Every finding on record at Jnh-Madison Inn

Based on observation, interview, and record review, the facility failed to implement infection prevention practices during medication administration for one (1) of three (3) observed residents (Resident #42) as evidenced by the Licensed Practical Nurse (LPN) #1 failed to use a barrier when placing resident medications on an unclean surface, and failed to disinfect the medications before returning them to the medication cart.Findings include:On 10/29/25 at 8:25 AM, observed LPN #1 remove eye drops and inhaled medication (Albuterol) from the medication cart and placed both items directly onto Resident #42's bedside dresser without the use of a protective barrier. The medications were administered, and afterwards, LPN #1 returned the medications to the cart without disinfecting them before placing them in the drawer alongside medications for other residents.In an interview at 8:28 AM, on 10/29/25, LPN #1 acknowledged that she should have placed a barrier between the resident's dresser and the medications. She further stated that she had no idea what type of fluids or contaminants might be present on the resident's dresser and recognized the risk for cross-contamination.On 10/29/25 At 8:48 AM, during an interview the Director of Nursing (DON) confirmed that the resident's dresser top could harbor infectious organisms, and that the facility's recommendation is for nurses to use a barrier when placing medication items on resident furniture to prevent cross-contamination with items returned to the medication cart.On 10/29/25 at 10:13 AM, during an interview the Infection Preventionist Nurse confirmed that nurses are trained that any object that touches surfaces in a resident's room should either remain in the room or be disinfected prior to being returned to shared areas such as the medication cart. The nurse explained that, at a minimum, a disinfectant wipe should be used to clean the surface before placing items on the surface.A record review of the facility's procedure guide indicated that medications such as eye drops should be placed on a clean, dry surface prior to administration.A record review of Resident #42's Identification and Summary Sheet revealed an admission date of 6/4/15 with diagnoses including Schizophrenia.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/5/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.Record review of physician orders for Resident #42 included: Thera eye drops 0.25%, one drop in each eye three times daily, with a start date of 2/10/23. Albuterol 90 MCG inhaler, 2 puffs by mouth twice daily, with a start date of 8/15/25.

Based on observation, interview, and facility policy review, the facility failed to ensure the safe storage and labeling of food and beverages in accordance with accepted food safety practices and the facility policy for one (1) of three (3) days of survey. Findings include: A review of the facility's Food Storage policy, dated June 2025 revealed: .2. When drink mix has been prepared, a label will be on jug/container and date opened will be used for date prepared.4. Document name of product on label if it has been removed from its original package. On 10/27/2025 at 10:26 AM, during a tour of the pantry in Building #28, the State Agency observed the following: Pitchers containing Kool-Aid and Lemonade were not labeled with a preparation date or discard date. Tuna salad was stored in Styrofoam cups covered with plastic wrap and did not have a preparation or discard date.On 10/29/2025 at 8:30 AM, the Administrator acknowledged that discard dates are required on all drink pitchers and food containers to prevent the growth of pathogens and avoid potential illness among residents.On 10/29/2025 at 10:45 AM, the Infection Preventionist stated during an interview that failure to label food with discard dates can result in contamination and resident illness. She confirmed that pantry staff receive monthly and as-needed training on food handling and storage protocols.On 10/29/2025 at 11:43 AM, the Pantry Supervisor acknowledged she had prepared the Kool-Aid, lemonade, and tuna salad on Sunday for resident snacks. She stated that she had failed to label the items with discard dates and admitted it was an oversight. She further confirmed that labeling food items is necessary to prevent contamination and illness.

Based on observation, staff interview, and facility policy review, the facility failed to ensure a safe, sanitary, and comfortable environment by not preventing the buildup of dust and debris on kitchen and dining room vent covers for two (2) out of four (4) days of survey. Findings include: A review of the facility's policy titled Cleaning of Patient/Resident Areas, dated 11/24, revealed, . II. Policy This policy provides procedures to clean and disinfect all patient/resident areas to prevent the spread of infection . Procedure B. Steps to cleaning and disinfecting a building: . 2. The following should be free of stains, visible dust, streaks, gross soil, spider webs and handprints. Clean and disinfect as needed . k. Vents . On 12/02/2024 at 10:45 AM, during an observation of Building 28, the vent cover in the pantry was noted to be unsanitary, with a significant buildup of solid dust and debris on the cover. On 12/02/2024 at 11:30 AM, during an interview with Dietary Staff #1 related to the cleaning schedule of the vents she stated, Sometimes I do it myself, but it's done once a month. On 12/03/2024 at 1:45 PM, during a follow-up observation of Building 28, the vent in the pantry was again noted to have thick dust present on the vent cover. On 12/03/2024 at 2:00 PM, during an observation of Building 34's dining room, both vent covers were noted to be heavily soiled with approximately 3/8 inch of thick dust accumulation. On 12/03/2024 at 2:30 PM, during an interview with the Administrator, she stated that a work order for cleaning the vents had been in place for a week but had not been completed at the time of the interview. On 12/03/2024 at 2:45 PM, during an interview with Maintenance Staff #1, he stated that vent cleaning is usually performed by housekeeping and was unsure of how often this is done. On 12/03/2024 at 2:55 PM, during a phone interview with the Housekeeping Supervisor, she stated that vents should be cleaned weekly. She explained that housekeeping can clean vents with a washcloth or soap but that Maintenance staff is responsible for removing and performing thorough weekly dusting of the vents. On 12/03/2024 at 3:05 PM, during an interview with Dietary Staff #2, she stated that maintenance is usually responsible for cleaning the vents but admitted , No one has been here in a while. She confirmed the vents were thickly covered in dust, adding, I see why you are concerned because the vents have a lot of dust covering them.

