bracelet was initiated and care planned at that time. Review of the Minimum Data Set (MDS), dated [DATE], for admission, with an Assessment Reference Date (ARD) of 3/21/18, revealed a Brief Interview for Mental Status (BIMS) of a 6, meaning Resident #5 was unable to make independent decisions for himself and was cognitively impaired. The MDS documented that he had wandering behavior. He was care planned on 3/14/18 for exit seeking behavior with interventions to notify the nurse as needed Record review of the facility's investigation revealed on 3/25/18, between 5:10 AM and 5:30 AM, the door and Wanderguard alarm sounded from the exit door beside the beauty shop. Certified Nurses Aide (CNA) #1 responded to the alarm approximately 10 minutes later, as she couldn't leave a resident she was bathing at the time the alarm first sounded. There was no evidence in the investigation of anyone else hearing the alarms. CNA #1 went outside this exit into the parking lot and looked but did not see anyone and returned inside and silenced the alarms. CNA#1 then continued to finish the bed bath. She did not alert the nurse supervisor of the alarm, per care plan (report to nurse as needed) or begin the facility's elopement protocol. At approximately 6:30 AM, Registered Nurse (RN) # 2 was notified, by a House Supervisor Nurse of the local hospital, that there was a man in a wheelchair inside the hospital that may belong to the nursing home. RN #2 took her vehicle to the front door of the local hospital. Resident #5 was with a hospital staff member at that front door of the hospital. RN #2 then returned Resident #5, per private vehicle, to facility. The investigation revealed that the front door of the local hospital is approximately 100 yards from the exit door that alarmed at the facility. Review of an incident report, documented Elopement, dated 3/25/18 at 6:32, and revised 4/13/18, revealed Resident #5 was off facility grounds and was returned to the facility unharmed. The Predisposing Psychological factors included confused, impulsive, and impaired memory. The Predisposing Situation Factors included Active Exit Seeker and Wanderer. Interview with Certified Nurses Aide (CNA) #1 on 4/3/18 at 11:00 AM, revealed on 3/25/18 she was in a resident's room giving a bed bath when she heard the door alarm sounding. She stated there were two (2) different sounding alarms. She stated that one was sounding for the door lock, and the other was for the Wanderguard system. She stated the time was after 5:00 AM,. but before 5:30 AM. CNA #1 stated that the alarms were sounding approximately 10 minutes before she went to the door. She stated that she went outside to look all the way to the parking lot and didn't see anything. She stated that she silenced the alarm after she looked up the hall. She stated that she saw Registered Nurse #3 and told her the alarms were sounding, RN #3 said ok, so she went and finished her baths. She stated, I didn't know I couldn't cut that alarm off. Interview with LPN #1 on 4/3/18 at 11:20 AM, revealed elopement residents are checked every hour to see where they are. LPN #1 stated she saw Resident #5 at approximately 4:00 AM on 3/25/18, at the vending matching. LPN #1 stated between 4:00 AM and 5:00 AM, she saw him propelling his wheelchair toward C wing nurse's station. LPN #1 stated that RN #2 called her after 6:00 AM to bring a wheelchair to the front door because she had picked the resident up from the hospital. LPN #1 denied hearing alarms or being told of the alarm sounding. Interview with CNA #2 on 4/17/18 at 12:30 PM, revealed if staff hear an alarm, they are to tell a supervisor, look outside, check rooms and count residents. CNA #2 stated, No you don't turn a door alarm off and walk away and not tell a Supervisor. She stated that this had been covered many times in in-service, prior to Resident #5's elopement. She stated that they were in-serviced on following the care plan for residents. Interview with the Director of Nurses (DON), on 4/19/18 at 10:20 AM, revealed, Careplans are done on admit then at least quarterly. We will revise careplans as needed with changes as necessary. Staff are inserviced on following the careplans. Interview with the Minimum Data Set nurse on 4/20/18 at 11:15 AM, revealed that careplans are started on admission and updated at least quarterly. The careplans are updated if there is a change with the resident or an incident. The MDS nurse acknowledged Resident #5 was care planned for the risk of elopement. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 4/18/18, for the IJ. Review of the facility's AoC revealed the facility took the following actions to remove the IJ: At approximately 2:30 p.m. on (MONTH) 17, (YEAR), the Facility was notified by the surveyor that an immediate jeopardy was being called. The Facility respectfully submits the allegation of compliance (A[NAME]). 1. On (MONTH) 25, (YEAR), at approximately 5:10 AM, CNA #1 was giving a resident a bed bath, covered resident, left room and responded to door alarm. CNA #1 searched parking lot and immediate area with no resident or visitor noted. CNA #1 proceeded back in to the facility and turned the alarm off. RN#2 was supervising and was not notified of the alarm. There was no headcount of residents conducted at this time. No other staff responded to the alarm. 