Based on record review, staff interview, and facility policy review, the facility failed to provide necessary nursing services and supervision for 15 of 15 residents with a sample of eight (8) residents residing on the 1st floor unit for the 3-11 shift and the 11-7 shift, on 7/12/21 through 7/13/21. Residents #1, #2, #3, #4, #5, #6, #7, and #8. The facility's failure to provide nursing services and supervision resulted in residents not receiving medications and treatments on 7/12/21 on the 3-11 shift continuing through 6:00 AM on 7/13/21. After the Licensed Practical Nurse on the 3-11 shift was notified she was positive for Covid-19, the facility failed to ensure a replacement was present on the unit. This placed the residents at risk, and in a situation which was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 7/12/21, when the facility failed to ensure a licensed nurse was available to provide necessary supervision, administer medications, treatments, PEG tube feedings and perform [CONDITION(S)] care. On 7/21/21, at 7:00 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the facility with the IJ Template. The facility submitted an acceptable Removal Plan on 7/22/21 at 5:16 PM, in which the facility alleged all corrective actions to remove the IJ were completed on 7/22/21 and the IJ removed as of 7/23/21. The SA validated the Removal Plan on 7/24/21 and determined the IJ was removed on 7/23/21, prior to exit. Therefore, the scope and severity for CFR 483.12(a)(1) Abuse and Neglect (F600), was lowered from a L to an F while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled, Injuries, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property or Exploitation of Residents, revised September 2019, revealed .2. POLICY. A. [NAME] Nursing Home (JNH) residents have a right to be free from abuse, neglect, exploitation, mistreatment, sexual battery, and misappropriation of property .B. Neglect: The failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of the facility Investigative Findings dated 7/13/21, BUILDING 34 POSSIBLE NEGLECTS OF MULTIPLE RESIDENTS, revealed that on, 7/13/21, the Administrator advised the Department of Safety & Investigative Services that on 7/12/21, the B-shift nurse for the downstairs unit on B34 tested Covid + and was sent home. It was determined that attempts were made to get nurse coverage for the unit; however, no replacement nurse came for B shift. An agency nurse came at midnight for C-shift, but refused to accept the assignment and left. Therefore, there was no nurse for the downstairs unit on B34 for C shift either . The facility failed to provide sufficient licensed nursing staff for the downstairs' unit of B34 from 6:00 PM - 6:00 AM on 7/13/21. Therefore, neglect by the facility is substantiated. Please do know that each of the Residents on the unit was assessed by (Formal Name of Physician) of the morning of 7/13/21 and none of the residents appear to have suffered an adverse effect as a result of this insufficiency . On 7/20/21 at 6:10 PM, in an interview with Registered Nurse (RN) #1 revealed on 7/12/21 at approximately 3:30 PM, License Practical Nurse (LPN) #1 relieved RN #1 and narcotic count was completed. Registered Nurse (RN) #1 revealed when she arrived on the unit on 7/13/21 at 6:00 AM, she was told that there had been no nursing coverage on the unit. She stated she immediately assessed Residents #2 and #4, who had tracheostomies and PEG tubes. She suctioned both tracheostomies and started the feeding pumps for Residents #2, #4 and #8, which were not functioning because there was no water in the bags. On 7/20/21 at 6:40 PM, in an interview with the RN/Administrator (RN/Admin) revealed on 7/12/21 LPN #1 was informed she was Covid-19 positive and was directed to leave the facility immediately, waiting for her relief in her car with the narcotics keys. On 7/12/21 at approximately 7:45 PM, LPN #1 gave the 2nd floor RN #2 the narcotic keys; but did not count the narcotics. The agency relief nurse presented at the facility at approximately 11:00 PM on 7/12/21; but would not accept the narcotic keys nor take the assignment of 1st floor nurse because the medication room was in disarray. The RN/Administrator (RN/Admin) revealed on 7/12/21 from approximately 6:00 PM until 7/13/21 at 6:00 AM there was no licensed nurse on the 1st floor resulting in 15 residents not receiving nursing services and supervision. On 7/21/21 at 9:30 AM, in an interview with the Administrator (Adm) revealed the facility's failure to provide sufficient nursing staff, resulted in medication/treatments being missed for approximately 12 hours from 7/12/21 at 6:00 PM until 7/13/21 at 6:00 AM. The Adm revealed the facility failed to ensure sufficient nursing staff was available to provide necessary nursing services. On 7/21/21 at 1:30 PM, in an interview with RN/Admin revealed the residents with [CONDITION(S)] could have had a mucous plug during the shift with no licensed nurse. RN/Admin explained the likelihood of harm was present on 7/12/21 at 6:00 PM through 7/13/21 at 6:00 AM for all residents not receiving medications or treatments. On 7/21/21 at 1:40 PM, in an interview with the Adm, he confirmed that because there was not licensed nursing staff on 7/12/21 in Building 34 1st floor there could have been a serious negative outcome among the residents. On 7/21/21 at 2:30 PM, in an interview with Certified Nursing Assistant (CNA) #2 revealed she was working on 7/12/21 on the 3:00 PM to 11:00 PM shift. LPN #1 informed her she tested positive for Covid-19 and was informed to leave facility immediately, but there would be another nurse to replace her. CNA #2 revealed at approximately 4:30 PM on 7/12/21, she was the only staff present on the 1st floor until around 7:00 PM when a CNA came in early to help her with the 15 residents. CNA #2 revealed there was an RN on the 2nd floor of Building 34. In the event of an emergency, RN #2 told CNA #2 to come get her. RN #2 came to the 1st floor and medicated a resident for pain, then RN #2 went back to the 2nd floor. There were no problems with any of the other residents on the 1st floor, the tube feedings were not empty, nor did the tube feeding machines made any beeps, and the [CONDITION(S)] residents had no problems. She said, I did give all my diabetic snacks out like I normally do. On 7/21/21 at 2:50 PM, in an interview with LPN #1 revealed she reported to Building 34 1st floor and counted the narcotics with the off going nurse. At approximately 4:00 PM, she received a phone call from the Medical Director on call for the campus who explained that she was Covid-19 positive and needed to leave the facility immediately. LPN #1 revealed she left the facility and waited in her car for the replacement nurse. LPN #1 revealed she contacted the Director of Nurses (DON) #2 on call for the campus and was informed relief would be there shortly. LPN #1 stated that she waited in her car until approximately 8:00PM when RN #2 came to her car and received the narcotic keys from LPN #1, then LPN #1 left the campus. On 7/21/21 at 3:00 PM, in an interview with RN #2 revealed when she was aware that LPN #1 was unable to work her scheduled shift, she informed the RN/Admin and was informed by the RN/Admin and DON #2 on call, that an agency nurse would report to the facility and would be responsible for the 1st floor Building 34 residents. Then, when the agency nurse failed to work on 1st floor Building 34, she was informed by the RN/Admin, that she was not responsible for 1st floor Building 34 medications and/or treatments. Record review of the facility's daily schedule for 7/12/21 on the 3:00 PM through 11:00 PM shift and 7/13/21 for the 11:00 PM through 6:00 AM shift for Building 34, 1st floor revealed that LPN #1 was assigned for both shifts. Record review of 1st floor Building 34 timecards revealed LPN #1 clocked in on 7/12/21 at 2:55 PM and clocked out 7/12/21 at 8:00 PM. RN #2's timecard revealed RN#2 clocked in on 7/12/21 at 2:55 PM and clocked out on 7/13/21 at 7:50 AM. Resident #1 Record review of Resident #1's Identification and Summary Sheet revealed Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Medication Chart revealed on 7/12/21 at 6:00 PM [MEDICATION(S)] 250 milligrams (mg) tablet take one (1) tablet by mouth twice a day, [MEDICATION(S)] 1000 mg tablet take one (1) tablet by mouth twice a day, and [MEDICATION(S)] 1 mg take one (1) tablet by mouth twice a day, was not initialed on the Medication Chart. Record review of Resident #1's Physician's Order Form for the month of 07/21 revealed orders for [MEDICATION(S)] 250 milligrams (mg) take one (1) tablet by mouth twice a day, [MEDICATION(S)] 1000 mg take one (1) tablet twice a day, and [MEDICATION(S)] one (1) mg by mouth two times a day. Record review of Resident #1's Treatment Chart revealed on 7/12/21 on B shift (3 to 11) monitor every day for dehydration (dry mucous membranes, urine output, fever), monitor for side effects of [CONDITION(S)] medications, monitor for signs and symptoms of pain (facial grimaces, moaning, verbal) document every shift and document according to scale. On 7/12/21 on B shift (3-11) these were not initialed on the Treatment Chart. Record review of Resident #1 annual Minimum Data Set (MDS) dated [DATE], indicated a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #1 was cognitively intact. Resident #2 Record review of Resident #2's Identification and Summary Sheet revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Medication Chart revealed on 7/12/21 at 6:00 PM [MEDICATION(S)] 50 mg tablet take one (1) tablet per tube twice a day, [MEDICATION(S)] 5mg/5ml give 10ml (10mg) per tube every 8 hours, Vitamin C 500mg tablet take 1 tablet per tube twice a day, Arginard 1 packet (pk) via PEG tube BID (twice a day), and Promod 30cc per PEG tube BID, were not initialed. On 7/12/21 at 6:00 PM and 7/13/21 at 12:00 AM, [MEDICATION(S)] 10mg tablet take 1 tablet per tube every 6 hours, [MEDICATION(S)] 20mg tablet take 2 tablets per tube every 6 hours, Iprat-Albut 0.5-3(2.5) mg/3ml compare to [MEDICATION(S)] 2.5-0.5mg/3ml use 1 vial in nebulizer every 6 hours, [MEDICATION(S)] DM syrup (regular) give 10ml per tube every 6 hours, [MEDICATION(S)] Sodium 100mg capsule take 1 capsule twice a day, was not initialed. At 10:00 PM on 7/12/21, Saline nebulization 3ml nebulized every 8 hours to thin secretions, use indefinitely, was not initialed. Record review of Resident #2's Tube Feeding Record revealed on 7/12/21 on the 3-11 shift initials with a line drawn through for Label bag/bottle with feeding type, name, date, time and initials, Flush with water (Record amount per flush) 60cc's/hr. Flush with 30cc's of water before and after each medication administered, Check for residuals & placement prior to medication and feedings by (Aspiration only), and Keep head of bed elevated 30 to 45 degrees and Check breath sounds for rales, rhonchi, or congestion every shift. Record review of Resident #2 Treatment Chart revealed on 7/12/21, the following treatment was not initialed for Monitor Q (every) day for dehydration. The following teatments had a diagonal line drawn through the signature box for B and C shifts, Ensure the left ear is positioned with no pressure at all times, PEG site care q (every) shift & PRN, clean with normal saline (NS), apply [MEDICATION(S)] and cover with drain sponge, [CONDITION(S)] care q shift and PRN, clean with NS, apply drain sponge, O2 at 5 liters with 28% humidified air via [CONDITION(S)] [NAME],Place brief under resident, do not try to pull brief between legs, change q 2 hours and PRN. The following treatments had a diagonal line drawn through the signature box for the B shift, [MEDICATION(S)] to right foot BID indefinitely, mouth care q shift and PRN with [MEDICATION(S)] swabs, All [CONDITION(S)], O2, nebulizer tubing checked q shift at the beginning and end of the shift to ensure its working properly, turn q 1 hour side to side, do not turn on back, Monitor for s/s of pain, The following had a diagonal line through the signature box for C shift, Change suction canister and tubing daily and PRN. Record review of Resident #2's Physician's Order Form dated 07/21 revealed [MEDICATION(S)] 50 mg give one (1) tablet per tube twice a day, [MEDICATION(S)] 5mg/5ml give 10ml (10mg) per tube every 8 hours, Vitamin C 500mg tablet take 1 tablet per tube twice a day, Arginard 1 packet (pk) via PEG tube BID (twice a day), and Promod 30cc per PEG tube BID, [MEDICATION(S)] 10mg tablet take 1 tablet per tube every 6 hours, [MEDICATION(S)] 20mg tablet take 2 tablets per tube every 6 hours, Iprat-Albut 0.5-3(2.5) mg/3ml compare to [MEDICATION(S)] 2.5-0.5mg/3ml use 1 vial in nebulizer every 6 hours, [MEDICATION(S)] DM syrup (regular) give 10ml per tube every 6 hours, [MEDICATION(S)] Sodium 100mg capsule take 1 capsule twice a day, and Saline nebulization 3ml nebulized every 8 hours to thin secretions, use indefinitely. Record review of the Physician Orders dated 4/27/21 revealed Diet, [MEDICATION(S)] 2.0 ,55 cubic centimeters (cc) per hour with 75cc/hr (hour) H2O (water) flush/Promod 30 cc per peg tube two times a day, and [MEDICATION(S)] one packet per PEG tube two (2) times a day, O2 (oxygen) at 5 liters per minute (lpm) via [CONDITION(S)] with 28 % (percent) humidified air and [CONDITION(S)] care every shift/as needed, clean with normal saline and apply drain dressing; suction PRN with 14 French (Fr) catheter using sterile technique. Record review of Resident #2's quarterly MDS dated [DATE] Section C, indicated BIMS summary score 00, which indicated severely impaired cognitive status. Resident #3 Record review of Resident #3's Identification and Summary Sheet revealed he was admitted to the facility on [DATE], with diagnose including status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] & 6PM, [MEDICATION(S)] 100 mg Kapseal disp as [MEDICATION(S)] sod Ext 100 mg CA take 1 capsule PO every 8AM, 1PM, and 6PM, and [MEDICATION(S)] 80 mg tablet disp as [MEDICATION(S)] 80 mg tablet take 1 tablet PO at bedtime. Record review of Resident #3's Medication Chart on 7/12/21 at 6:00 PM revealed a diagonal line drawn through the signature box for [MEDICATION(S)] 20mg tablet take 1 tablet PO twice a day, [MEDICATION(S)] SOD 500mg tab compare to [MEDICATION(S)] 500 mg 3 tablets PO at bedtime, [MEDICATION(S)] SOD 250mg tablet compare to [MEDICATION(S)] 250 mg take 1 tablet by mouth at bedtime, Polyethylene [MEDICATION(S)] Powder compare to [MEDICATION(S)] Powder dissolve & take 17 grams in fluid P daily at 6 PM, [MEDICATION(S)] 50mg Ingatab compare to [MEDICATION(S)] 50mg 1 tablet at 6:00 PM and [MEDICATION(S)] SOD EXT 100mg capsule compare to [MEDICATION(S)] 100mg one (1) capsule by mouth at 6:00 PM, and [MEDICATION(S)] 80mg tablet compare to [MEDICATION(S)] 80mg take 1 tablet PO at bedtime. Record review of Resident #3's Treatment Chart revealed on 7/12/21, a diagonal line drawn through the signature box for Monitor Q (every) day for dehydration, Monitor for [CONDITION(S)] activity, notify MD if present and Monitor for s/s (signs/symptoms) of pain (facial grimaces, moaning, verbal etc) every shift and document according to scale if pain is noted document intervention and outcoe in nurses note. Record review of Resident #3's quarterly MDS dated [DATE], Section C, revealed a BIMS summary score of 09 which indicated moderate cognitive impairment. Resident #4 Record review of Resident # 4's Identification and Summary Sheet revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's Physician's Order Form, dated 7/21, revealed Sodium CL (chloride) for inhalation .9 use 1 vial via nebulizer every 8 hours, [MEDICATION(S)] Sulfate 220mg/5ml [MEDICATION(S)] give 220mg (5ml) per tube 2 times a day, [MEDICATION(S)] 500mg tablets take 1 tablet per PEG 2 times a day, [MEDICATION(S)] 40mg tablet take 1 tablet per tube at bedtime, [MEDICATION(S)] 2.5-0.5mg/3ml solution dispense (disp) as Iprat-Albut 0.5-3 (2.5) mg/3 use 1 vial in nebulizer every 6 hours, [MEDICATION(S)] DR 20 mg capsule disp as [MEDICATION(S)] Mag DR 30 mg open 1 capsule and mix with 50 ml water give per tube 2 times a day, [MEDICATION(S)] 5 mg/5ml syrup disp as [MEDICATION(S)] 5mg/5 ml syrup give 5 ml per tube every 8 hours, Vitamin C 500mg tablet take 1 tablet per tube twice a day, [MEDICATION(S)] 0.4 mg capsule SA disp as Tamsulosin HCL 0.4 mg capsule give 1 capsule per tube twice daily, and [MEDICATION(S)] ointment apply topically to the affected area 2 times a day. Record review of Resident #4's Physicians Orders, dated 4/27/21, revealed, Diet, Diabetasource AC @ 65 cc/hr w/40 cc/hr H2O flus, check placement & residuals Q 4 hours, hold tube feedings if gastric residual >100 cc & then recheck in 1 hr. Flush PEG with 30 cc of H2O before & after meds and give 5-10 cc H2O between meds. Humidified oxygen via [CONDITION(S)] collar 28% at 5 liters per minute (lpm). [CONDITION(S)] care Q shift & prn, clean w/normal saline and apply dressing, wash hands daily use B hand rolls at all times, and PEG site care q shift & prn, clean PEG w/NS, blot dry, apply [MEDICATION(S)], then drain dressing. Record review of Resident #4's Medication Chart revealed [MEDICATION(S)] Sulfate 220mg/5ml [MEDICATION(S)] give 220mg (5ml) per tube 2 times a day, [MEDICATION(S)] 500 mg tablets take 1 tablet per PEG 2 times a day, [MEDICATION(S)] 40 mg tablet take 1 tablet per tube at bedtime, [MEDICATION(S)] Mag Dr 20 Mg C compared to [MEDICATION(S)] Dr 20 mg capsule opening capsule & mix with 50 ml water give per tube 2 times a day, Vitamin C 500 mg tablet take 1 tablet per tube twice a day, and Tamsulosin HCL 0.4 mg capsule give 1 capsule per tube twice daily, not initialed on 7/12/21 at 6:00 PM. Record review of Resident #4's Medication Chart revealed Iprat-Albut 0.5-3 (2.5) MG/3 comp use 1 vial in nebulizer every 6 hours and [MEDICATION(S)] 100 mg/5ml give 10 cc per tube every 6 hours not initialed on 7/12/21 at 6:00 PM and 7/13/21 at 12:00 AM. Record review of Resident #4's Medication Chart revealed [MEDICATION(S)] 5mg/5ml [NAME] comp to [MEDICATION(S)] 5mg/5ml syrup give 5 ml per tube every 8 hours and Sodium Chloride 0.9 % irrigation use 30 cc via nebulizer every 8 hours, not initialed on 7/12/21 at 10:00 PM. Record review of Resident #4's Treatment Chart revealed [CONDITION(S)] care q shift and prn clean [CONDITION(S)] site with NS blot dry apply drainage gauze, keep HOB elevated 30-45 degrees q shift, clean PEG site with NS apply antiseptic cover with drain sponge q shift, Hydrophore to heels truck and extremities BID, suction q shift and prn with 14 FR (french) suction catheter, O2 at 5 liters with 28% humidified air via [CONDITION(S)] collar, monitor q shift for dehydration- dry [MEDICATION(S)] membranes, decreased urine output, fever, was hands daily use bilateral hand rolls at all times, place pillows under calves to float heels at all times, and monitor for s/s (signs/symptoms) of pain (facial grimaces moaning, verbal etc) every shift and document according to scale, not initialed on 7/12/21 B shift. Record review of Resident #4's annual MDS dated [DATE], Section C indicated BIMS summary score 00, which indicated severely impaired cognitive status. Resident #5 Record review of Resident #5's Identification and Summary Sheet revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's Physician's Order Form dated 07/21 revealed [MEDICATION(S)] 200 mg tablet take 1 tablet PO twice a day, [MEDICATION(S)] 1 mg tablet take 1 tablet po twice daily for 28 days, [MEDICATION(S)] 250 mg/5ml S give 500 mg (10 ml) PO three times daily, Lac-Hydrin 12% lotion dispense as Ammonium Lact 12% lotion apply topically to affected area every evening, [MEDICATION(S)] 25 mg tablet take 1 tablet PO daily, [MEDICATION(S)] 25 mg tablet dispense as [MEDICATION(S)] 25 mg tablet take one tablet PO twice daily, and [MEDICATION(S)] 40 mg tablet take 1 tablet PO at bedtime. Record review of Resident #5's Medication Chart revealed [MEDICATION(S)] 250 mg/5 ml give 500 mg (10 ml) PO three times daily, [MEDICATION(S)] 25 mg tablet comp to [MEDICATION(S)] 25 mg tablet take one tablet PO twice daily, [MEDICATION(S)] 40 mg tablet take 1 tablet PO at bedtime, give med with Boost 1 container PO, [MEDICATION(S)] 1 mg PO BID, and [MEDICATION(S)] 200 mg PO @ 6PM each day not given on 7/12/21 at 6:00 PM. [MEDICATION(S)] 25 mg tablet take 1 tablet PO every 8 hours, not initialed on 7/12/21 at 10:00 PM. Record review of Resident #5's Treatment Chart revealed monitor q day for dehydration (dry mucous membranes, urine output, ever), monitor for side effects of [CONDITION(S)] medication, and Lac Hydrin 12% lotion to feet q evening, and monitor for s/s of pain (facial grimaces, moaning, verbal etc) every shift and document according to scale, not initialed on 7/12/21 B shift. Review of Resident #5's MDS dated [DATE] quarterly, indicated BIMS summary score of 00, which indicated severely impaired cognitive status. Resident #6 Record review of Resident #6's Identification and Summary Sheet revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's Physician's Order Form dated 07/21, revealed, [MEDICATION(S)] 125 mg sprinkle capsule dispense as [MEDICATION(S)] 125 mg sprinkle take six (6) twice daily, [MEDICATION(S)] 40 mg tablet take 1 tablet PO at bedtime, Os-Cal 500 plus D tablet dispense as Oyster Cal D 500 mg tablet take 1 tablet PO twice a day, [MEDICATION(S)] 10 mg/5ml solution give 5 mg (2.5 ml) PO every morning and 10 mg (5ml) at noon and at bedtime, and [MEDICATION(S)] 0.5 mg take 1 tablet by mouth at bedtime. Record review of Resident #6 Medication Chart on 7/12/21 at 6:00 PM revealed a diagonal line drawn through the signature box for [MEDICATION(S)] 125 mg springle compared to [MEDICATION(S)] 125 mg springle take 6 capsules PO twice daily, [MEDICATION(S)] 40 mg tablet take 1 tablet PO at bedtime, Oyster Cal D 500 mg tablet compared to Os-Cal 500 + D tablet take 1 tablet PO twice a day, [MEDICATION(S)] 10mg/5ml solution 5mg (2.5ml) PO give 10 mg (5ml) at bedtime, and [MEDICATION(S)] 0.5 mg tablet compared to [MEDICATION(S)] 0.5 mg tablet take 1 tablet PO at bedtime. Record review of Resident #6's Treatment Chart on 7/12/21 on B and C shift not initialed to monitor Q (every) day for dehydration (dry mucous, membranes, urine output, fever), monitor for [CONDITION(S)] activity and monitor for s/s of pain (facial grimaces moaning, verbal etc) every shift and document. Record review of Resident #6's quarterly MDS dated [DATE] Section C, indicated BIMS summary score of 03, which indicated severely impaired cognitive status. Resident #7 Record review of Resident #7's Identification and Summary Sheet revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #7's Physician's Order Form dated 7/21, revealed, Lorazepam 0.5 mg take one (1) tablet PO twice daily, Lorazepam 1 mg tablet take one (1) tablet PO twice daily, [MEDICATION(S)] powder dispense as Polyethylene [MEDICATION(S)] Powder dissolve 17 grams in liquid and give PO 3 times a day, [MEDICATION(S)] 20 mg tablet dispense as [MEDICATION(S)] 20 mg tablet take 1 tablet PO every evening, [MEDICATION(S)] 500 mg capsule take 1 capsule PO 3 times a day, [MEDICATION(S)] 1 mg tablet take 1 tablet PO every evening, [MEDICATION(S)] 40 mg tablet take 1 tablet PO twice a day, [MEDICATION(S)] 5 mg tablet by mouth twice a day, and [MEDICATION(S)] 100 mg capsule dispense as [MEDICATION(S)] Sod 100 mg capsule take 2 capsule PO twice daily, Senna tablets take 2 tablets PO twice daily, and [MEDICATION(S)] 3 mg tablets take 1 tablet PO every evening. Record review of Resident #7's Medication Chart on 7/12/21 at 6:00 PM revealed a diagonal line drawn through the signature box for [MEDICATION(S)] 10 mg suppository compared to [MEDICATION(S)] 10 mg suppository insert 1 suppository rectally on Monday, Wednesday and Friday, Lorazepam0.5 mg tablet take 1 tablet PO twice daily, Lorazepam 1 mg tablet take 1 tablet PO twice daily, Polyethylene [MEDICATION(S)] Powder compared to [MEDICATION(S)] Powder dissolve 17 grams in Liquid and give PO 3 times daily, [MEDICATION(S)] 20 mg tablet compared to [MEDICATION(S)] 20 mg tablet take 1 tablet every evening, [MEDICATION(S)] 500 mg capsule take 1 capsule PO 3 times a daily, [MEDICATION(S)] 1 mg tablet take 1 tablet PO every evening, [MEDICATION(S)] 40 mg tablet take 1 tablet PO twice a day, [MEDICATION(S)] 40 mg tablet take 1 tablet PO at bedtime, [MEDICATION(S)] 5 mg tablet take 1 tablet PO twice a day, Thera Tears 0.25% eye drops instill 1 drop in each eye three times a day, [MEDICATION(S)] Sod 100 mg capsule compared to [MEDICATION(S)] 100 mg capsule take 2 capsules PO twice daily, Senna Tablets take 2 tablets PO twice daily, and [MEDICATION(S)] 3mg tablets take 1 tablet PO every evening. Record review of Resident #7's Treatment Chart on 7/12/21 on B and C shift not recorded in signature box, to monitor Q day for dehydration (dry mucous, membranes, urine output, fever), monitor for side effects of [CONDITION(S)] medications, lap tray to geri-chair while out of bed r/t (related to) safety, and monitor for s/s of pain (facial grimaces moaning, verbal etc) every shift and document. Record review of Resident #7's MDS dated [DATE] quarterly, revaled a BIMS summary score of 04, which indicated severely impaired cognitive status. Resident #8 Record review of Resident #8's Identification and Summary Sheet revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's Physicians Orders dated 4/21/21, revealed Isosurce 1.5 at 50 cc/hr with 55 cc/hr H2O flush; check gastric residuals Q4h (every 4 hours), if residual greater than 100cc hold TF (tube feeding) for 1 hour then recheck. [MEDICATION(S)] to buttocks Q shift, heel protectors on at all times, and clean PEG site W/NS (with normal saline) & apply drain dressing Q shift. Record review of Resident #8's Physician's Order Form dated 7/21, revealed [MEDICATION(S)] 500 mg tablets take 1 tablet per tube each evening, [MEDICATION(S)] 40 mg tablet take 1 tablet per tube each evening, and [MEDICATION(S)] HCL 200 mg take 1 tablet per tube every eight (8) hours. Record review of Resident #8's quarterly MDS dated [DATE] Section C, indicated a BIMS Summary score, 00, which indicated severely impaired cognitive status. Record review of Resident #8's Medication Chart on 7/12/21 at 6:00 PM, revealed a diagonal line drawn through the signature box for [MEDICATION(S)] 500 mg tablets take 1 tablet per tube twice a day. Record review of Resident #8's Medication Chart on 7/12/21 at 10:00 PM, revealed a diagonal line drawn through the signature box for [MEDICATION(S)] HCL 200 mg take 1 tablet per tube every eight (8) hours. Record review of Resident #8's Treatment Chart on 7/12/21 on B shift revealed, no signature in signature box for monitor Q day for Dehydration (mucous membranes, urine output, fever), clean PEG site with sterile saline apply drain sponge q shift, heel protectors at all times, mouth care q shift, notify MD for vomiting, evidence of respirator issues or for diarrhea, keep HOB elevated 30-40° at all times, insure heel protectors are in place and that no pressure is against mattress or padded siderail is against the tips of her toes, monitor for s/s of pain (facial grimaces, moaning, verbal, etc) every shift and document. Record review of Resident #8's Tube Feeding Record revealed on 7/13/21there were no initials for label bag/bottle with feeding type, Isosurce 1.5 at 50 cc/hr with flush with water at 55 cc/hr. The facility did not have a nurse on the first floor of Building 34 from appoximately 4:00 PM on 7/12/21 until 6:00 AM on 7/13/21, after the 3-11 nurse was notified that she was positive for Covid-19 and left the building. This left 15 residents without licensed nursing services from approximately 4:00 PM on 4/12/21 through 6:00 AM on 7/13/21. Removal Plan The facility submitted an acceptable Removal Plan on 7/22/21 for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: In response to the Immediate Jeopardy (IJ) template provided to the Administrator cited on July 21,2021 at 7:00 p.m., the following is a summary of the event and the actions taken by the facility to remove the Immediate Jeopardy. Brief Summary Madison Inn building 34 had insufficient licensed nursing staff on 7/12/2021 from 6:00 p.m. to 6:00 a.m. which gives us neglect of Residents #1, #2, #3, #4, and #5 on the first floor of building 34. Medications and treatments were missed for Residents #1, #2, #3, #4, and #5 during this time frame. [CONDITION(S)] care was not provided on Residents #2 and #4 during the time frame. The following corrective actions were taken for Residents #1, #2, #3, #4, and #5 affected by the insufficient licensed nursing staff and other facility Residents who could be potentially affected by insufficient licensed nursing staff in the future. 1.On July 13, 2021 at 6:15am RN#1 assessed Residents #1, #2, #3, #4, and #5 and gave 6 am medications and treatments to Residents #1, #2, #3, #4, and #5 and no negative outcomes or harm noted. RN#1 notified the attending physician that building 34 had insufficient licensed nursing staff on 7/12/2021 from 6:00 p.m. to 6:00 a.m. on 7/13/2021, the first floor. Medications and treatments were missed for Residents #1, #2, #3, #4, and #5 during this time frame. [CONDITION(S)] care was not provided on Residents #2 and #4 during the time frame. On 7/13/2021 at 9:00 a.m. attending phy