2. On (MONTH) 25, (YEAR), at approximately 6:35 AM, RN#2 received a call from the local hospital stating Resident #5 was in his personal wheelchair and had entered the nearby hospital which is across the parking lot from the nursing facility. RN #2 proceeded to the hospital in her private car and assisted Resident #5 back to the facility. The resident returned without incident and was calm and easy to direct when back at the facility. 3. Resident #5 was assessed by RN #2 in the resident's room on (MONTH) 25, (YEAR) at approximately 6:40 AM for injury, after the resident returned to the nursing facility. No injuries were noted. RN #2 directed facility staff at 6:35 AM, to count all residents in the facility and 100% of residents were accounted for once Resident #5 returned to the nursing facility. Resident #5's attending physician and Facility Medical Director were notified of the incident on 3/25/18, at approximately 7:00 AM, with no new orders noted. Resident #5's Resident Representative was notified of the incident on 3/25/18 at approximately 7:10 AM. Resident #5's signaling device was observed on and functioning by RN #2 on 3/25/18 at approximately 6:40 AM. Resident #5's signaling device triggered the alarm when resident returned to the nursing facility. Resident #5 was placed on one on one monitoring with RN #2 and resident #5's elopement care plan was updated by RN #1 on (MONTH) 25, (YEAR), at approximately 8:00 AM. Resident #5 is a [AGE] year old male admitted with the [DIAGNOSES REDACTED]. Resident #5 had a Brief Interview for Mental Status score of 6, indicating a severe cognitive impairment on Assessment Reference Date 03-21-2018. 4. On (MONTH) 25, (YEAR), at approximately 11:00 AM, RN #1 completed an audit of all residents at the Facility currently assessed to be at risk for elopement who had a signaling device in place to check functioning and placement. Signaling devices were observed on 11 residents and working appropriately at the time of the audit. On (MONTH) 27, (YEAR), at approximately 4:00 PM, RN #1 completed a new wander evaluation for 100% of the 105 residents in the Facility. No new residents were assessed to be at risk. Three (3) residents were removed from risk. 5. On (MONTH) 25, (YEAR), at approximately 6:55 AM, education was initiated by RN #2 to staff of three (3) RNs, six (6) LPNs, 19 CNAs, and one (1) Respiratory Therapist, regarding Facility elopement policy and responding to door alarms. The in-services were continued by Staff Development Coordinator to 33 CNAs, 11 LPNs, 12 RNs, two (2) Respiratory Therapists, five (5) Administrative Staff, two (2) Social Services, three (3) Maintenance staff, two (2) Activity Staff, eight (8) Dietary Staff, nine (9) Housekeeping staff and eight (8) Therapy staff. The staff was in-serviced on policy and procedures for searching for a missing resident and what code to call overhead to ensure other staff members are aware. Also discussed was responding to door alarms and not to silence the alarm unless the resident is located or all residents are accounted for. Staff is to search immediate area and widen search until resident is located or all accounted for. Staff was in-serviced to immediately report a missing resident to the direct supervisor and to report to the Director of Nursing and/or the Administrator. Staff is to report any allegations of abuse or neglect to the abuse coordinator immediately. The in-service included reviewing and updating care plans for residents at risk for elopement as needed. Elopement drills were initiated by the Administrator with Facility staff on (MONTH) 26, (YEAR) at the time of 2:50 PM. and continued 11:20 PM; on (MONTH) 27, (YEAR) at times of 10:30 AM and 8:20 PM; and (MONTH) 28, (YEAR) at times of 4:40 AM, 1:30 PM, and 10:00 PM. In-services continued with new hires being trained on (MONTH) 17, (YEAR) with 1 LPN and 1 C.N.A. in attendance. 6. A Quality Assurance (QA) meeting was conducted on (MONTH) 3, (YEAR), at approximately 9:00 AM, with the following in attendance: Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Social Services, Dietary Manager, Activity Director, Staff Development Coordinator, Maintenance Director, Business Office Manager, MDS Nurse, Housekeeping Supervisor, and Lead CNA. Items discussed were: Elopement Policy, Missing Resident Policy, Abuse and Neglect Policy, removal of the 15 second delay release of the exit doors, response to door alarms, residents being reassessed for wandering/elopement, and facility to continue Elopement Drills. There were no new Policy or Procedure changes. 7. No staff will be allowed to work until each has received in-services on Elopement Policy and Procedures, Wandering Residents, Missing Residents Policy, Abuse and Neglect, Responding to Alarms, and following Resident Care Plan. 8. The incident was called in by the Administrator to the Mississippi State Department of Health Licensure and Certification on (MONTH) 25, (YEAR), at approximately 7:30 PM. The written report was submitted by the Administrator on (MONTH) 28, (YEAR), to the Mississippi State Department of Health Licensure and Certification at approximately 4:34 PM, and to the Office of Attorney General at approximately 4:30 PM. 9. CNA #1 received a verbal counseling on (MONTH) 27, (YEAR), by the Administrator, on responding to door alarms, not to turn off alarms unless residents are accounted for, notify supervisor immediately of alarms, and the Missing Resident Procedures. 10. Facility is alleging that the IJ was removed as of (MONTH) 18, (YEAR). On 4/20/18, the SA validated the facility had implemented the following measures to remove the IJ: 1. The SA validated the facility's investigation of Resident #5's elopement on 3/25/18. CNA #1 responded to the door alarm, searched in the parking lot, did not see anything then returned to the facility, turned off alarm and went back to do resident care. She did not alert the nurse supervisor RN #2, and there was not a head count of residents. This was verified by record review, interviews and written statements of staff and written reports to the SA. 2. The SA validated by staff interviews, review of the facility investigation, review of written statements of staff that RN #2 received a call from the local hospital and was told they had a resident of the facility at the hospital. RN #2 went to the hospital and picked up Resident #5 and he was returned to the facility without incident. 3. The SA verified through record review, staff interviews and written statements that Resident #5 was assessed and found with no injuries, a count of all residents began at 6:35 AM, with all residents accounted for. When Resident #5 was returned to the facility, his primary Medical Doctor and Representative was notified of the elopement, Resident #5's Wanderguard bracelet was on and functioning upon facility return. This was noted by the bracelet setting the alarm off as he entered the facility. Resident #5 was put one on one, his elopement care plan was updated to included the elopement and intervention of 1:1. 4. The SA verified through record review and RN #1 interview, that on 3/25/18, she completed an audit of all 11 residents in the facility assessed to be an elopement risk to ensure signaling devices were in place and functioning with no issues noted. On 3/25/18, RN #1 completed a new wander evaluation on 100% of the 105 residents in the facility. She found no new residents to be at risk and removed three (3) residents from risk. 5. The SA verified through record review and staff interview that RN #2 began in-services on 3/25/18 at approximately 6:35 AM, regarding facility elopement policy and responding to door alarms. These in-services were continued by the Staff Development Coordinator. Staff was inserviced on the policy and procedure for searching for a missing resident, the code to use overhead to let other staff be aware of a missing resident, responding to door alarms, not to silence the alarm until all residents are accounted for, search immediate area and widen search until resident is located, immediately report a missing resident to the Direct Supervisor, Director of Nurses and Administrator, reporting any allegations of abuse and neglect to the Abuse Coordinator, and to review and update careplans for residents at risk for elopement as needed. Interviews and record reviews confirmed elopement drills were initiated by the Administrator on 3/26/18 at 2:50 PM and have continued. On 4/20/18, the SA verified the in-services and elopement drills by interviewing four (4) Licensed Practical Nurses, four (4) Registered Nurses, one (1) Speech Therapist, one (1) Respiratory Therapist, one (1) Business Office Worker, six (6) Certified Nurses Aides, four (4) Housekeeping/Laundry workers, one (1) Dietary staff, two (2) Social Services staff, one (1) Therapy Director, one (1) Admission Director, one (1) Activities employee, one (1) Human Resource employee and one (1) Transportation Driver. Review of in-service records revealed in-services continued with new hires being trained on (MONTH) 17, (YEAR) with 1 LPN and 1 C.N.A. in attendance. 6. The SA validated through record review and interview of staff in attendance, that a QA Meeting was held 4/3/18, and included the Medical Director, Administrator, Director of Nurses, Assistant Director of Nurses, Social Services and Minimum Data Set Nurse along with other management staff and the items discussed were the elopement policy, missing resident policy, abuse and neglect policy, removal of the 15 second delay release of the exit doors, response to the door alarms, residents being reassessed for wandering/elopement, and the facility continuing to conduct elopement drills. This QA meeting did not result in any policy or procedure changes. 7. The SA validated through in-service record review, staff roster review, and staff interview that no staff were allowed to work until they had been in-serviced on the Elopement Policy and Procedures, Wandering Residents, Missing Residents Policy, Abuse and Neglect, Responding to Alarms and Following Resident Care Plans. 8. The SA validated through record review and administrative staff interview the incident was reported to the SA on 3/25/18 at approximately 7:30 AM, by phone, the written report was submitted on 3/28/18 at 4:34 PM, and the Office of the Attorney General was notified on 3/28/18 at 4:28 PM. 9. The SA validated through Administrator interview and through record review of the written verbal counseling form, that CNA #1 was verbally counseled on responding to door alarms, the missing resident procedures, not to turn off alarms unless accounting for. Residents and to notify the supervisor immediately of any alarms. 10. The SA verified that all corrective actions had been completed by 4/18/18, and the IJ was removed, prior to exit on 4/20/18.