Based on record review, schedule review, staff interview, facility policy review, and timecard review the facility failed to ensure a licensed nurse was present to administer medications and treatments, monitor and provide necessary supervision, and provide Percutaneous Endoscopic Gastrostomy (PEG) feedings for 15 of 15 residents on the 1st floor Building 34 on the 3-11 shift on 7/12/21 through 6:00 AM on 7/13/21. The facility's failure to provide a licensed nurse to administer medications and treatments for 12 hours had the likelihood to cause all residents residing on the 1st Floor of Building 34 serious harm, serious injury, serious impairment, or possible death. The State Agency (SA) identified an Immediate Jeopardy (IJ) which began on 7/12/21, when the facility failed to provide a licensed nurse to monitor and provide necessary supervision, administer medications, Percutaneous Endoscopy Gastroscopy (PEG) tube feedings and perform [CONDITION(S)] care. On 7/21/21 at 7:00 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and provided the facility with the IJ Template. The facility submitted an acceptable Removal Plan on 7/22/2021 at 5:16 PM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of 7/23/21. The SA validated the Removal Plan on 7/24/21 and determined the IJ was removed on 7/23/21 prior to exit. Therefore, the scope and severity for CFR(s) §483.35(a)(1) Sufficient Nursing Staff (F725), was lowered from a L to an F while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings: Review of facility policy titled, [NAME] Nursing Home (JNH) Administrator on Call, revised August 2020, 1. Purpose and Applicability. This policy establishes guidelines for the Administrator of Call (AOC) to provide management continuity at all times. This policy applies to the management staff of [NAME] Nursing Home (JNH). 2. Policy. It is the policy of JNH to ensure the availability and accessibility of administrative support on a continuing basis, not only to provide prompt decisions requiring policy interpretations but also to deal with administrative emergencies which arise at times other than normal business hours . F. In the absence of the Registered Nurse (RN) Shift Supervisor, the AOC, and Director of Nursing (DON) on call will be responsible for coordinating nurse staff assignments based on a predetermined plan approved by JNH Nurse Administrator between the hours of 5:00 PM and 8:00 AM and during weekends and holiday. Any instances of non-compliance with required minimum numbers of licensed personnel will be immediately reported by the AOC to the JNH Director. Review of the facility policy titled, Accountability for Nursing Personnel Assignment dated August 2020, revealed 1. PURPOSE AND APPLICABILITY. This policy defines the steps to be followed in accounting for nursing personnel reporting to [NAME] Nursing Home (JNH) on each shift. This policy applies to all JHN personnel. 2. POLICY. [NAME] Nursing Home will assign licensed nurses and Certified Nurses Assistants (CNA's) to each unit in accordance with the minimum requirements directed by the Mississippi Department of Health, Division of Licensure and Certification .3. PROCEDURE. B .The NSC or DON on call will reassign nurses as necessary to assure a minimum of one licensed nurse per floor, per building in the unit. C. The staffing personnel on Building 36 . will take call-ins form nursing staff every shift. The staffing personnel will notify the DON on call who will attempt to cover the shift or shifts with a nurse from their building/unit. The NSC will make changes on the Master Schedule and contact the authorized agencies for contract nurses as needed. D. The RN Grounds Supervisor or DON on call will take call-ins after 3:30 p.m. Monday through Friday and all shifts on weekends and Holidays. Record review of the facility Investigative Findings dated 7/13/21, BUILDING 34 POSSIBLE NEGLECTS OF MULTIPLE RESIDENTS, revealed that on, 7/13/21, the Administrator advised the Department of Safety & Investigative Services that on 7/12/21, the B-shift nurse for the downstairs unit on B34 tested Covid + and was sent home. It was determined that attempts were made to get nurse coverage for the unit; however, no replacement nurse came for B shift. An agency nurse came at midnight for C-shift, but refused to accept the assignment and left. Therefore, there was no nurse for the downstairs unit on B34 for C shift either . The facility failed to provide sufficient licensed nursing staff for the downstairs' unit of B34 from 6:00 PM - 6:00 AM on 7/13/21. Therefore, neglect by the facility is substantiated. Please do know that each of the Residents on the unit was assessed by (Formal Name of Physician) of the morning of 7/13/21 and none of the residents appear to have suffered an adverse effect as a result of this insufficiency . On 7/20/21 at 6:40 PM, in an interview with RN/Administrator (RN/Admin) revealed on 7/12/21 LPN #1 was informed she was Covid-19 positive and was directed to leave the facility immediately. She waited on her relief in her car with the narcotics keys. On 7/12/21 at approximately 7:45 PM, LPN #1 gave the 2nd floor Building 34, RN #2 the narcotic keys. The agency relief nurse presented at the facility at approximately 11:00 PM on 7/12/21 but would not accept the narcotic keys nor take the assignment of 1st floor Building 34 because the medication room was in disarray. On 7/21/21 at 9:30 AM, in an interview with the Administrator (Adm) revealed the facility failed to provide sufficient nursing staff which resulted in medications/treatments being missed for approximately 12 hours from 7/12/21 at 6:00 PM through 7/13/21 at 6:00 AM. On 7/21/21 at 1:30 PM, in an interview with RN/Admin revealed the residents with tracheostomies could have had a mucous plug during the shift with no licensed nurse. RN/Admin explained the likelihood of harm was present on 7/12/21 from 6:00 PM through 7/13/21 at 6:00 AM for all residents not receiving medications or treatments. On 7/21/21 at 1:40 PM, in an interview with the Adm she confirmed that on 7/12/21 there could have been a serious negative outcome among the residents with no licensed nursing staff on the 1st floor of Building 34. On 07/21/21 at 2:30 PM, in an interview with Certified Nursing Assistant (CNA) #2 revealed she was working on 7/12/21 the 3:00 PM through 11:00 PM shift. LPN #1 informed her she tested positive for Covid-19 and was informed to leave the facility immediately, but there would be another nurse to replace her. CNA #2 revealed at approximately 4:30 PM on 7/12/21, she was the only staff present on the 1st floor until around 7:00 PM when a CNA came in early to help her with the 15 residents. CNA #2 revealed there was an RN on the 2nd floor of Building 34 who explained to CNA #2 that if an emergency would happen, she would assist. RN #2 came down to the 1st floor and medicated a resident for pain, then RN #2 returned to the 2nd floor. On 7/21/21 at 2:50 PM, in an interview with LPN #1 revealed she reported to 1st Floor Building 34 and counted the narcotics with the off going nurse. At approximately 4:00PM, she received a phone call from the Medical Director on call for the campus who explained that she was Covid-19 positive and needed to leave the facility immediately. LPN #1 revealed she left the facility and waited in her car for her replacement. LPN #1 revealed she contacted the Director of Nurse (DON)#2 on call for the campus and was informed relief would be there shortly. LPN #1 stated that she remained in her car until 8:00PM when RN #2 came to the car and received the narcotic keys from LPN #1. LPN #1 left the campus. On 7/21/21 at 3:00 PM, in an interview with RN #2 revealed when she was aware that LPN #1 was unable to work her scheduled shift, she was informed by RN/Admin and DON#2 on call, an agency nurse would report to the facility which would be responsible for 1st floor Building 34, residents. Then, when the agency nurse failed to work on 1st floor Building, she was informed by the RN/Admin, she was not responsible for 1st floor Building 34 medications and/or treatments. Record review of the Unit Daily Sign-in Sheet for 7/12/21 for 3:00 PM through 11:00 PM shift and 7/13/21 11:00 through 6:00 AM shift for 1st floor Building 34, LPN #1 was assigned to the unit for B and C shifts. Record review of 1st floor Building 34 Timecard revealed LPN #1 clocked in on 7/12/21 at 2:55 PM and clocked out 7/12/21 at 8:00 PM. Record review of the Staffing Grid revealed, the facility had one (1) RN on 2nd floor Building 34 on 7/12/21 from 3:00 PM through 7/13/21 6:00 AM. The facility did not have a nurse on the first floor of Building 34 from appoximately 4:00 PM on 7/12/21 until 6:00 AM on 7/13/21, after the 3-11 nurse was notified that she was positive for Covid-19 and left the building. This left 15 residents without licensed nursing services from approximately 4:00 PM on 4/12/21 through 6:00 AM on 7/13/21. The facility submitted an acceptable Removal Plan on 7/22/21 for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: In response to the Immediate Jeopardy (IJ) template provided to the Administrator cited on July 21,2021 at 7:00 p.m., the following is a summary of the event and the actions taken by the facility to remove the Immediate Jeopardy. Removal Plan Brief Summary Madison Inn building 34 had insufficient licensed nursing staff on 7/12/2021 from 6:00 p.m. to 6:00 a.m. which gives us neglect of Residents #1, #2, #3, #4, and #5 on the first floor of building 34. Medications and treatments were missed for Residents #1, #2, #3, #4, and #5 during this time frame. [CONDITION(S)] care was not provided on Residents #2 and #4 during the time frame. The following corrective actions were taken for Residents #1, #2, #3, #4, and #5 affected by the insufficient licensed nursing staff and other facility Residents who could be potentially affected by insufficient licensed nursing staff in the future. 1.On July 13, 2021, at 6:15am RN#1 assessed Residents #1, #2, #3, #4, and #5 and gave 6 am medications and treatments to Residents #1, #2, #3, #4, and #5 and no negative outcomes or harm noted. RN#1 notified the attending physician that building 34 had insufficient licensed nursing staff on 7/12/2021 from 6:00 p.m. to 6:00 a.m. on 7/13/2021, the first floor. Medications and treatments were missed for Residents #1, #2, #3, #4, and #5 during this time frame. [CONDITION(S)] care was not provided on Residents #2 and #4 during the time frame. On 7/13/2021 at 9:00 a.m. attending physician assessed Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15 and no injuries or harm noted. 2.On July 14, 2021, at 3:30pm until 4:30pm [NAME] Nursing Home Nurse Administrator counseled the Agency LPN scheduled and declined to work 11-7 shift on 7/13/21and Contract RN working on building 34 on 3-11 and 11-7 shifts on 7/12/21 and 7/13/21 on the policy and procedure of notifying the on-call Administrator and Director of Nursing as needed for unintended occurrences. 3.On July 15, 2021, at 01:30 p.m., a Quality Assurance meeting was conducted with [NAME] Nursing Home Director, Chief Medical Doctor, Safety Investigative Services,[NAME] Nursing Administrator, Director of Nursing #1 and Director of Nursing #2, Nurse Staffing Director, Administrator in Training #1 and Administrator in Training #2, Service Outcome Director to discuss and determine corrective actions for further incidents of this magnitude. Corrective actions discussed were to inform resident's representative of incident on 7/12/21 and 7/13/21. Educate staff on notifying leadership through proper communication (campus switchboard). Inservice staff (agency/contract) on Injuries, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property or Exploitation of Resident POL J530-55. Establishing protocol of nurse's responsibility and Chain of Notification for Staffing Concerns. Contracting additional staff for Covid-19 buildings. 4. On July 16, 2021, at 7:00am Emergency Covid-19 staffing contract executed to obtain more licensed agency staff to work on units with Covid-19 cases. Social Worker#1 called Residents #1, #2, #3, #4, and #5 representative of the incident and documented in resident's medical chart. Administrator In Training # 1 in serviced staff (pantry, housekeeping, laundry, full time/ agency/contract licensed nurses and certified nurse assistants) for Madison Inn on Policy J530-55 (Injuries, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property or Exploitation of Resident) 5. On July 20, 2021, at 4:00pm JNH Nurse Administrator developed an emergency Contract and Agency Licensed Competency Checklist to ensure nurses remain aware of the Mississippi State Hospital policy and procedures, physician, and DON's phone numbers for notification of falls, incidents, accidents, incorrect narcotic count, and other unusual occurrences. To also ensure the nurse comply to the facility policies and procedures on Abuse, Neglect, Exploitation, Misappropriation of Resident items, notification of abuse and neglect, Orientation to service area, Review of Medication and treatment records, [CONDITION(S)] Care, Feeding Tube administration, Following Medication administration policy and procedure, Care plan policy and procedure, and following physician orders. 6. On July 22, 2021, at 12:30pm JNH Nurse Administrator will begin in-servicing all nursing staff, Director of Nursing, Director of Staffing on these policies and procedures: Medication Administration, [CONDITION(S)] care, Following the Care plan, Abuse and Neglect, Notification of DON, or DON on call for medication concerns such as medication errors, incorrect narcotic count, Resident Rights for Health and safety, and Chain of Notification for Staffing Concerns. No staff will be allowed to work until Inservice is completed. On 7/22/2021 at 1:30p.m. Contract and Agency Licensed Competency Checklist started and will be ongoing for new contract and agency staff. 7.The facility will be in compliance 7/22/2021 at 4:00pm. On 7/24/21, the SA validated the facility's Removal Plan by staff interviews, record reviews, and review of in-service sheets. The SA verified the facility had implemented the following measures to remove the IJ: 1. SA validated through record review and interview with RN#1 that on July 13, 2021, at 6:15AM, RN#1 assessed Residents #1, #2, #3, #4, #5, #6, #7, and #8 and gave 6 am medications and treatments to Residents #1, #2, #3, #4, #5, #7, and #8 and no negative outcomes or harm noted. RN#1 notified the attending physician that building 34 had insufficient licensed nursing staff on 7/12/2021 from 6:00 PM to 6:00 AM. on 7/13/2021, the first floor. Medications and treatments were missed for Residents #1, #2, #3, #4, #5, #7, and #8 during this time frame. [CONDITION(S)] care was not provided on Residents #2 and #4 during the time frame. On 7/13/2021 at 9:00 a.m. AM the attending physician assessed Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15 and no injuries or harm were noted. 2. SA validated through record review and interview with the RN/Admin that on July 14, 2021, at 3:30 PM until 4:30 PM [NAME] Nursing Home Nurse Administrator counseled the Agency LPN scheduled and declined to work 11-7 shift on 7/13/21and Contract RN working on building 34 on 3-11 and 11-7 shifts on 7/12/21 and 7/13/21 on the policy and procedure of notifying the on-call Administrator and Director of Nursing as needed for unintended occurrences. 3. SA validated through record review and interview with the Administrator, Administrator in Training (AIT) and RN/Admin that on July 15, 2021, at 01:30 PM a Quality Assurance meeting was conducted with [NAME] Nursing Home Director, Chief Medical Doctor, Safety Investigative Services, [NAME] Nursing Administrator, Director of Nursing #1 and Director of Nursing #2, Nurse Staffing Director, Administrator in Training #1 and Administrator in Training #2, Service Outcome Director to discuss and determine corrective actions for further incidents of this magnitude. Corrective actions discussed were to inform resident's representative of incident on 7/12/21 and 7/13/21. Educate staff on notifying leadership through proper communication (campus switchboard). Inservice staff (agency/contract) on Injuries, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property or Exploitation of Resident POL J530-55. Establishing protocol of nurse's responsibility and Chain of Notification for Staffing Concerns. Contracting additional staff for Covid-19 buildings. 4. SA validated through record review and interview with RN/Admin, Social Worker, and AIT that on July 16, 2021, at 7:00 AM Emergency Covid-19 staffing contract executed to obtain more licensed agency staff to work on units with Covid-19 cases. Social Worker#1 called Residents #1, #2, #3, #4, #5, #7, and #8 representative of the incident and documented in ?6 resident's medical chart. Administrator In Training # 1 in serviced staff (pantry, housekeeping, laundry, full time/ agency/contract licensed nurses and certified nurse assistants) for Madison Inn on Policy J530-55 (Injuries, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property or Exploitation of Resident). 5. SA validated through record review, sign in-sheets, and interview RN/Admin that on July 20, 2021, at 4:00 PM JNH Nurse Administrator developed an emergency Contract and Agency Licensed Competency Checklist to ensure nurses remain aware of the Mississippi State Hospital policy and procedures, physician, and DON's phone numbers for notification of falls, incidents, accidents, incorrect narcotic count, and other unusual occurrences. To also ensure the nurse comply to the facility policies and procedures on Abuse, Neglect, Exploitation, Misappropriation of Resident items, notification of abuse and neglect, Orientation to service area, Review of Medication and treatment records, [CONDITION(S)] Care, Feeding Tube administration, Following Medication administration policy and procedure, Care plan policy and procedure, and following physician orders. 6. SA validated through record review, sign in sheets, and interview with DON #1 and AIT that on July 22, 2021, at 12:30 PM JNH Nurse Administrator will begin in-servicing all nursing staff, Director of Nursing, Director of Staffing on these policies and procedures: Medication Administration, [CONDITION(S)] care, Following the Care plan, Abuse and Neglect, Notification of DON, or DON on call for medication concerns such as medication errors, incorrect narcotic count, Resident Rights for Health and safety, and Chain of Notification for Staffing Concerns. No staff will be allowed to work until Inservice is completed. On 7/22/2021 at 1:30p.m. Contract and Agency Licensed Competency Checklist started and will be ongoing for new contract and agency staff. The SA validated on 07/24/2021, that all as of 7/22/21 all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on 07/23/2021, prior to exit.

Based on record review, staff interview, and facility policy review, the facility failed to ensure significant medications (anti-coagulants, anti-[CONDITION(S)], anti-diabetic, heart, and [CONDITION(S)]) were administered to prevent discomfort or complications for eight (8) of 15 residents reviewed for medication administration. Resident #1, #2, #3, #4, #5, #6, #7, and #8. The facility's failure to provide nursing services and administer significant medications on eight (8) residents on the 3-11 shift on 7/12/21 through 6:00 AM on 7/13/21. This placed these residents and all other residents who reside on the first floor of Building 34, at risk, and in a situation which was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 7/12/21 when the facility failed to ensure a licensed nurse was available to provide necessary supervision and administer medications. On 07/21/21 at 7:00 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the facility with the IJ Template. The facility submitted an acceptable Removal Plan on 7/22/21 at 5:16 PM, in which the facility alleged all corrective actions to remove the IJ were completed on 7/22/21 and the IJ removed as of 7/23/21. The SA validated the Removal Plan on 7/24/21 and determined the IJ was removed on 7/23/21, prior to exit. Therefore, the scope and severity for CFR(s) §483.45(f)(2)- Residents are free of any significant medication errors (F-760), was lowered from a K to an E while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled, Medications, Administration, Timing, and Treatment, revised October 2018, revealed, 1. PURPOSE AND APPLICABILITY. This policy specifies the clinicians who are authorized to administer medications and provides guidelines for scheduling medication administration and treatment by all clinical nurses at Mississippi State Hospital including [NAME] Nursing Home (JNH) . 2. POLICY. Physicians, nurse practitioners, dentists, nurses, podiatrists, optometrists, and radiology technologist may administer medications within their scope of practice . C. Time critical scheduled medications. Time critical medications are those for which an early or late administration of greater than thirty minutes might cause harm or have significant, negative impact on the intended therapeutic or pharmacological effect. These medications must be administered within thirty minutes before or after their scheduled dosing time, for a total window of one (1) hour . Record review of the facility Investigative Findings dated 7/13/21, BUILDING 34 POSSIBLE NEGLECTS OF MULTIPLE RESIDENTS, revealed that on, 7/13/21, the Administrator advised the Department of Safety & Investigative Services that on 7/12/21, the B-shift nurse for the downstairs unit on B34 tested Covid + and was sent home. It was determined that attempts were made to get nurse coverage for the unit; however, no replacement nurse came for B shift. An agency nurse came at midnight for C-shift but refused to accept the assignment and left. Therefore, there was no nurse for the downstairs unit on B34 for C shift either . The facility failed to provide sufficient licensed nursing staff for the downstairs' unit of B34 from 6:00 PM - 6:00 AM on 7/13/21. Therefore, neglect by the facility is substantiated. Please do know that each of the Residents on the unit was assessed by (Formal Name of Physician) of the morning of 7/13/21 and none of the residents appear to have suffered an adverse effect as a result of this insufficiency . On 7/21/21 at 10:00 AM, in an interview with Registered Nurse (RN) #1 revealed when the physician orders a medication, it is the nurses' responsibility to give the medication as ordered. On 7/12/21 at 6:00 PM through 7/13/21 at 6:00 AM since there was no nurse working on 1st floor Building 34, medication was not given. The medications prescribed were to prevent [CONDITION(S)] activity, anti-coagulants, anti-diabetic, heart, and [CONDITION(S)]. They should have been given as prescribed to maintain constant concentration in the blood. On 7/21/21 at 1:13 PM, in an interview with the Director of Nurses (DON) #1 revealed the staff should follow the physician orders for residents to provide safety and compliance. On 7/12/21 from 6:00 PM until 07/13/21 at 6:00 AM, significant medications were not given because there was no nurse present on 1st floor Building 34, to administer medications. On 7/21/21 at 1:21 PM, in an interview with Registered Nurse Administrator (RN/NS-Admin) revealed on 7/12/21 from 6:00 AM until 7/13/21 6:00 AM the medications were not given on the 1st floor Building 34 because a licensed nurse was not present. Holding the medication without a physician order on the Residents could have caused a [CONDITION(S)] or stroke and would have been harm. Resident #1 Record review of Resident #1's Identification and Summary Sheet revealed Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Medication Chart revealed on 7/12/21 at 6:00 PM [MEDICATION(S)] 250 milligrams (mg) tablet take one (1) tablet by mouth twice a day, [MEDICATION(S)] 1000 mg tablet take one (1) tablet by mouth twice a day, and [MEDICATION(S)] 1 mg take one (1) tablet by mouth twice a day, was not initialed on the Medication Chart. Record review of Resident #1's Physician's Order Form for the month of 07/21 revealed orders for [MEDICATION(S)] 250 milligrams (mg) take one (1) tablet by mouth twice a day, [MEDICATION(S)] 1000 mg take one (1) tablet twice a day, and [MEDICATION(S)] one (1) mg by mouth two times a day. Record review of Resident #1 annual Minimum Data Set (MDS) dated [DATE], indicated a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #1 was cognitively intact. Resident #2 Record review of Resident #2's Identification and Summary Sheet revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Medication Chart revealed on 7/12/21 at 6:00 PM, [MEDICATION(S)] 50 mg tablet take one (1) tablet per tube twice a day, was not initialed. Record review of Resident #2's Physician's Order Form dated 07/21 revealed [MEDICATION(S)] 50 mg give one (1) tablet per tube twice a day. Record review of Resident #2's quarterly MDS dated [DATE] Section C, indicated BIMS summary score 00, which indicated severely impaired cognitive status. Resident #3 Record review of Resident #3's Identification and Summary Sheet revealed he was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] & 6PM, and [MEDICATION(S)] 100 mg Kapseal disp as [MEDICATION(S)] sod Ext 100 mg CA take 1 capsule PO every 8AM, 1PM, and 6PM. Record review of Resident #3's Medication Chart on 7/12/21 at 6:00 PM revealed a diagonal line drawn through the signature box for [MEDICATION(S)] SOD 500mg tab compare to [MEDICATION(S)] 500 mg 3 tablets PO at bedtime, [MEDICATION(S)] SOD 250mg tablet compare to [MEDICATION(S)] 250 mg take 1 tablet by mouth at bedtime, [MEDICATION(S)] 50mg Ingatab compare to [MEDICATION(S)] 50 MG 1 tablet at 6:00 PM and [MEDICATION(S)] SOD EXT 100mg capsule compare to [MEDICATION(S)] 100 MG one (1) capsule by mouth at 6:00 PM. Record review of Resident #3's quarterly MDS dated [DATE], Section C, revealed a BIMS summary score of 09 which indicated moderate cognitive impairment. Resident #4 Record review of Resident # 4's Identification and Summary Sheet revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review Resident #4 Physician's Order Form, dated 7/21, revealed [MEDICATION(S)] 500 mg tablets take 1 tablet per PEG 2 times a day. Record review Resident #4 Medication Chart revealed [MEDICATION(S)] 500 mg tablets take 1 tablet per PEG 2 times a day was not initialed on 7/12/21 at 6:00 PM. Record review of Resident #4 annual MDS dated [DATE], Section C indicated BIMS summary score 00, which indicated severely impaired cognitive status. Resident #5 Record review of Resident #5's Identification and Summary Sheet revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review Resident #5's Physician's Order Form dated 07/21 revealed [MEDICATION(S)] 200 mg tablet take 1 tablet PO twice a day, [MEDICATION(S)] 1 mg tablet take 1 tablet po twice daily for 28 days, [MEDICATION(S)] 250 mg/5ml S give 500 mg (10 ml) PO three times daily, [MEDICATION(S)] 25 mg tablet take 1 tablet PO daily, and [MEDICATION(S)] 25 MG tablet dispense as [MEDICATION(S)] 25 mg tablet take one tablet PO twice daily. Record review Resident #5's Medication Chart revealed [MEDICATION(S)] 250 mg/5 ml give 500 mg (10 ml) PO three times daily, [MEDICATION(S)] 25 mg tablet comp to [MEDICATION(S)] 25 mg tablet take one tablet PO twice daily, and [MEDICATION(S)] 200 mg PO at 6PM each day not given on 7/12/21 at 6:00 PM. [MEDICATION(S)] 25 mg tablet take 1 tablet PO every 8 hours, not initialed on 7/12/21 at 10:00 PM. Review of Resident #5's MDS dated [DATE] quarterly, indicated BIMS summary score of 00, which indicated severely impaired cognitive status. Resident #6 Record review of Resident #6's Identification and Summary Sheet revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6 Physician's Order Form dated 07/21, revealed, [MEDICATION(S)] 125 mg sprinkle capsule dispense as [MEDICATION(S)] 125 mg sprinkle take six (6) twice daily, and [MEDICATION(S)] 0.5 mg take 1 tablet by mouth at bedtime. Record review of Resident #6 Medication Chart on 7/12/21 at 6:00 PM revealed a diagonal line drawn through the signature box for [MEDICATION(S)] 125 mg springle compared to [MEDICATION(S)] 125 mg springle take 6 capsules PO twice daily, and [MEDICATION(S)] 0.5 mg tablet compared to [MEDICATION(S)] 0.5 mg tablet take 1 tablet PO at bedtime. Record review of Resident #6's quarterly MDS dated [DATE] Section C, indicated BIMS summary score of 03, which indicated severely impaired cognitive status. Resident #7 Record review of Resident #7's Identification and Summary Sheet revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #7's Physician's Order Form dated 7/21, revealed, Lorazepam 0.5 mg take one (1) tablet PO twice daily, Lorazepam 1 mg tablet take one (1) tablet PO twice daily, [MEDICATION(S)] 20 mg tablet dispense as [MEDICATION(S)] 20 mg tablet take 1 tablet PO every evening, [MEDICATION(S)] 500 mg capsule take 1 capsule PO 3 times a day, [MEDICATION(S)] 1 mg tablet take 1 tablet PO every evening, [MEDICATION(S)] 40 mg tablet take 1 tablet PO twice a day, and [MEDICATION(S)] 5 mg tablet by mouth twice a day. Record review of Resident #7's Medication Chart on 7/12/21 at 6:00 PM revealed a diagonal line drawn through the signature box for Lorazepam0.5 mg tablet take 1 tablet PO twice daily, Lorazepam 1 mg tablet take 1 tablet PO twice daily, [MEDICATION(S)] 20 mg tablet compared to [MEDICATION(S)] 20 mg tablet take 1 tablet every evening, [MEDICATION(S)] 500 mg capsule take 1 capsule PO 3 times a daily, [MEDICATION(S)] 1 mg tablet take 1 tablet PO every evening, [MEDICATION(S)] 40 mg tablet take 1 tablet PO twice a day, [MEDICATION(S)] 40 mg tablet take 1 tablet PO at bedtime, and [MEDICATION(S)] 5 mg tablet take 1 tablet PO twice a day. Record review of Resident #7's MDS dated [DATE] quarterly, revealed a BIMS summary score of 04, which indicated severely impaired cognitive status. Resident #8 Record review of Resident #8's Identification and Summary Sheet revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's Physician's Order Form dated 7/21, revealed [MEDICATION(S)] 500 mg tablets take 1 tablet per tube each evening, and [MEDICATION(S)] 200 mg take 1 tablet per tube every eight (8) hours. Record review of Resident #8's Medication Chart on 7/12/21 at 6:00 PM, revealed a diagonal line drawn through the signature box for [MEDICATION(S)] 500 mg tablets take 1 tablet per tube twice a day. Record review of Resident #8's Medication Chart on 7/12/21 at 10:00 PM, revealed a diagonal line drawn through the signature box for [MEDICATION(S)] 200 mg take 1 tablet per tube every eight (8) hours. Record review of Resident #8's quarterly MDS dated [DATE] Section C, indicated a BIMS Summary score, 00, which indicated severely impaired cognitive status. The facility submitted an acceptable Removal Plan on 7/22/21 for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan In response to the Immediate Jeopardy (IJ) template provided to the Administrator cited on July 21,2021 at 7:00 p.m., the following is a summary of the event and the actions taken by the facility to remove the Immediate Jeopardy. Brief Summary Madison Inn building 34 had insufficient licensed nursing staff on 7/12/2021 from 6:00 p.m. to 6:00 a.m. which gives us neglect of Residents #1, #2, #3, #4, and #5 on the first floor of building 34. Medications and treatments were missed for Residents #1, #2, #3, #4, and #5 during this time frame. [CONDITION(S)] care was not provided on Residents #2 and #4 during the time frame. The following corrective actions were taken for Residents #1, #2, #3, #4, and #5 affected by the insufficient licensed nursing staff and other facility Residents who could be potentially affected by insufficient licensed nursing staff in the future. 1.On July 13, 2021, at 6:15am RN#1 assessed Residents #1, #2, #3, #4, and #5 and gave 6 am medications and treatments to Residents #1, #2, #3, #4, and #5 and no negative outcomes or harm noted. RN#1 notified the attending physician that building 34 had insufficient licensed nursing staff on 7/12/2021 from 6:00 p.m. to 6:00 a.m. on 7/13/2021, the first floor. Medications and treatments were missed for Residents #1, #2, #3, #4, and #5 during this time frame. [CONDITION(S)] care was not provided on Residents #2 and #4 during the time frame. On 7/13/2021 at 9:00 a.m. attending physician assessed Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15 and no injuries or harm noted. 2.On July 14, 2021, at 3:30pm until 4:30pm [NAME] Nursing Home Nurse Administrator counseled the Agency LPN scheduled and declined to work 11-7 shift on 7/13/21and Contract RN working on building 34 on 3-11 and 11-7 shifts on 7/12/21 and 7/13/21 on the policy and procedure of notifying the on-call Administrator and Director of Nursing as needed for unintended occurrences. 3.On July 15, 2021, at 01:30 p.m., a Quality Assurance meeting was conducted with [NAME] Nursing Home Director, Chief Medical Doctor, Safety Investigative Services, [NAME] Nursing Administrator, Director of Nursing #1 and Director of Nursing #2, Nurse Staffing Director, Administrator in Training #1 and Administrator in Training #2, Service Outcome Director to discuss and determine corrective actions for further incidents of this magnitude. Corrective actions discussed were to inform resident's representative of incident on 7/12/21 and 7/13/21. Educate staff on notifying leadership through proper communication (campus switchboard). Inservice staff (agency/contract) on Injuries, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property or Exploitation of Resident POL J530-55. Establishing protocol of nurse's responsibility and Chain of Notification for Staffing Concerns. Contracting additional staff for Covid-19 buildings. 4. On July 16, 2021, at 7:00am Emergency Covid-19 staffing contract executed to obtain more licensed agency staff to work on units with Covid-19 cases. Social Worker#1 called Residents #1, #2, #3, #4, and #5 representative of the incident and documented in resident's medical chart. Administrator In Training # 1 in serviced staff (pantry, housekeeping, laundry, full time/ agency/contract licensed nurses and certified nurse assistants) for Madison Inn on Policy J530-55 (Injuries, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property or Exploitation of Resident). 5. On July 20, 2021, at 4:00pm JNH Nurse Administrator developed an emergency Contract and Agency Licensed Competency Checklist to ensure nurses remain aware of the Mississippi State Hospital policy and procedures, physician, and DON's phone numbers for notification of falls, incidents, accidents, incorrect narcotic count, and other unusual occurrences. To also ensure the nurse comply to the facility policies and procedures on Abuse, Neglect, Exploitation, Misappropriation of Resident items, notification of abuse and neglect, Orientation to service area, Review of Medication and treatment records, [CONDITION(S)] Care, Feeding Tube administration, Following Medication administration policy and procedure, Care plan policy and procedure, and following physician orders. 6. On July 22, 2021, at 12:30pm JNH Nurse Administrator will begin in-servicing all nursing staff, Director of Nursing, Director of Staffing on these policies and procedures: Medication Administration, [CONDITION(S)] care, Following the Care plan, Abuse and Neglect, Notification of DON, or DON on call for medication concerns such as medication errors, incorrect narcotic count, Resident Rights for Health and safety, and Chain of Notification for Staffing Concerns. No staff will be allowed to work until Inservice is completed. On 7/22/2021 at 1:30p.m. Contract and Agency Licensed Competency Checklist started and will be ongoing for new contract and agency staff. 7.The facility will be in compliance 7/22/2021 at 4:00pm. On 7/24/21, the SA validated the facility's Removal Plan by staff interviews, record reviews, and review of in-service sheets. The SA verified the facility had implemented the following measures to remove the IJ: 1. SA validated through record review and interview with RN#1 that on July 13, 2021, at 6:15am RN#1 assessed Residents #1, #2, #3, #4, #5, #7, and #8 and gave 6 am medications and treatments to Residents #1, #2, #3, #4, #5, #7, and #8 and no negative outcomes or harm noted. RN#1 notified the attending physician that building 34 had insufficient licensed nursing staff on 7/12/2021 from 6:00 p.m. to 6:00 a.m. on 7/13/2021, the first floor. Medications and treatments were missed for Residents #1, #2, #3, #4, #5, #7, and #8 during this time frame. [CONDITION(S)] care was not provided on Residents #2 and #4 during the time frame. On 7/13/2021 at 9:00 a.m. attending physician assessed Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15 and no injuries or harm noted. 2. SA validated through record review and interview with the RN/Admin that on July 14, 2021, at 3:30pm until 4:30pm [NAME] Nursing Home Nurse Administrator counseled the Agency LPN scheduled and declined to work 11-7 shift on 7/13/21and Contract RN working on building 34 on 3-11 and 11-7 shifts on 7/12/21 and 7/13/21 on the policy and procedure of notifying the on-call Administrator and Director of Nursing as needed for unintended occurrences. 3. SA validated through record review and interview with the Administrator, Administrator in Training (AIT) and RN/Admin that on July 15, 2021, at 01:30 p.m., a Quality Assurance meeting was conducted with [NAME] Nursing Home Director, Chief Medical Doctor, Safety Investigative Services, [NAME] Nursing Administrator, Director of Nursing #1 and Director of Nursing #2, Nurse Staffing Director, Administrator in Training #1 and Administrator in Training #2, Service Outcome Director to discuss and determine corrective actions for further incidents of this magnitude. Corrective actions discussed were to inform resident's representative of incident on 7/12/21 and 7/13/21. Educate staff on notifying leadership through proper communication (campus switchboard). Inservice staff (agency/contract) on Injuries, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property or Exploitation of Resident POL J530-55. Establishing protocol of nurse's responsibility and Chain of Notification for Staffing Concerns. Contracting additional staff for Covid-19 buildings. 4. SA validated through record review and interview with RN/Admin, Social Worker, and AIT that on July 16, 2021, at 7:00am Emergency Covid-19 staffing contract executed to obtain more licensed agency staff to work on units with Covid-19 cases. Social Worker#1 called Residents #1, #2, #3, #4, #5, #7, and #8 representative of the incident and documented in resident's medical chart. Administrator In Training # 1 in serviced staff (pantry, housekeeping, laundry, full time/ agency/contract licensed nurses and certified nurse assistants) for Madison Inn on Policy J530-55 (Injuries, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property or Exploitation of Resident). 5. SA validated through record review, sign in-sheets, and interview RN/Admin that on July 20, 2021, at 4:00pm JNH Nurse Administrator developed an emergency Contract and Agency Licensed Competency Checklist to ensure nurses remain aware of the Mississippi State Hospital policy and procedures, physician, and DON's phone numbers for notification of falls, incidents, accidents, incorrect narcotic count, and other unusual occurrences. To also ensure the nurse comply to the facility policies and procedures on Abuse, Neglect, Exploitation, Misappropriation of Resident items, notification of abuse and neglect, Orientation to service area, Review of Medication and treatment records, [CONDITION(S)] Care, Feeding Tube administration, Following Medication administration policy and procedure, Care plan policy and procedure, and following physician orders. 6. SA validated through record review, sign in sheets, and interview with DON #1 and AIT that on July 22, 2021, at 12:30pm JNH Nurse Administrator will begin in-servicing all nursing staff, Director of Nursing, Director of Staffing on these policies and procedures: Medication Administration, [CONDITION(S)] care, Following the Care plan, Abuse and Neglect, Notification of DON, or DON on call for medication concerns such as medication errors, incorrect narcotic count, Resident Rights for Health and safety, and Chain of Notification for Staffing Concerns. No staff will be allowed to work until Inservice is completed. On 7/22/2021 at 1:30p.m. Contract and Agency Licensed Competency Checklist started and will be ongoing for new contract and agency staff. The SA validated on 07/24/2021, that all as of 7/22/21 all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on 07/23/2021, prior to exit.