Based on observation, record review, facility policy and procedure review, and interviews, the facility failed to provide adequate supervision to one (1) of nine (9) elopement risk residents reviewed, Resident # 5. Resident #5, a cognitively impaired resident, who was deemed an elopement risk, eloped from the facility between 5:10 AM and 5:30 AM, on 3/25/18. The facility was not aware of the elopement until notified by the local hospital at approximately 6:30 AM, on 3/25/18, that the resident was at the hospital in a wheelchair. Facility staff had not accounted for elopement risk residents when the door alarms sounded between 5:10 AM and 5:30 AM. Staff, Certified Nursing Assistant #1, turned off the alarms without activating the Elopement Risk Policy Protocol and notifying the Nurse Supervisor, to ensure all at risk residents were accounted for in the facility. Resident #5 was returned to the facility unharmed. Failure to follow the facility's Elopement Risk policy and procedure, by not clearly notifying the Nurse Supervisor, and silencing the door alarm without accounting for elopement risk residents, resulted in resident #5, a cognitively impaired resident, leaving the facility unattended and unsupervised in a wheelchair. This put Resident #5 and other elopement risk residents in a situation that was likely to cause serious harm, injury, impairment or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 3/25/18. The facility's Administrator was notified of the IJ and SQC on 4/17/18 at 2:30 PM. An acceptable credible Allegation of Compliance (AoC) was received on 4/18/18, in which the facility alleged all corrective actions were completed as of 4/18/18, and the IJ removed. The State Agency (SA) validated the AoC and determined the IJ was removed prior to exit. The scope and severity for the IJ at CFR(s) 483.25(d)(1)(2), F689, Free of Accident Hazards/Supervision/Devices, was lowered to a D, while the facility develops a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facilities Policy and procedure for Elopement and the Elopement Risk Reduction Plan with a revision date of 7/07, revealed a goal: It is the goal of this facility to protect our residents from harm without restricting their movements and to promote ambulation and foster independence and to ensure a safe environment for the resident. The plan included systems will be in place to alert staff of attempts to elope (i.e., alarms, Wanderguards, special looks, etc.) Review of the facility's Alarm response protocol, undated, revealed that staff must respond to every alarm and responding to a Wanderguard alarm normally takes precedence over other tasks unless leaving the task endangered a resident. Specific instructions for staff on what to do when the alarm sounds: Do not reset the alarm until you know the whereabouts of ALL residents wearing signaling devices (alarms). Review of Resident #5's medical record revealed he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On admission, he was assessed as an elopement risk, with a prior history of wandering, and a Wanderguard bracelet was initiated at that time. Resident #5 was care planned for an elopement risk on 3/14/18. The physician's orders [REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], with an Assessment Reference Date (ARD) of 3/21/18, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) of 6, meaning he was unable to make independent decisions for himself and had severe cognitive impairment. Resident #5 was identified on the MDS with wandering behavior. Review of Wandering Evaluations for Resident #5 dated 3/14/18 and 3/20/18, revalued that he was at risk for wandering, and putting himself at risk of harm. Review of a Nursing Skilled Charting note, dated 3/23/18 revealed that Resident #5 had confusion, wandered the halls and goes into other resident rooms all throughout the night. Review of the facility's investigation revealed on 3/25/18, Resident #5 was last seen by RN #3 on 3/25/18 around 5:00 AM, rolling in his wheelchair on C-Wing corridor. Between 5:10 AM and 5:30 AM, the door and wander guard alarm from the exit door beside the beauty shop, began to sound. Certified Nurses Aide (CNA) #1 was providing a bed bath to a resident in a room near this exit and waited approximately 10 minutes to respond to the alarms. CNA #1 responded to the door alarms, went outside this exit into the parking lot, and looked but did not see anyone. CNA #1 then returned inside the facility, turned the alarms off and went to finish the bed bath. She did not alert the Nurse Supervisor of the alarm, or begin the facility's elopement protocol to ensure all residents wearing a Wanderguard was accounted for. At approximately 6:30 AM on 3/25/18, Registered Nurse (RN) #2 was notified by a House Supervisor Nurse of the local hospital that there was a man in a wheelchair inside the hospital that may belong to the nursing home. (The resident had been out of the facility from approximately 5:05 AM-6:35 AM without staff knowledge per facility timeline). RN #2 immediately took her private vehicle to the front door of the local hospital. Resident #5 was with a hospital staff member at the hospital's front door and RN #2 placed Resident #5 into her vehicle and returned him the facility unharmed. Resident #5 was placed 1:1 supervision upon return to the facility. The investigation revealed that the facility was approximately 100 yards from the hospital, across a parking lot. The investigation revealed they thought the resident had exited the beauty shop door around 5:05 AM. The door, when pressure applied for 15 seconds, would release, however the alarm would have still sounded. Review of a facility incident report, headed Elopement, dated 3/25/18 at 6:32 AM, and revised 4/13/18, revealed Resident #5 was off the facility grounds and was