Based on staff interview, record review, and facility policy review, the facility failed to implement care plan interventions related to medication administration, Percutaneous Endoscopic Gastrostomy (PEG) tube feedings, monitoring, and treatments for eight (8) of 15 residents care plans reviewed from the 3-11 shift on 7/12/21 through 6:00 AM on 7/13/21. Residents #1, #2, #3, #4, #5, #6, #7, and #8. The facility's failure to implement care plans, placed the residents at risk, and in a situation which was likely to cause injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) which began on 7/12/21 when the facility failed to provide a licensed nurse to implement care plans resulted in residents not receiving necessary services and treatments. On 7/21/21 at 7:00 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and provided the facility with the IJ template. The facility submitted an acceptable Removal Plan on 7/22/21 at 5:16 PM, in which the facility alleged all corrective actions to remove the IJ were completed on 7/22/21 and the and the IJ removed as of 7/23/21. The SA validated the Removal Plan on 7/24/21 and determined the IJ was removed on 7/23/21, prior to exit. Therefore, the scope and severity for CFR(s)483.21(b)(1)-Develop/Implement Comprehensive Care Plan (F656), was lowered from a K to an E while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Finding include: Review of facility policy titled, Standard of Care, revised May 2017, revealed .2. Policy. The Lippincott manual of Nursing Procedures is the designated nursing reference manual for clinical practice .Care Plan Preparation . A nursing care plan serves as a database for planning assignments, giving change-of-shift reports, conferring with the practioner or other members of the health care team, planning patient discharge, and documenting patient care. In addition, the care plan can be used as a management tool to determine staffing needs and assignments. Record review of the facility Investigative Findings dated 7/13/21, BUILDING 34 POSSIBLE NEGLECTS OF MULTIPLE RESIDENTS, revealed that on, 7/13/21, the Administrator advised the Department of Safety & Investigative Services that on 7/12/21, the B-shift nurse for the downstairs unit on B34 tested Covid + and was sent home. It was determined that attempts were made to get nurse coverage for the unit; however, no replacement nurse came for B shift. An agency nurse came at midnight for C-shift, but refused to accept the assignment and left. Therefore, there was no nurse for the downstairs unit on B34 for C shift either . The facility failed to provide sufficient licensed nursing staff for the downstairs' unit of B34 from 6:00 PM - 6:00 AM on 7/13/21. Therefore, neglect by the facility is substantiated. Please do know that each of the Residents on the unit was assessed by (Formal Name of Physician) of the morning of 7/13/21 and none of the residents appear to have suffered an adverse effect as a result of this insufficiency . On 7/21/21 at 10:00 AM, in an interview with Registered Nurse (RN) #1 revealed when the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/12/21 from 6:00 PM through 7/13/21 at 6:00 AM the care plans where not followed on 1st floor Building 34, because there was no scheduled nurse. On 7/21/21 at 1:13 PM, in an interview with the Director of Nurse (DON) #1 revealed the staff should follow the care plans on the residents to provide safety and compliance. On 7/12/21 from 6:00 PM until 07/13/21 at 6:00 AM, the care plans were not followed. No nurse was present on the 1st floor Building 34 to follow care plans. On 7/21/21 at 1:21 PM, in an interview with Registered Nurse Administrator (RN/NS-Admin) revealed on 7/12/21 from 6:00 AM until 7/13/21 at 6:00 AM, the care plans on residents that required medications and/or treatments where not followed because no license nurse was present on 1st floor Building 34. Resident #1 Record review of Resident #1's Identification and Summary Sheet revealed Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Medication Chart revealed on 7/12/21 at 6:00 PM [MEDICATION(S)] 250 milligrams (mg) tablet take one (1) tablet by mouth twice a day, [MEDICATION(S)] 1000 mg tablet take one (1) tablet by mouth twice a day, and [MEDICATION(S)] 1 mg take one (1) tablet by mouth twice a day, was not initialed on the Medication Chart. Record review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Treatment Chart revealed on 7/12/21 on B shift (3 to 11) monitor every day for dehydration (dry mucous membranes, urine output, fever), monitor for side effects of [CONDITION(S)] medications, monitor for signs and symptoms of pain (facial grimaces, moaning, verbal) document every shift and document according to scale. On 7/12/21 on B shift (3-11) these were not initialed on the Treatment Chart. Record review of Resident's #1 Care Plan with a goal and target date of 8/5/21, revealed Behavior-diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The intervention's include [MEDICATION(S)] 1mg PO (by mouth) twice a day and [MEDICATION(S)] 250mg 1 tab (tablet) by mouth two (2) times a day (BID). Record review of Resident #1's Care Plan with a goal and target date of 8/5/21, revealed Potential for complications R/T (related to) Diabetes with the intervention of [MEDICATION(S)] 1000mg 1 tab PO BID. Record review of Resident #1's Care Plan with a goal and target date of 8/5/21, revealed Risk for Dehydration related to dependence on staff for hydration with interventions to assess daily for S/S (signs/symptoms) of dehydration, (tenting of skin, increased thirst, dry mucous membranes, fever, etc.). Record review of Resident #1's Care Plan with a goal and target date of 8/5/21, revealed Potential for SE (side effects) of [CONDITION(S)] medication with interventions to monitor for S/S of side effects daily, [CONDITION(S)], dizziness, faintness, rapid heart rate on rising from sitting/lying position. Record review of Resident #1's annual Minimum Data Set (MDS) dated [DATE], indicated a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #1 was cognitively intact. Resident #2 Record review of Resident #2's Identification and Summary Sheet revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Medication Chart revealed on 7/12/21 at 6:00 PM [MEDICATION(S)] 50 mg tablet take one (1) tablet per tube twice a day, [MEDICATION(S)] 5mg/5ml give 10ml (10mg) per tube every 8 hours, Vitamin C 500mg tablet take 1 tablet per tube twice a day, Arginard 1 packet (pk) via PEG tube BID (twice a day), and Promod 30cc per PEG tube BID, were not initialed. On 7/12/21 at 6:00 PM and 7/13/21 at 12:00 AM, [MEDICATION(S)] 10mg tablet take 1 tablet per tube every 6 hours, [MEDICATION(S)] 20mg tablet take 2 tablets per tube every 6 hours, Iprat-Albut 0.5-3(2.5) mg/3ml compare to [MEDICATION(S)] 2.5-0.5mg/3ml use 1 vial in nebulizer every 6 hours, [MEDICATION(S)] DM syrup (regular) give 10ml per tube every 6 hours, [MEDICATION(S)] Sodium 100mg capsule take 1 capsule twice a day, was not initialed. At 10:00 PM on 7/12/21, Saline nebulization 3ml nebulized every 8 hours to thin secretions, use indefinitely, was not initialed. Record review of Resident #2's Tube Feeding Record revealed on 7/12/21 on the 3-11 shift initials with a line drawn through for Label bag/bottle with feeding type, name, date, time and initials, Flush with water (Record amount per flush) 60cc's/hr. Flush with 30cc's of water before and after each medication administered, Check for residuals & placement prior to medication and feedings by (Aspiration only), and Keep head of bed elevated 30 to 45 degrees and Check breath sounds for rales, rhonchi, or congestion every shift. Record review of Resident #2 Treatment Chart revealed on 7/12/21, the following treatment was not initialed for Monitor Q (every) day for dehydration. The following treatments had a diagonal line drawn through the signature box for B and C shifts, Ensure the left ear is positioned with no pressure at all times, PEG site care q (every) shift & PRN, clean with normal saline (NS), apply [MEDICATION(S)] and cover with drain sponge, [CONDITION(S)] care q shift and PRN, clean with NS, apply drain sponge, O2 at 5 liters with 28% humidified air via [CONDITION(S)] collar, Place brief under resident, do not try to pull brief between legs, change q 2 hours and PRN. The following treatments had a diagonal line drawn through the signature box for the B shift, [MEDICATION(S)] to right foot BID indefinitely, mouth care q shift and PRN with [MEDICATION(S)] swabs, All [CONDITION(S)], O2, nebulizer tubing checked q shift at the beginning and end of the shift to ensure its working properly, turn q 1 hour side to side, do not turn on back, Monitor for s/s of pain, The following had a diagonal line through the signature box for C shift Change suction canister and tubing daily and PRN. Record review of Resident's #2 Care Plan with a goal and target date of 9/30/21, revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] @60cc/hour. Record review of Resident's #2 Care Plan with a goal and target date of 9/30/21, revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident's #2 Care Plan with a goal and target date of 9/30/21, revealed Increased risk for aspiration d/t (due to) use of feeding tube with interventions HOB elevated 30-45 degrees at all times, check placement and residual Q (every) 4 hours (hold feeding 1 hour if residual is >100cc's, and nurse to provide [MEDICATION(S)] 2.0 @ (at) 55cc/hr with 60 cc hr H2O flush. Record review of Resident's #2 Care Plan with a goal and target date of 9/30/21, revealed high risk for dehydration r/t dependent on nurse to provide fluids via feeding tube, use of [MEDICATION(S)] with interventions assess daily for s/s of dehydration (increased thirst, tenting of skin, dry mucous membranes, fever, decreased urination), and nurse to provide H2O flush @ 60cc/hr. Record review of Resident's #2 Care Plan with a goal and target date of 9/30/21, revealed increased risk for ineffective airway clearance and high risk for infection R/T [CONDITION(S)] with interventions provide nebulizer TX as ordered, [CONDITION(S)] care every shift and prn clean with normal saline/apply dressing, [MEDICATION(S)] 2.3-0.5 mg/3 ml use 1 vial in nebulizer every 6 hours, Robitussin DM syrup give 10 cc per tube every 6 hours, and provide O2 at 5L with 28% humidified air via [CONDITION(S)] collar. Record review of Resident's #2 Care Plan with a goal and target date of 9/30/21, revealed resident incontinent of bowel, H/O (history of) [CONDITION(S)]'s wears adult briefs with interventions monitor for s/s of dysuria and flank pain. Record review of Resident's #2 Care Plan with a goal and target date of 9/30/21, revealed high risk for constipation with interventions [MEDICATION(S)] 100 mg 1 cap per tube twice daily and nurse to provide H2) flush @ 60 cc/hr. Record review of Resident's #2 Care Plan with a goal and target date of 9/30/21, revealed increase risk for pressure ulcers with interventions [MEDICATION(S)] cream to buttocks q shift, right foot pillow at all times, turn/re-position every 2 hours/prn, thread 4x4's between fingers to right/left hands and right/left wrist BID, Vitamin C 500 mg 1 tablet per tube twice a day, [MEDICATION(S)] Ointment to right food BID, [MEDICATION(S)] 1 pk per peg tube BID, Promod 30 cc per peg tube BID, and nurse to provide H2O flush @ 60 cc/hr. Record review of Resident's #2 Care Plan with a goal and target date of 9/30/21, revealed dental needs will met with interventions oral care q shift and prn. Record review of Resident's #2 Care Plan with a goal and target date of 9/30/21, revealed resident totally dependent on staff for ADL with interventions turn and reposition every 2 hours/prn, keep [CONDITION(S)] clean at all times, [MEDICATION(S)] 10 mg 1 tab per tube 4 times a day, [MEDICATION(S)] 20 mg 2 tabs per tube 4 times a day, nurse to provide [MEDICATION(S)] @ 55 cc/hr with 50 cc/hr H20 flush, incontinent care q 2 hours/prn, and provide oral care q shift/prn. Record review of Resident #2's quarterly MDS dated [DATE] Section C, indicated BIMS summary score 00, which indicated severely impaired cognitive status. Resident #3 Record review of Resident #3's Identification and Summary Sheet revealed he was admitted to the facility on [DATE], with diagnose including status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] & 6PM, [MEDICATION(S)] 100 mg Kapseal disp as [MEDICATION(S)] sod Ext 100 mg CA take 1 capsule PO every 8AM, 1PM, and 6PM, and [MEDICATION(S)] 80 mg tablet disp as [MEDICATION(S)] 80 mg tablet take 1 tablet PO at bedtime. Record review of Resident #3's Medication Chart on 7/12/21 at 6:00 PM revealed a diagonal line drawn through the signature box for [MEDICATION(S)] 20mg tablet take 1 tablet PO twice a day, [MEDICATION(S)] SOD 500mg tab compare to [MEDICATION(S)] 500 mg 3 tablets PO at bedtime, [MEDICATION(S)] SOD 250mg tablet compare to [MEDICATION(S)] 250 mg take 1 tablet by mouth at bedtime, Polyethylene [MEDICATION(S)] Powder compare to [MEDICATION(S)] Powder dissolve & take 17 grams in fluid P daily at 6 PM, [MEDICATION(S)] 50mg Ingatab compare to [MEDICATION(S)] 50 MG 1 tablet at 6:00 PM and [MEDICATION(S)] SOD EXT 100mg capsule compare to [MEDICATION(S)] 100 MG one (1) capsule by mouth at 6:00 PM, and [MEDICATION(S)] 80mg tablet compare to [MEDICATION(S)] 80mg take 1 tablet PO at bedtime. Record review of Resident #3's Treatment Chart revealed on 7/12/21, a diagonal line drawn through the signature box for Monitor Q (every) day for dehydration , Monitor for [CONDITION(S)] activity, notify MD if present and Monitor for s/s (signs/symptoms) of pain (facial grimaces, moaning, verbal etc.) every shift and document according to scale if pain is noted document intervention and outcome in nurses note. Record review of Resident #3's Care Plan with a goal and target date of 9/30/21, revealed diagnosis [CONDITION(S)] with intervention to give [MEDICATION(S)] 80 mg 1 tablet PO at bedtime. Record review of Resident #3's Care Plan with a goal and target date of 9/30/21, revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's Care Plan with a goal and target date of 9/30/21, revealed potential for alteration in comfort r/t (related to) lumbar spondylosis with intervention to assess quality and location of pain. Record review of Resident #3's Care Plan with a goal and target date of 9/30/21, Care Plan revealed diagnosis [CONDITION(S)] with interventions to monitor and document onset, duration, and post ictal response, document seizures on [CONDITION(S)] chart, [MEDICATION(S)] 50 mg 1 PO every 8 AM and 6 PM, [MEDICATION(S)] 100 mg 1 cap PO every 8 AM, 1 PM, 6 PM, [MEDICATION(S)] 500 mg 2 PO in the morning/noon and 3 tabs at bedtime, and [MEDICATION(S)] 250 mg 1 PO at bedtime. Record review of Resident's #3 Care Plan with a goal and target date of 9/30/21, revealed risk for constipation with interventions [MEDICATION(S)] 100 mg 2 caps po daily and [MEDICATION(S)] powder-dissolve take 17 grams in fluid PO daily. Record review of Resident's #3 Care Plan with a goal and target date of 9/30/21, revealed risk for dehydration with interventions to assess for dehydration every day. Record review of Resident's #3 Care Plan revealed resident is incontinent of bladder with interventions notify MD of any s/s of [CONDITION(S)], burning upon urination and flank pain. Record review of Resident #3's quarterly MDS dated [DATE], Section C, revealed a BIMS summary score of 09 which indicated moderate cognitive impairment. Resident #4 Record review of Resident # 4's Identification and Summary Sheet revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's Physicians Orders, dated 4/27/21, revealed, Diet, Diabetasource AC @ 65 cc/hr w/40 cc/hr H2O flus, check placement & residuals Q 4 hours, hold tube feedings if gastric residual >100 cc & then recheck in 1 hr. Flush PEG w/30 cc of H2O before & after meds and give 5-10 cc H2O between meds. Humidified oxygen via [CONDITION(S)] collar 28% (5LPM). [CONDITION(S)] care Q shift & prn, clean w/normal saline and apply dressing, wash hands daily use B hand rolls at all times, and PEG site care q shift & prn, clean PEG w/NS, blot dry, apply [MEDICATION(S)], then drain dressing. Record review of Resident #4's Medication Chart revealed [MEDICATION(S)] Sulfate 220mg/5ml [MEDICATION(S)] give 220mg (5ml) per tube 2 times a day, [MEDICATION(S)] 500 mg tablets take 1 tablet per PEG 2 times a day, [MEDICATION(S)] 40 mg tablet take 1 tablet per tube at bedtime, [MEDICATION(S)] Mag Dr 20 Mg C compared to [MEDICATION(S)] Dr 20 mg capsule opening capsule & mix with 50 ml water give per tube 2 times a day, Vitamin C 500 mg tablet take 1 tablet per tube twice a day, and Tamsulosin HCL 0.4 mg capsule give 1 capsule per tube twice daily, not initialed on 7/12/21 at 6:00 PM. Record review of Resident #4's Medication Chart revealed Iprat-Albut 0.5-3 (2.5) MG/3 comp use 1 vial in nebulizer every 6 hours and [MEDICATION(S)] 100 mg/5ml give 10 cc per tube every 6 hours not initialed on 7/12/21 at 6:00 PM and 7/13/21 at 12:00 AM. Record review of Resident #4's Medication Chart revealed [MEDICATION(S)] 5mg/5ml [NAME] compare to [MEDICATION(S)] 5mg/5ml syrup give 5 ml per tube every 8 hours and Sodium Chloride 0.9 % irrigation use 30 cc via nebulizer every 8 hours, not initialed on 7/12/21 at 10:00 PM. Record review of Resident #4's Treatment Chart revealed [CONDITION(S)] care q shift and prn clean [CONDITION(S)] site with NS blot dry apply drainage gauze, keep HOB elevated 30-45 degrees q shift, clean PEG site with NS apply antiseptic cover with drain sponge q shift, Hydrophore to heels truck and extremities BID, suction q shift and prn with 14 FR suction catheter, O2 at 5L with 28% humidified air via [CONDITION(S)] collar, monitor q shift for dehydration- dry [MEDICATION(S)] membranes, decreased urine output, fever, was hands daily use bilateral hand rolls at all times, place pillows under calves to float heels at all times, and monitor for S/s of pain (facial grimaces moaning, verbal etc.) every shift and document according to scale, not initialed on 7/12/21 B shift. Record review Resident #4's Care Plan with a goal and target date of 8/26/21, revealed diagnosis [CONDITION(S)] with intervention to give [MEDICATION(S)] 40 mg 1 tab per Peg tube at bedtime. Record review Resident #4's Care Plan with a goal and target date of 8/26/21, revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's Care Plan with a goal and target date of 8/26/21, revealed diagnosis [CONDITION(S)] with interventions [MEDICATION(S)] Sulf 220 mg/5ml elix- give 220 mg (5ml) per tube 2 times a day and Vitamin C 500 mg 1 per Peg tube BID. Record review of Resident #4's Care Plan with a goal and target date of 8/26/21, revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's Care Plan with a goal and target date of 8/26/21, revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's Care Plan with a goal and target date of 8/26/21, revealed resident totally dependent on staff to provide ADL with intervention diet of Diabetasource AC @ 65 cc/hour with 40 cc/hour flush. Record review of Resident #4's Care Plan with a goal and target date of 8/26/21, revealed resident incontinent of bladder with interventions notify MD of any s/s of [CONDITION(S)], burning upon urination and flank pain. Record review of Resident #4 's Care Plan with a goal and target date of 8/26/21, revealed high risk for dehydration with intervention to assess daily for s/s dehydration. Record review of Resident #4's Care Plan with a goal and target date of 8/26/21, revealed increased risk for ineffective airway clearance with interventions to provide humidified O2 at 28% via [CONDITION(S)] collar, suction resident as ordered with 14 FR cath, [MEDICATION(S)] 2.5-0.5 MG/3ML solution use 1 vial in nebulizer every 6 hours, [MEDICATION(S)] 100 mg/3 ml give 10 ccl per tube every 6 hours, tach care every shift/prn clean wit normal saline and apply dressing, and 3 ml sodium chloride via nebulizer every 8 hours indefinitely. Record review of Resident #4's Care Plan with a goal and target date of 8/26/21, revealed potential for complication R/T Diabetes with interventions [MEDICATION(S)] 500 mg 1 tab per Peg tube BID. Record review of Resident #4's annual MDS dated [DATE], Section C indicated BIMS summary score 00, which indicated severely impaired cognitive status. Resident #5 Record review of Resident #5's Identification and Summary Sheet revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's Medication Chart revealed [MEDICATION(S)] 250 MG/5 ml give 500 mg (10 ml) PO three times daily, [MEDICATION(S)] 25 mg tablet comp to [MEDICATION(S)] 25 mg tablet take one tablet PO twice daily, [MEDICATION(S)] 40 mg tablet take 1 tablet PO at bedtime, give med with boost 1 container PO, [MEDICATION(S)] 1 mg PO BID, and [MEDICATION(S)] 200 mg PO at 6PM each day not given on 7/12/21 at 6:00 PM. [MEDICATION(S)] 25 mg tablet take 1 tablet PO every 8 hours, not initialed on 7/12/21 at 10:00 PM. Record review of Resident #5's Treatment Chart revealed monitor q day for dehydration (dry mucous membranes, urine output, ever), monitor for side effects of [CONDITION(S)] medication, and Lac Hydrin 12% lotion to feet q evening, and monitor for S/S of pain (facial grimaces, moaning, verbal etc.) every shift and document according to scale, not initialed on 7/12/21 B shift. Record review of Resident #5's Care Plan with a goal and target date of 10/21/21, revealed Behavior with interventions [MEDICATION(S)] 1 mg 1 tab PO BID and [MEDICATION(S)] 200 mg 1 tab PO BID. Record review of Resident #5's Care Plan with a goal and target date of 10/21/21, revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's Care Plan with a goal and target date of 10/21/21, revealed diagnosis [CONDITION(S)] with intervention to give [MEDICATION(S)] 250 mg/5ml 500 mg (10 ml) PO three times daily. Record review of Resident #5's Care Plan with a goal and target date of 10/21/21, revealed potential for side effects of [CONDITION(S)] medication with intervention to monitor or s/s of side effects-hypertension, dizziness, faintness, rapid heart rate on rising from sitting/lying position. Record review of Resident's #5 Care Plan with a goal and target date of 10/21/21, revealed potential for alteration in comfort with intervention assess quality and location of pain. Record review of Resident #5's Care Plan with a goal and target date of 10/21/21, revealed Dehydration with interventions to assess for dehydration every day. Record review of Resident #5's Care Plan with a goal and target date of 10/21/21, revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's Care Plan with a goal and target date of 10/21/21, revealed diagnosis [CONDITION(S)] with interventions to give [MEDICATION(S)] 40 mg 1 tab PO every HS. Review of Resident #5's quarterly MDS dated [DATE], indicated BIMS summary score of 00, which indicated severely impaired cognitive status. Resident #6 Record review of Resident #6's Identification and Summary Sheet revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's Medication Chart on 7/12/21 at 6:00 PM revealed a diagonal line drawn through the signature box for [MEDICATION(S)] 125 mg springle compared to [MEDICATION(S)] 125 mg springle take 6 capsules PO twice daily, [MEDICATION(S)] 40 mg tablet take 1 tablet PO at bedtime, Oyster Cal D 500 mg tablet compared to Os-Cal 500 + D tablet take 1 tablet PO twice a day, [MEDICATION(S)] 10mg/5ml solution 5mg (2.5ml) PO give 10 mg (5ml) at bedtime, and [MEDICATION(S)] 0.5 mg tablet compared to [MEDICATION(S)] 0.5 mg tablet take 1 tablet PO at bedtime. Record review of Resident #6's Treatment Chart on 7/12/21 on B and C shift not initialed to monitor Q day for dehydration (dry mucous, membranes, urine output, fever), monitor for [CONDITION(S)] activity and monitor for s/s of pain (facial grimaces moaning, verbal etc.) every shift and document. Record review of Resident #6's Care Plan with a goal and target date of 8/12/21, revealed Behavior with interventions to [MEDICATION(S)] 0.5 mg 1 tab PO every HS and [MEDICATION(S)] Sprinkles 125 mg 6 caps PO BID. Record review of Resident #6's Care Plan with a goal and target date of 8/12/21, revealed diagnosis [CONDITION(S)] disorder with interventions monitor and document onset, duration and post ictal response, document [CONDITION(S)] on [CONDITION(S)] chart, and [MEDICATION(S)] Sprinkles 125 mg 6 caps PO BID. Record review of Resident #6's Care Plan with a goal and target date of 8/12/21, revealed [CONDITION(S)] with interventions [MEDICATION(S)] 40 mg 1 tab PO every HS. Record review of Resident #6's Care Plan with a goal and target date of 8/12/21, revealed potential for alteration in comfort with interventions assess quality and location of pain, Os-Cal 500 +D 1 tab PO BID and [MEDICATION(S)] 10mg/(5ml) at bedtime. Record review of Resident #6's Care Plan with a goal and target date of 8/12/21, revealed Dehydration with interventions to assess for dehydration every day. Record review of Resident #6's quarterly MDS dated [DATE] Section C, indicated BIMS summary score of 03, which indicated severely impaired cognitive status. Resident #7<

Based on record review, staff interview, and facility policy review, the facility failed to provide respiratory care to residents with tracheostomies (trachs) on the 1st floor, building 34 for two (2) of two (2) residents on the 3-11 shift on 7/12/21 until 6 AM on 7/13/21. Residents #2 and #4. The facility's failure to provide respiratory care and supervision resulted in two (2) residents not receiving proper [CONDITION(S)] care on the 3-11 shift on 7/12/21 until 6 AM on 7/13/21, placed these residents at risk and in a situation which was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 7/12/21 when the facility failed to provide a licensed nurse to perform [CONDITION(S)] care on two (2) residents. On 7/21/21 at 7:00 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the facility with the IJ Template. The facility submitted an acceptable Removal Plan on 7/22/21 at 5:16 PM, in which the facility alleged all corrective actions to remove the IJ were completed on 7/22/21 and the IJ was removed as of 7/23/21. The SA validated the Removal Plan on 7/24/21 and determined the IJ was removed on 7/23/21, prior to exit. Therefore, the scope and severity for CFR (s) § 483.25(i) Respiratory care, including [CONDITION(S)] care and tracheal suctioning (695), was lowered from a L to an F while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Finding include: Review of facility policy titled, Standard of Care, revised May 2017, revealed, .2. POLICY. The Lippincott Manual of Nursing Procedures is the designated nursing reference manual for clinical practice . Record review of the Lippincott Manual of Nursing Procedures, seventh edition, revealed [CONDITION(S)] care, page 763, Change the dressing frequently when secretions begin to collect because a wet dressing with excaudate or secretions predisposes the patient to skin excoriation, breakdown, and infection. Complications- Secretions that collect under dressings can encourage skin excoriation and infection. Hardened [MEDICATION(S)] or a slipped cuff can occlude the cannula opening and obstruct the airway . Record review of the facility Investigative Findings dated 7/13/21, BUILDING 34 POSSIBLE NEGLECTS OF MULTIPLE RESIDENTS, revealed that on, 7/13/21, the Administrator advised the Department of Safety & Investigative Services that on 7/12/21, the B-shift nurse for the downstairs unit on B34 tested Covid + and was sent home. It was determined that attempts were made to get nurse coverage for the unit; however, no replacement nurse came for B shift. An agency nurse came at midnight for C-shift but refused to accept the assignment and left. Therefore, there was no nurse for the downstairs unit on B34 for C shift either . The facility failed to provide sufficient licensed nursing staff for the downstairs' unit of B34 from 6:00 PM - 6:00 AM on 7/13/21. Therefore, neglect by the facility is substantiated. Please do know that each of the Residents on the unit was assessed by (Formal Name of Physician) of the morning of 7/13/21 and none of the residents appear to have suffered an adverse effect as a result of this insufficiency . On 7/21/21 at 10:00 AM, in an interview with Registered Nurse (RN) #1 revealed there is only two residents on 1st floor that have tracheostomies and they both require [CONDITION(S)] care every shift and more frequently as needed. Since there was no nurse on 7/12/21 on the 3-11 shift through 6:00 AM on 7/13/21 neither one of them receive [CONDITION(S)] care. On 07/21/2021 at 1:13 PM, in an interview with Director of Nurses (DON) #1 revealed the staff should follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/21/21 at 1:21 PM, in an interview with Registered Nurse Administrator (RN/NS-Admin) revealed on 7/12/21 on the 3-11 shift until 7/13/21 at 6:00 AM both residents on 1st floor Building 34 did not receive [CONDITION(S)] care as prescribed by physician. There was not a nurse present on 1st floor Building 34. The treatments were not completed on either resident. Either resident could have had a [CONDITION(S)] plug which would have been harmful. Resident #2 Record review of Resident #2's Identification and Summary Sheet revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Medication Chart revealed on 7/12/21 at 6:00 PM Iprat-Albut 0.5-3(2.5) (milligrams/milliliter) mg/3ml compared to [MEDICATION(S)] 2.5-0.5mg/3ml use 1 vial in nebulizer every 6 hours, [MEDICATION(S)] DM syrup (regular) give 10ml per tube every 6 hours, was not initialed. At 10:00 PM on 7/12/21, Saline nebulization 3ml nebulized every 8 hours to thin secretions, use indefinitely, was not initialed. Record review of Resident #2 Treatment Chart revealed on 7/12/21, the following treatment was not initialed for the following treatments and had a diagonal line drawn through the signature box for B and C shifts, [CONDITION(S)] care q (every) shift and PRN (as needed), clean with NS(normal saline), apply drain sponge, and O2(Oxygen) at 5 liters with 28% humidified air via [CONDITION(S)] collar. The following treatments had a diagonal line drawn through the signature box for the B shift, All [CONDITION(S)], O2, nebulizer tubing checked q shift at the beginning and end of the shift to ensure its working properly. The following had a diagonal line through the signature box for C shift Change suction canister and tubing daily and PRN. Record review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's quarterly MDS dated [DATE] Section C, indicated Brief Interview for Mental Status (BIMS) summary score 00, which indicated severely impaired cognitive status. Resident #4 Record review of Resident # 4's Identification and Summary Sheet revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's Physicians Orders, dated 4/27/21, revealed, Humidified oxygen via [CONDITION(S)] collar 28% (5LPM). [CONDITION(S)] care Q shift & prn, clean with normal saline and apply dressing. Record review of Resident #4's Medication Chart revealed Iprat-Albut 0.5-3 (2.5) MG/3 comp use 1 vial in nebulizer every 6 hours and [MEDICATION(S)] 100 mg/5ml give 10 cc per tube every 6 hours not initialed on 7/12/21 at 6:00 PM and 7/13/21 at 12:00 AM. Record review of Resident #4's Medication Chart revealed Sodium Chloride 0.9 % irrigation use 30 cc via nebulizer every 8 hours, not initialed on 7/12/21 at 10:00 PM. Record review of Resident #4's Treatment Chart revealed [CONDITION(S)] care q shift and prn clean [CONDITION(S)] site with NS blot dry apply drainage gauze, suction q shift and prn with 14 FR(French) suction catheter, and O2 at 5L with 28% humidified air via [CONDITION(S)] collar, not initialed on 7/12/21 B shift. Record review of Resident #4 annual MDS dated [DATE], Section C indicated BIMS summary score 00, which indicated severely impaired cognitive status. The facility submitted an acceptable Removal Plan on 7/22/21 for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: In response to the Immediate Jeopardy (IJ) template provided to the Administrator cited on July 21,2021 at 7:00 p.m., the following is a summary of the event and the actions taken by the facility to remove the Immediate Jeopardy. Brief Summary Madison Inn building 34 had insufficient licensed nursing staff on 7/12/2021 from 6:00 p.m. to 6:00 a.m. which gives us neglect of Residents #1, #2, #3, #4, and #5 on the first floor of building 34. Medications and treatments were missed for Residents #1, #2, #3, #4, and #5 during this time frame. [CONDITION(S)] care was not provided on Residents #2 and #4 during the time frame. The following corrective actions were taken for Residents #1, #2, #3, #4, and #5 affected by the insufficient licensed nursing staff and other facility Residents who could be potentially affected by insufficient licensed nursing staff in the future. 1.On July 13, 2021, at 6:15am RN#1 assessed Residents #1, #2, #3, #4, and #5 and gave 6 am medications and treatments to Residents #1, #2, #3, #4, and #5 and no negative outcomes or harm noted. RN#1 notified the attending physician that building 34 had insufficient licensed nursing staff on 7/12/2021 from 6:00 p.m. to 6:00 a.m. on 7/13/2021, the first floor. Medications and treatments were missed for Residents #1, #2, #3, #4, and #5 during this time frame. [CONDITION(S)] care was not provided on Residents #2 and #4 during the time frame. On 7/13/2021 at 9:00 a.m. attending physician assessed Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15 and no injuries or harm noted. 2.On July 14, 2021, at 3:30pm until 4:30pm [NAME] Nursing Home Nurse Administrator counseled the Agency LPN scheduled and declined to work 11-7 shift on 7/13/21and Contract RN working on building 34 on 3-11 and 11-7 shifts on 7/12/21 and 7/13/21 on the policy and procedure of notifying the on-call Administrator and Director of Nursing as needed for unintended occurrences. 3.On July 15, 2021, at 01:30 p.m., a Quality Assurance meeting was conducted with [NAME] Nursing Home Director, Chief Medical Doctor, Safety Investigative Services,[NAME] Nursing Administrator, Director of Nursing #1 and Director of Nursing #2, Nurse Staffing Director, Administrator in Training #1 and Administrator in Training #2, Service Outcome Director to discuss and determine corrective actions for further incidents of this magnitude. Corrective actions discussed were to inform resident's representative of incident on 7/12/21 and 7/13/21. Educate staff on notifying leadership through proper communication (campus switchboard). Inservice staff (agency/contract) on Injuries, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property or Exploitation of Resident POL J530-55. Establishing protocol of nurse's responsibility and Chain of Notification for Staffing Concerns. Contracting additional staff for Covid-19 buildings. 4.On July 16, 2021, at 7:00am Emergency Covid-19 staffing contract executed to obtain more licensed agency staff to work on units with Covid-19 cases. Social Worker#1 called Residents #1, #2, #3, #4, and #5 representative of the incident and documented in resident's medical chart. Administrator In Training # 1 in serviced staff (pantry, housekeeping, laundry, full time/ agency/contract licensed nurses and certified nurse assistants) for Madison Inn on Policy J530-55 (Injuries, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property or Exploitation of Resident). 5.On July 20, 2021, at 4:00pm JNH Nurse Administrator developed an emergency Contract and Agency Licensed Competency Checklist to ensure nurses remain aware of the Mississippi State Hospital policy and procedures, physician, and DON's phone numbers for notification of falls, incidents, accidents, incorrect narcotic count, and other unusual occurrences. To also ensure the nurse comply to the facility policies and procedures on Abuse, Neglect, Exploitation, Misappropriation of Resident items, notification of abuse and neglect, Orientation to service area, Review of Medication and treatment records, [CONDITION(S)] Care, Feeding Tube administration, Following Medication administration policy and procedure, Care plan policy and procedure, and following physician orders. 6.On July 22, 2021, at 12:30pm JNH Nurse Administrator will begin in-servicing all nursing staff, Director of Nursing, Director of Staffing on these policies and procedures: Medication Administration, [CONDITION(S)] care, Following the Care plan, Abuse and Neglect, Notification of DON, or DON on call for medication concerns such as medication errors, incorrect narcotic count, Resident Rights for Health and safety, and Chain of Notification for Staffing Concerns. No staff will be allowed to work until Inservice is completed. On 7/22/2021 at 1:30p.m. Contract and Agency Licensed Competency Checklist started and will be ongoing for new contract and agency staff. 7.The facility will be in compliance 7/22/2021 at 4:00pm. On 7/24/21, the SA validated the facility's Removal Plan by staff interviews, record reviews, and review of in-service sheets. The SA verified the facility had implemented the following measures to remove the IJ: 1. SA validated through record review and interview with RN#1 that on July 13, 2021, at 6:15 AM RN#1 assessed Residents #1, #2, #3, #4, #5, #7, and #8 and gave 6 AM medications and treatments to Residents #1, #2, #3, #4, #5, #7, and #8 and no negative outcomes or harm noted. RN#1 notified the attending physician that building 34 had insufficient licensed nursing staff on 7/12/2021 from 6:00 p.m. to 6:00 AM. on 7/13/2021, the first floor. Medications and treatments were missed for Residents #1, #2, #3, #4, #5, #7, and #8 during this time frame. [CONDITION(S)] care was not provided on Residents #2 and #4 during the time frame. On 7/13/2021 at 9:00 a.m. attending physician assessed Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15 and no injuries or harm noted. 2. SA validated through record review and interview with the RN/Admin that on July 14, 2021, at 3:30 PM until 4:30 PM [NAME] Nursing Home Nurse Administrator counseled the Agency LPN scheduled and declined to work 11-7 shift on 7/13/21and Contract RN working on building 34 on 3-11 and 11-7 shifts on 7/12/21 and 7/13/21 on the policy and procedure of notifying the on-call Administrator and Director of Nursing as needed for unintended occurrences. 3. SA validated through record review and interview with the Administrator, Administrator in Training (AIT) and RN/Admin that on July 15, 2021, at 01:30 PM., a Quality Assurance meeting was conducted with [NAME] Nursing Home Director, Chief Medical Doctor, Safety Investigative Services, [NAME] Nursing Administrator, Director of Nursing #1 and Director of Nursing #2, Nurse Staffing Director, Administrator in Training #1 and Administrator in Training #2, Service Outcome Director to discuss and determine corrective actions for further incidents of this magnitude. Corrective actions discussed were to inform resident's representative of incident on 7/12/21 and 7/13/21. Educate staff on notifying leadership through proper communication (campus switchboard). Inservice staff (agency/contract) on Injuries, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property or Exploitation of Resident POL J530-55. Establishing protocol of nurse's responsibility and Chain of Notification for Staffing Concerns. Contracting additional staff for Covid-19 buildings. 4. SA validated through record review and interview with RN/Admin, Social Worker, and AIT that on July 16, 2021, at 7:00 PM Emergency Covid-19 staffing contract executed to obtain more licensed agency staff to work on units with Covid-19 cases. Social Worker#1 called Residents #1, #2, #3, #4, #5, #7, and #8 representative of the incident and documented in resident's medical chart. Administrator In Training # 1 in serviced staff (pantry, housekeeping, laundry, full time/ agency/contract licensed nurses and certified nurse assistants) for Madison Inn on Policy J530-55 (Injuries, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property or Exploitation of Resident). 5. SA validated through record review, sign in-sheets, and interview RN/Admin that on July 20, 2021, at 4:00 PM JNH Nurse Administrator developed an emergency Contract and Agency Licensed Competency Checklist to ensure nurses remain aware of the Mississippi State Hospital policy and procedures, physician, and DON's phone numbers for notification of falls, incidents, accidents, incorrect narcotic count, and other unusual occurrences. To also ensure the nurse comply to the facility policies and procedures on Abuse, Neglect, Exploitation, Misappropriation of Resident items, notification of abuse and neglect, Orientation to service area, Review of Medication and treatment records, [CONDITION(S)] Care, Feeding Tube administration, Following Medication administration policy and procedure, Care plan policy and procedure, and following physician orders. 6. SA validated through record review, sign in sheets, and interview with DON #1 and AIT that on July 22, 2021, at 12:30 PM JNH Nurse Administrator will begin in-servicing all nursing staff, Director of Nursing, Director of Staffing on these policies and procedures: Medication Administration, [CONDITION(S)] care, Following the Care plan, Abuse and Neglect, Notification of DON, or DON on call for medication concerns such as medication errors, incorrect narcotic count, Resident Rights for Health and safety, and Chain of Notification for Staffing Concerns. No staff will be allowed to work until Inservice is completed. On 7/22/2021 at 1:30p.m. Contract and Agency Licensed Competency Checklist started and will be ongoing for new contract and agency staff. The SA validated on 07/24/2021, all corrective actions had been taken by the facility to remove the IJ as of 7/22/21 and the IJ was removed on 07/23/2021, prior to exit.