returned to the facility unharmed. The Predisposing Phychological factors included confused, impulsive, and impaired memory. The Predisposing Situation Factors included Active Exit Seeker and Wanderer. Observation of the facility's front door and parking lot, on 4/3/18 from 5:00 AM-5:10 AM, revealed one (1) food truck and one (1) vehicle on the street. Observation on 4/20/18 at 1:00 PM, revealed the front door of the local hospital, driven, was less than 0.2 miles from the exit door that alarmed at the facility. Both parking lots meet and the paved lots were smooth with no noted potholes or hazards. Review of the AccuWeather Forecast for 3/25/18, revealed the lowest temperature was 58 degrees and the high was 70 degrees. Interview with Certified Nurses Assistant (CNA) #1, on 4/3/18 at 11:00 AM, revealed on 3/25/18 she was in a resident's room giving a bed bath when she heard the door alarm sounding. She stated there are two (2) different sounding alarms, one alarm was for the door lock and the other was for the Wander Guard system. She stated the time was after 5:00 AM but before 5:30 AM. She stated that the alarms were beeping approximately 10 minutes before she went to the door, because she couldn't leave the resident safely. CNA #1 stated she went outside to look all the way to the parking lot and didn't see anyone. She stated that she silenced the alarm after looking up the hall. CNA #1 stated that she saw Registered Nurse #3 and told her the alarms were sounding, and RN #3 said okay. CNA #1 stated that she finished her baths. CNA #1 stated, I didn't know I couldn't cut that alarm off. I thought we were to tell a nurse the alarm was sounding. I didn't know. CNA #1 admitted she had been trained on the elopement protocol when she was hired. Interview with RN #3 on 4/3/18 at 9:16 AM, and 4/25/18 at 8:45 AM, revealed the last time she saw Resident #5 was between 5:00 AM and 5:30 AM, on 3/25/18. She stated the resident was in his wheelchair going down the hall and she spoke to him. RN #3 stated she thought Resident #5 wore an alarm bracelet and stated, If he went out a door, someone would have had to put in the code to make the door alarm stop. RN #3 denied hearing the door alarms between 5:00 AM and 5:30 AM. She stated that she accounted for all of her elopement risk residents and checked the exit doors after she was notified of Resident #5's elopement. Further interview, post survey, with RN #3 on 4/25/18 at 8:45 AM, revealed that CNA #1 never told her about that door alarming on 3/25/18. RN #3 stated, If she did, I didn't hear her. She stated if CNA #1 had told her about the alarm, she would have gone outside and looked herself. Interview with Licensed Practical Nurse (LPN) #1 on 4/3/18 at 11:20 AM, revealed she had worked on 3/25/18, and it had been a chaotic night. She stated the last time she saw Resident #5 was about 5:00 AM. LPN #1 stated, He was propelling his wheelchair towards the nursing station on C wing. LPN #1 stated, I never heard any alarms. LPN #1 stated the next time she saw Resident #1 was after 6:00 AM, when she was told to bring a wheelchair to the front door because RN #2 had gone to the hospital to pick up Resident #5. She stated that RN #2 assessed Resident #5 with no injury and all residents were accounted for at that time. LPN #1 stated she could not recall checking the resident's Wanderguard bracelet that night, but the shift hadn't been over when the resident left the building. LPN #1 stated that Resident #5 was really confused, and one time he had told her he was going to New York. LPN #1 stated she usually checked her wandering risk residents every hour. LPN #1 acknowledged Resident #5 wandered into other resident's rooms but had not seen him push on exit doors. Interview with RN #2, on 4/9/18 at 3:55 PM, revealed she was the charge nurse on 3/25/18, and she never heard the door alarm sounding. She recalled seeing Resident #5 around 4:00 AM. She stated she got a call from the hospital between 6:00 AM. and 6:30 AM from an emergency room nurse, who said she had one of our residents, Resident #5. She stated she left to go get the resident and told staff to start counting residents. RN #2 stated the resident had no injuries and he was dressed appropriately and had has his Wanderguard on. She stated Resident #5 said he was going to New York, he was not able to say how he got out of the facility. She stated, Resident #5's alarm sounded when I brought him inside the facility. She said she contacted the Administrator and Director of Nurses and started an in-service on abuse and neglect, responding to door alarms, following care plans, and elopement policy and procedure. RN #2 put Resident #5 one on one (1:1) at the time of his return to the facility. RN #2 stated that she found CNA #1, the one who said she'd heard the alarm, and the CNA stated she went outside and saw nothing and told the nurse, RN #3, but the nurse denied being told of alarms going off. RN #2 stated no one counted the elopement risk residents until the hospital called saying they had a resident there. RN #2 said that CNA #1 stated she'd turned the alarm off and went back to work. RN #2 stated she knew at that time that she needed to re-educate everybody on the elopement protocol. Interview with CNA #2 on 4/5/18 at approximately 11:15 AM, revealed staff had been trained to respond to door alarms, to go outside and look for residents, count all of the residents and initiate the elopement protocol. Additional interview with CNA #2 on 4/17/18 at 12:30 PM, revealed if staff hear an alarm, they are to tell a supervisor, look outside, check rooms and count residents. CNA #2 stated, No you don't turn a door alarm off and walk away and not tell a Supervisor. She stated that this had been covered many times in in-service, prior to Resident #5's elopement. Interview with CNA #4 on 4/17/18, revealed staff should never turn a door alarm off and just go back to work. She stated there was a reason the door alarm goes off, and the nurse has to be told when an alarm sounds. She stated this had been in-serviced prior to Resident #5's elopement. Interview with LPN #2 on 4/18/18 at 11:20 AM, revealed she had worked on 3/25/18 and had not seen Resident #5 that shift, but a CNA had told her (after the elopement) that she had heard the alarm from the beauty shop door and had looked, not seen anyone and had asked RN #3 if she'd seen anyone, and RN #3 told her no. LPN #2 stated CNA #1 never said what happened with the alarm, but she had to have silenced the alarm or it would have still been sounding if the code had not been put in. LPN #2 stated she had not heard the alarm that night. LPN #2 stated if an alarm sounds, the supervisor of the shift is notified and residents should be counted. Observation and interview with Resident #5 on 4/3/18 at 5:20 AM, revealed he was asleep with a Wanderguard intact to the Right wrist. Further observation on 4/17/18 at approximately 5:25 PM, revealed he was in a wheelchair with the Wanderguard bracelet intact and he was pleasantly confused and unable to answer questions. Interview with Hospital RN #1 on 4/17/18 at 11:45 AM, revealed Resident #5 was in a wheelchair and in the hospital near Admissions when she saw him. Hospital RN #1 stated she did not know how the resident arrived at the hospital, but the doors usually were unlocked between 6:00 AM and 6:30 AM. She stated the resident was dressed in blue jeans and a long sleeve shirt and had an alarm bracelet intact. She stated she took a chance and called the facility and told one of the nurses about Resident #5 being at the hospital. She stated it was foggy outside but not cold. Hospital RN #1 stated the nurse came and got Resident #5 and he did not resist going with the nurse. She stated that the resident was pleasantly confused. Interview with the Director of Nurses (DON) on 4/3/18 at 11:30 AM, revealed once she was made aware of the elopement for Resident #5, on 3/25/18, she instructed RN #2 to start the elopement protocol, to check the doors and count the residents. The DON stated that she had RN #2 to start an in-service on what to do when staff hear an alarm. When staff hear an alarm for the Wanderguard, they are to immediately let a nurse know an alarm is sounding so a resident head count can start and staff can account for all residents at risk for wandering. Additional interview with the DON, on 4/17/18 at 10:30 AM, revealed that the procedure was for any staff member to respond to the door alarms. She stated there was no specific time to silence the alarm, however, a supervisor or nurse has to be notified of the alarms sounding right then, and everyone had to be accounted for if an alarm sounded. Interview with the Administrator, on 4/3/18 at 11:55 AM, revealed CNA #1 said she told RN #3 about the alarm sounding but the nurse denied being told. The Administrator stated that he verbally counseled CNA #1 on making sure to tell a nurse before turning off a door alarm. The Administrator acknowledged the protocol was not followed when the door alarms sounded, upon review of the written verbal counseling form for CNA #1, dated 3/27/18. Additional interview with the Administrator on 4/17/18 at 10:55 AM, revealed that new staff are taught on hire about the Wanderguard system and the door alarms. He stated that the different alarm sounds are demonstrated while taking staff to the doors and staff are taught why codes are needed. The Administrator stated staff had been in-serviced on responding to alarms prior to 3/25/18. (In-service records revealed in-service on 8/23/18 included responding to alarms). Interview with the Maintenance Supervisor, on 4/17/18 at 9:55 AM, revealed the exit door by the beauty shop had not malfunctioned. He stated there was a 15 second delay when pressure was applied to the door and then the door would release without a code. He stated that the alarm would still sound. He stated that he removed the delay mechanism from the door, but the door would still release for the fire alarm. Review of an in-service dated 8/23/17, included instruction on responding to door alarms. Review of CNA #1's in-service records revealed she had been trained, when hired on 7/20/17, of the elopement risk protocol. She signed the elopement risk reduction plan at that time. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 4/18/18, for the IJ. Review of the facility's AoC revealed the facility took the following actions to remove the IJ: At approximately 2:30 p.m. on (MONTH) 17, (YEAR), the Facility was notified by the surveyor that an immediate jeopardy was being called. The Facility respectfully submits the allegation of compliance (A[NAME]). 1. On (MONTH) 25, (YEAR), at approximately 5:10 AM, CNA #1 was giving a resident a bed bath, covered resident, left room and responded to door alarm. CNA #1 searched parking lot and immediate area with no resident or visitor noted. CNA #1 proceeded back in to the facility and turned the alarm off. RN #2 was supervising and was not notified of the alarm. There was no headcount of residents conducted at this time. No other staff responded to the alarm. 