Based on staff interview, facility policy review and record review the facility failed to maintain continuous Percutaneous Endoscopic Gastrostomy (PEG) feedings, resulting in missed PEG tube feedings for two (2) of three (3) sampled residents reviewed for PEG feedings. Resident #2 and #8. Findings include: Review of facility policy titled, Standard of Care, revised May 2017, revealed, .2. POLICY. The Lippincott Manual of Nursing Procedures is the designated nursing reference manual for clinical practice . Record review of the Lippincott Manual of Nursing Procedures, Seventh Edition, page 767, revealed, Transabdominal Tube Feeding and Care .Nursing care for patients receiving intermittent enteral feeding through a PEG or Percuaneous Endoscopic Jejunostomy (PEJ) tube includes providing skin care at the tube site, maintaining the feeding tube, administering feedings, monitoring the patients response to tube feedings, adjusting the feeding schedule . On 7/20/21 at 6:10 PM, in an interview with Registered Nurse (RN) #1 revealed when arrived on the unit on 7/13/21 at 6:00 AM all three (3) feedings were stopped because there was no water in the bags. When asked when the pumps may have stopped or when the bags were hung, she stated, I don't know. On 7/20/21 at 6:40 PM in an interview with RN/Administrator (RN/Admin) revealed on 7/12/21 from approximately 6:00 PM till 7/13/21 6:00 AM there was no license nurse on the 1st floor resulting in three (3) residents did not receive their complete PEG tubes feedings. On 7/21/21 at 9:30 AM, in an interview with the Administrator (Adm) revealed that on 7/12/21, 3-11 shift throught 6:00 AM on 7/13/21, the facility failed to provide sufficient nursing staff which resulted in three (3) residents not receiving their prescribed PEG tube feedings. Resident # 2: Record review of Resident #2 's Identification and Summary Sheet revealed admitted to the facility on [DATE] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Minimum Data Set (MDS) dated [DATE], quarterly, indicated a Brief Interview for Mental Status (BIMS) summary score of 00, which indicated that the resident was severely cognitively impaired Record review of Resident #2 Tube Feeding Record revealed on 7/12/21 on 3-11 shift a line was drawn through the box for Label bag/bottle with feeding type, name, date, time and initials, Flush with water (Reocrd amounty per flush) 60cc's/hour, Flush with 30 cc's of water before and after each medication administered, Check for residuals and placement prior to medication and feedings by Aspiration only) and Keep head of bed elevated 30 to 45 degrees and Check breath sounds for rales, rhonchi, or congestion every shiftf. Resident #8 Record review of Resident #8 Identification and Summary Sheet revealed the resident was admitted to facility on 4/18/16 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's Tube Feeding Record revealed on 7/12/21 on the 3-11 and 11-7 shifts, there were initials in each box for Label bag/bottle with feeding type, name, date, time and initials (unless Bolus) Isosurce 1.5 at 50 cc/hr, Flush with water (Record amount per flush) 55 cc's/hr. Flush with 30 cc's of water before and after each medication administered, Check for residuals & placement prior to medication and feedings by (Aspiration only) and Keep head of bed elevated 30 to 45 degrees and check breath sounds for rales, rhonchi, or congestion every shift. Record review of Resident #8 MDS dated [DATE], quarterly, indicated BIMS 00.