2. On (MONTH) 25, (YEAR), at approximately 6:35 AM, RN #2 received a call from the local hospital stating Resident #5 was in his personal wheelchair and had entered the nearby hospital which is across the parking lot from the nursing facility. RN #2 proceeded to the hospital in her private car and assisted Resident #5 back to the facility. The resident returned without incident and was calm and easy to direct when back at the facility. 3. Resident #5 was assessed by RN #2 in the resident's room on (MONTH) 25, (YEAR) at approximately 6:40 AM for injury, after the resident returned to the nursing facility. No injuries were noted. RN #2 directed facility staff at 6:35 AM, to count all residents in the facility and 100% of residents were accounted for once Resident #5 returned to the nursing facility. Resident #5's attending physician and Facility Medical Director were notified of the incident on 3/25/18, at approximately 7:00 AM, with no new orders noted. Resident #5's Resident Representative was notified of the incident on 3/25/18 at approximately 7:10 AM. Resident #5's signaling device was observed on and functioning by RN #2 on 3/25/18 at approximately 6:40 AM. Resident #5's signaling device triggered the alarm when resident returned to the nursing facility. Resident #5 was placed on one on one monitoring with RN #2 and resident #5's elopement care plan was updated by RN #1 on (MONTH) 25, (YEAR), at approximately 8:00 AM. Resident #5 is a [AGE] year old male admitted with the [DIAGNOSES REDACTED]. Resident #5 had a Brief Interview for Mental Status score of 6, indicating a severe cognitive impairment on Assessment Reference Date 03-21-2018. 4. On (MONTH) 25, (YEAR), at approximately 11:00 AM, RN #1 completed an audit of all residents at the Facility currently assessed to be at risk for elopement who had a signaling device in place to check functioning and placement. Signaling devices were observed on 11 residents and working appropriately at the time of the audit. On (MONTH) 27, (YEAR), at approximately 4:00 PM, RN #1 completed a new wander evaluation for 100% of the 105 residents in the Facility. No new residents were assessed to be at risk. Three (3) residents were removed from risk. 5. On (MONTH) 25, (YEAR), at approximately 6:55 AM, education was initiated by RN #2 to staff of three (3) RNs, six (6) LPNs, 19 CNAs, and one (1) Respiratory Therapist, regarding Facility elopement policy and responding to door alarms. The in-services were continued by Staff Development Coordinator to 33 CNAs, 11 LPNs, 12 RNs, two (2) Respiratory Therapists, five (5) Administrative Staff, two (2) Social Services, three (3) Maintenance staff, two (2) Activity Staff, eight (8) Dietary Staff, nine (9) Housekeeping staff and eight (8) Therapy staff. The staff was in-serviced on policy and procedures for searching for a missing resident and what code to call overhead to ensure other staff members are aware. Also discussed was responding to door alarms and not to silence the alarm unless the resident is located or all residents are accounted for. Staff is to search immediate area and widen search until resident is located or all accounted for. Staff was in-serviced to immediately report a missing resident to the direct supervisor and to report to the Director of Nursing and/or the Administrator. Staff is to report any allegations of abuse or neglect to the abuse coordinator immediately. The in-service included reviewing and updating care plans for residents at risk for elopement as needed. Elopement drills were initiated by the Administrator with Facility staff on (MONTH) 26, (YEAR) at the time of 2:50 PM. and continued 11:20 PM; on (MONTH) 27, (YEAR) at times of 10:30 AM and 8:20 PM; and (MONTH) 28, (YEAR) at times of 4:40 AM, 1:30 PM, and 10:00 PM. In-services continued with new hires being trained on (MONTH) 17, (YEAR) with 1 LPN and 1 C.N.A. in attendance. 6. A Quality Assurance (QA) meeting was conducted on (MONTH) 3, (YEAR), at approximately 9:00 AM, with the following in attendance: Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Social Services, Dietary Manager, Activity Director, Staff Development Coordinator, Maintenance Director, Business Office Manager, MDS Nurse, Housekeeping Supervisor, and Lead CNA. Items discussed were: Elopement Policy, Missing Resident Policy, Abuse and Neglect Policy, removal of the 15 second delay release of the exit doors, response to door alarms, residents being reassessed for wandering/elopement, and facility to continue Elopement Drills. There were no new Policy or Procedure changes. 7. No staff will be allowed to work until each has received in-services on Elopement Policy and Procedures, Wandering Residents, Missing Residents Policy, Abuse and Neglect, Responding to Alarms, and following Resident Care Plan. 8. The incident was called in by the Administrator to the Mississippi State Department of Health Licensure and Certification on (MONTH) 25, (YEAR), at approximately 7:30 PM. The written report was submitted by the Administrator on (MONTH) 28, (YEAR), to the Mississippi State Department of Health Licensure and Certification at approximately 4:34 PM, and to the Office of Attorney General at approximately 4:30 PM. 9. CNA #1 received a verbal counseling on (MONTH) 27, (YEAR), by the Administrator, on responding to door alarms, not to turn off alarms unless residents are accounted for, notify supervisor immediately of alarms, and the Missing Resident Procedures. 10. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of (MONTH) 18, (YEAR), and the Immediate Jeopardy removed. On 4/20/18, the SA validated the facility had implemented the following measures to remove the IJ: 1. The SA validated the facility's investigation of Resident #5's elopement on 3/25/18. CNA #1 responded to the door alarm, searched in the parking lot, did not see anything then returned to the facility, turned off alarm and went back to do resident care. She did not alert the nurse supervisor RN #2, and there was not a head count of residents. This was verified by record review, interviews and written statements of staff and written reports to the SA. 2. The SA validated by staff interviews, review of the facility investigation, review of written statements of staff that RN #2 received a call from the local hospital and was told they had a resident of the facility at the hospital. RN #2 went to the hospital and picked up Resident #5 and he was returned to the facility without incident. 3. The SA verified through record review, staff interviews and written statements that Resident #5 was assessed and found with no injuries, a count of all residents began at 6:35 AM, with all residents accounted for. When Resident #5 was returned to the facility, his primary Medical Doctor and Representative was notified of the elopement, Resident #5's Wanderguard bracelet was on and functioning upon facility return. This was noted by the bracelet setting the alarm off as he entered the facility. Resident #5 was put one on one, his elopement care plan was updated to included the elopement and intervention of 1:1. 4. The SA verified through record review and RN #1 interview, that on 3/25/18, she completed an audit of all 11 residents in the facility assessed to be an elopement risk to ensure signaling devices were in place and functioning with no issues noted. On 3/25/18, RN #1 completed a new wander evaluation on 100% of the 105 residents in the facility. She found no new residents to be at risk and removed three (3) residents from risk. 5. The SA verified through record review and staff interview that RN #2 began in-services on 3/25/18 at approximately 6:35 AM, regarding facility elopement policy and responding to door alarms. These in-services were continued by the Staff Development Coordinator. Staff was inserviced on the policy and procedure for searching for a missing resident, the code to use overhead to let other staff be aware of a missing resident, responding to door alarms, not to silence the alarm until all residents are accounted for, search immediate area and widen search until resident is located, immediately report a missing resident to the Direct Supervisor, Director of Nurses and Administrator, reporting any allegations of abuse and neglect to the Abuse Coordinator, and to review and update careplans for residents at risk for elopement as needed. Interviews and record reviews confirmed elopement drills were initiated by the Administrator on 3/26/18 at 2:50 PM and have continued. On 4/20/18, the SA verified the in-services and elopement drills by interviewing four (4) Licensed Practical Nurses, four (4) Registered Nurses, one (1) Speech Therapist, one (1) Respiratory Therapist, one (1) Business Office Worker, six (6) Certified Nurses Aides, four (4) Housekeeping/Laundry workers, one (1) Dietary staff, two (2) Social Services staff, one (1) Therapy Director, one (1) Admission Director, one (1) Activities employee, one (1) Human Resource employee and one (1) Transportation Driver. Review of in-service records revealed in-services continued with new hires being trained on (MONTH) 17, (YEAR) with 1 LPN and 1 C.N.A. in attendance. 6. The SA validated through record review and interview of staff in attendance, that a QA Meeting was held 4/3/18, and included the Medical Director, Administrator, Director of Nurses, Assistant Director of Nurses, Social Services and Minimum Data Set Nurse along with other management staff and the items discussed were the elopement policy, missing resident policy, abuse and neglect policy, removal of the 15 second delay release of the exit doors, response to the door alarms, residents being reassessed for wandering/elopement, and the facility continuing to conduct elopement drills. This QA meeting did not result in any policy or procedure changes. 7. The SA validated through in-service record review, staff roster review, and staff interview that no staff were allowed to work until they had been in-serviced on the Elopement Policy and Procedures, Wandering Residents, Missing Residents Policy, Abuse and Neglect, Responding to Alarms and Following Resident Care Plans. 8. The SA validated through record review and administrative staff interview the incident was reported to the SA on 3/25/18 at approximately 7:30 AM, by phone, the written report was submitted on 3/28/18 at 4:34 PM, and the Office of the Attorney General was notified on 3/28/18 at 4:28 PM. 9. The SA validated through Administrator interview and through record review of the written verbal counseling form, that CNA #1 was verbally counseled on responding to door alarms, the missing resident procedures, not to turn off alarms unless accounting for. Residents and to notify the supervisor immediately of any alarms. 10. The SA verified that all corrective actions had been completed by 4/18/18, and the IJ was removed, prior to exit, on 4/20/18.