Based on observation, staff interview, record review, and facility policy review the facility failed to prevent the possible spread of infection, during Percutaneous Endoscopic Gastrostomy (PEG) site care, as evidenced by placing soiled items on Resident #3's bed and floor, without the use of a biohazard bag, for one (1) of five (5) resident care observations. Findings include: Review of the facility's Skin/Wound Care policy, dated (MONTH) 2014, revealed: treatment of [REDACTED]. Review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 01/17/2020 revealed, Section K (Nutritional Status) was coded to indicate the resident had a feeding tube. During an observation of Resident #3's PEG site care, on 01/23/2020 at 10:04 AM, Registered Nurse (RN) #1 removed the soiled dressing from the stoma site, and placed the dressing inside her soiled gloves, and laid them on the resident's bed. RN #1 stated she forgot the red bag for the garbage. After completing the care, RN #1 picked up the soiled dressing and gloves from the bed, placed them in a regular garbage bag. RN #1 then placed the regular garbage bag on the floor by the sink. She washed her hands, left the room to retrieve a red biohazard bag. When RN #1 returned to the resident's room, she placed the regular garbage bag, inside of the red biohazard bag, and then placed the red biohazard bag on the floor, while she washed her hands. RN #1 never changed Resident #3's bed sheet, after providing the care. During an interview, on 01/23/2020 at 10:27 AM, RN #1 confirmed she placed the dirty items on Resident #3's bed and on the resident's floor. RN #1 revealed the issue with placing the dirty gloves and dressing on the bed and floor could cause the spread of infection. RN #1 stated she didn't know what to do with the bag while she was washing her hands. An interview with the Director of Nursing (DON), on 01/23/2020 at 1:28 PM, revealed, the facility's policy was to use the biohazard bag for disposal of waste materials. The DON revealed RN #1 was was trained on the care of PEG tube sites and discarding of waste materials. The facility did not provide a copy of RN #1's training records related to PEG site care. A review of the facility's Identification and Summary Sheet revealed, Resident #3 was admitted by the facility on 07/02/2012, with [DIAGNOSES REDACTED].

Based on observation, record review, and staff interview, the facility failed to prevent the risk of aspiration for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube, as evidenced by, the Certified Nursing Assistant (CNA) placing Resident #49's head of bed (HOB) flat, without notifying licensed nurse to hold/stop a continuous feeding pump, during incontinent care, for one (1) of five (5) care observations for residents with PEG tubes. Findings include: Review of the Perry and Potter Nursing Skills and Procedures - Eighth Edition, copyright (YEAR), revealed: Enteral Nutrition via a Gastrostomy or Jejunostomy Tube - Elevate the head of bed to a minimum of 30 degrees (preferably 45 degrees). Rationale - Elevated head helps prevent [MEDICAL CONDITION] aspiration. A review of Resident #49's revised physician orders, dated 11/18/2019, revealed an order for [REDACTED]. Review of Resident #49's comprehensive care plan revealed a problem to address the risk of aspiration related to the use of the feeding tube, with an onset date of 0418/2015, and target date of 04/02/2020. Approaches included to elevate the HOB 30-45 degrees at all times. An observation of Resident #49's incontinent care, on 01/22/2020 at 2:29 PM, revealed Certified Nursing Assistant (CNA) #1 lowered the head of the bed (HOB) to flat position. CNA #1 and CNA #2 failed to notify the nursing staff to stop the feeding pump before or during incontinent care. The pump was noted to be infusing Diabetic Source at 70 cc/hour. CNA #1 placed Resident #49's HOB back after performing incontinent. During an interview, on 01/22/2020 at 2:50 PM, CNA #1 and CNA #2 stated they had completed yearly competency checks, which included incontinent care. The CNA revealed they were not to touch the feeding pump, so they didn't turn it off. CNA #1 stated she was taught not to let the HOB down completely, but could provide care. CNA #1 confirmed she did let Resident #49's HOB down, while the feeding pump was running, during the resident's incontinent care. An interview on 01/23/2020 at 1:33 PM, with the Director of Nursing (DON), revealed she stated, the facility's policy was for staff to notify the nurse, to turn off the tube feeding during care, to decrease the risk of aspiration. The DON revealed both CNAs had received training related to caring for residents. The facility did not provide a copy of the training records for CNA #1 or CNA #2. The facility failed to provide of a policy related Peg Tube care and procedures. A review of the facility's Identification and Summary Sheet for Resident #49, revealed the facility admitted the resident on 04/18/2016 with [DIAGNOSES REDACTED].

Based on observation, staff interview, record review, and facility policy review, the facility failed to follow comprehensive care plan related to Percutaneous Endoscopic Gastrostomy (PEG) tube care for one (1) of five (5) PEG tube care plans reviewed, Resident #49. Findings include: A review the facility's Nursing Documentation policy, dated (MONTH) (YEAR), revealed: It is the professional responsibility of all licensed nurses to provide an accurate, in-depth clinical record of care for assigned residents. Documentation to meet this criteria included the care plan. A review of Resident #49's comprehensive care plan, revealed a problem to address the risk of aspiration related to the use of the feeding tube, onset date of 04/18/2016, and a target date of 04/02/2020. Approaches included to elevate head of bed (HOB) 30-45 degrees at all times. An observation of Resident #49's incontinent care, on 01/22/2020 at 2:29 PM, revealed Certified Nursing Assistant (CNA) #1 placed the HOB in a flat lying position for Resident #49's care. CNA #1 and CNA #2, who was assisting with incontinent care, failed to notify the nursing staff to stop the feeding pump, which had Diabetic Source running at 70 cubic centimeters (cc) per hour (cc/hr). CNA #1 placed Resident #49's HOB back in an upright position, after performing incontinent care. During an interview, on 01/22/2020 at 2:50 PM, CNA #1 and CNA #2 stated they had completed yearly competency checks which included incontinent care. Both CNAs stated they were not to touch the feeding pump, so they did not turn it off. CNA #1 further stated she was taught not to let the HOB down completely, but could provide care. CNA #1 confirmed she placed Resident #49's HOB in a flat position during incontinent care. An interview on 01/23/2020 at 1:33 PM, with the Director of Nursing (DON), revealed the facility's policy was for staff to notify the nurse to turn off the feeding pump during care to decrease the risk of aspiration. The DON stated both CNAs had received training related to the care of residents. The facility failed to provide a policy related to PEG tube care. During an interview, on 1/23/2020 at 2:55 PM, Registered Nurse (RN) #2, Minimum Data Set (MDS) Nurse, stated the expectation was for staff to follow the care plan according to the assessment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement the care plan related to Activities of Daily Living (ADL) care for one (1) of 18 care plans reviewed, Resident #9 Findings include: A review of the facility policy titled Nursing Documentation, dated (MONTH) (YEAR), addressed the care plan, which included that care plans were initiated on admission, updated on re-admission, or whenever resident care changes happened. The policy did not include implementation of the care plan. A review of Resident #9's comprehensive care plan revealed a problem with an onset date of 12/11/17, of Resident requires assistance with ADLs, with a goal of having ADLs met and hygiene maintained over the next 90 days with a target date of 4/4/19. Approaches included to complete oral care after meals and at bedtime and to wash hands and face before and after meals and as needed (PRN). An observation on 03/05/19 at 11:45 AM, of Resident #9 in her room, revealed the resident lying in bed with dry crusty residue on her upper lip, both sides of her mouth, under her lower lip, and a line of residue from the the left corner of her mouth down to her chin. A review Resident #9 's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/14/19, revealed Resident #9 was assessed by staff to be severely impaired and was totally dependent on staff for personal hygiene. An observation and interview on 03/05/19 at 03:03 PM, of Resident #9 in the resident's room, revealed the resident lying in bed with dry crusty residue on her upper lip, both sides of her mouth, under her lower lip, and a line of residue from the left corner of her mouth down to her chin. An interview with Certified Nursing Assistant (CNA) #1 revealed she was assigned to care for the resident and had bathed the resident in bed that morning. The CNA stated she had washed the resident's mouth and provided oral care this morning, but had not done so since. CNA #1 stated it appeared that no one had cleaned the resident's face since this morning, but she would do it now. CNA #1 stated she was supposed to check on the resident every two (2) hours and if she saw a need to clean the resident's face, she was to do it then. CNA #1 stated she had provided care to the resident since this morning, but had not cleaned her mouth or face, and she should have. A review of Resident #9's Activities of Daily Living (ADL) log revealed Personal Hygiene was listed under AM (morning) care and PM (evening) care. A review of Resident # 9's Treatment Chart for (MONTH) 2019, revealed treatments of Clean mouth with lemon [MEDICATION NAME] swab Q (every) shift and Oral Care Q shift. Each of these treatments had no initials for the A shift (7 AM-3 PM) on (MONTH) 1st, 3rd, or 4th. There was no other treatments regarding cleaning the resident's face, mouth or oral care listed on the Treatment Chart. The chart listed CNAs as responsible for completing the interventions. An interview on 03/07/19 at 10:05 AM, with Registered Nurse (RN) #1, who was the Charge Nurse, revealed it was expected that CNAs should observe dependent residents at least every two (2) hours and provide hygiene care if needed, per care plan. An interview with RN #2, MDS/Care Plan Nurse, on 03/07/19 at 02:20 PM, confirmed the care plan for Resident #9 had an intervention to wash hands and face before and after meals and PRN. The MDS nurse stated that if the resident's mouth had residue on it, nursing staff should have cleaned it as needed. She stated that if the Treatment Chart/Treatment Administration Record (TAR) was not initialed for oral care/lemon [MEDICATION NAME] swab, then there is no way to know if the care was done. The RN confirmed the TAR or ADL sheet did not include the intervention of washing hands and face before and after meals and PRN and believed the TAR should match the interventions on the care plan.

Based on record review, staff interview, and facility policy review, the facility failed to revise a care plan for oral care following re-entry to the facility for one (1) of 18 resident's care plans reviewed, Resident#26. Findings include: Review of the Facility Policy titled NURSING D[NAME]UMENTATION, dated (MONTH) (YEAR), revealed: It is the professional responsibility of all licensed nurses to provide an accurate, in-depth clinical record of care for assigned residents. Documentation criteria included: Care Plans-Updated upon re-admission and whenever resident care changes. Record review of the Care Plan with a Problem Onset date of 6/20/11, revealed Resident #26 required total assistance with Activities of Daily Living (ADL). The Goal: Resident will have all ADL's met and hygiene maintained over the next 90 days. Target Date: 4/18/19. Approaches included oral care every shift. Record review of the Physician's Orders for Resident #26, dated 2/26/19, revealed an order for [REDACTED]. On 03/07/19 at 08:51 AM, interview with Registered Nurse #2 (RN), Minimum Data Set (MDS) Nurse, revealed that Resident #26 had a new order for mouth care to be performed every four (4) hours upon re-entry on 2/26/19. She stated that mouth care should be done every four (4) hours . She revealed that the Care Plan was last updated on 1/14/19, and that she did not update the care plan with the new order to include every four (4) hours for mouth care. She stated that it would be important to update the care plan because anyone who reads the care plan should know how to be able to take care of the resident. Record review of the Identification and Summary Sheet, for Resident #26, revealed that the facility admitted the resident on 6/20/11, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], Section C, revealed the staff assessed Resident #26's cognitive skills for daily decision making as severely impaired.

Based on observation, staff interview, and facility policy review, the facility failed to provide Activity of Daily Living (ADL) care to maintain good personal hygiene for two (2) of three (3) residents reviewed for ADL care, Resident #9 and Resident #26. Findings include: Review of the Facility Policy titled, Resident Personal Hygiene, dated (MONTH) (YEAR), revealed: This policy provides guidelines for assisting residents with daily hygiene and grooming. This policy applies to all facility residents and employees. Daily personal grooming needs will be met in order to maintain the dignity and health of all residents. Residents will be encouraged to receive oral care at least daily and PRN, with staff assistance as needed. Resident #26 On 03/05/19, at 11:30 AM, an observation of Resident #26 revealed dry, tan, crusty matter on the resident's lips and tongue. The Residents mouth was open. During an observation on 03/06/19 at 04:30 PM, Resident #26 had tan, crusty matter observed on the tongue and lips. The Resident appeared to be mouth breathing, with the tongue pushing toward the lips. Tan crust was noted on the left side of the resident's chin. On 03/06/19 at 05:02 PM, observation of Resident #26 and interview with LPN #1, confirmed that the resident had tan, crusty secretions on his lips, tongue and chin. LPN #1 stated, Looks like he could could use some mouth care. The crusts on his chin could be secretions from his mouth. On 03/06/19 at 04:52 PM, interview with Licensed Practical Nurse #1 (LPN), revealed nurses perform oral care for Resident #26. LPN #1 stated that it should be documented on the Treatment Chart (TC) and upon his review of the the Treatment Chart, he stated, I don't see it on here. I think his mouth care is once a day and as needed (prn). I thought it would be on the TC. On 03/06/19 at 05:16 PM, during an interview and observation of Resident #26, the Director of Nursing (DON) confirmed the tan crusts on the lips, tongue and left side of chin, she stated, That certainly should not look like that, that needs to be taken care of right now. He's a mouth breather and would need more frequent mouth care. The DON revealed that the nurses perform the mouth care for all residents with Percutaneous Endoscopic Gastrostomy (PEG) tubes and that it would be documented on the Treatment Chart (TC). On 03/07/19 at 08:51 AM, interview with Registered Nurse #2, Minimum Data Set (MDS) Nurse, revealed that Resident #26 had a new order for mouth care upon re-entry from the hospital on [DATE]. She stated that mouth care should be done every four (4) hours . Record review of the (MONTH) 2019 Treatment Chart, the (MONTH) 2019 Medication Chart, and the (MONTH) 2019 Activity of Daily Living (ADL) records, revealed that oral care was not found to be listed on these records. Record review of the Identification and Summary Sheet for Resident #26 revealed that the facility admitted resident on 6/20/11, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed that the resident was totally dependent on staff for Personal Hygiene and staff assessed Resident #26's cognitive skills for daily decision making as severely impaired. Resident #9 An observation on 03/05/19 at 11:45 AM, of Resident #9 in her room, revealed the resident lying in bed with dry crusty residue on her upper lip, both sides of her mouth, under her lower lip, and a line of residue from the the left corner of her mouth down to her chin. An observation of Resident #9, and interview with Certified Nursing Assistant (CNA) #1, on 03/05/19 at 03:03 PM, revealed the resident lying in bed with dry crusty residue on her upper lip, both sides of her mouth, under her lower lip, and a line of residue from the left corner of her mouth down to her chin. CNA #1 revealed she was assigned to care for the resident and had bathed the resident in bed this morning. CNA #1 stated she had washed the resident's mouth and provided oral care this morning, but had not done so since. CNA #1 stated it appeared that no one had cleaned the resident's face since this morning, but she would do it now. CNA #1 stated she was supposed to check on the resident every two (2) hours and if she saw a need to clean the resident's face, she was to do it then. CNA #1 stated she had provided care to the resident since this morning, but had not cleaned her mouth or face and should have. A review of Resident #9's Activities of Daily Living (ADL) log revealed Personal Hygiene was listed under AM (morning) care and PM (evening) care. A review of Resident #9's Treatment Chart for (MONTH) 2019, revealed treatments of Clean mouth with lemon [MEDICATION NAME] swab Q (every) shift and Oral Care Q shift. Each of these treatments had no initials for the A shift (7 AM-3 PM) on (MONTH) 1st, 3rd, or 4th. There were no other treatments regarding cleaning the resident's face, mouth or oral care listed on the Treatment Chart. The chart listed CNAs as responsible for completing the interventions. An interview on 03/07/19 at 10:05 AM, with Registered Nurse (RN) #1, who was the Charge Nurse, revealed it was expected that CNAs should observe dependent residents at least every two (2) hours and provide hygiene care if needed. An interview with RN #2, MDS/Care Plan nurse on 03/07/19 at 02:20 PM, confirmed the care plan for Resident #9 had an intervention to wash hands and face before and after meals and PRN. The MDS nurse stated that if the resident's mouth had residue on it, nursing staff should have cleaned it as needed. She stated that if the Treatment Chart/Treatment Administration Record (TAR) was not initialed for oral care and/or lemon [MEDICATION NAME] swab, then there is no way to know if the care was done. The RN confirmed the TAR nor ADL sheet included the intervention of washing hands and face before and after meals and PRN, and believes the TAR should match the interventions on the care plan. A review Resident #9's quarterly MDS with an Assessment Reference Date (ARD) of 12/14/19, revealed Resident #9 was assessed by staff to be severely impaired and was totally dependent on staff for personal hygiene.

Based on Observation, Staff Interview, and Record Review, the facility failed to implement the care plan related to monitoring a resident with a restraint for one (1) of four (4) resident care plans reviewed with restraints, Resident #3. Findings Include: A policy for care plans was not provided. A review of Resident #3's current Comprehensive Care Plan revealed a care plan for Restraint-Soft helmet to be used while awake, updated and continued, with a problem onset date of 09/21/17. Approaches included: Circulation checks every 30 minutes, release and reposition every two (2) hours, assigned to Certified Nursing Assistant (CNA). An observation on 11/20/17, from approximately 8:00 AM until 9:30 AM, in the second floor day room of the facility, revealed Resident #3 seated in a geri chair wearing a soft helmet, with a chin strap securing the helmet on her head. No staff was observed to check Resident #3 or positioning of her helmet during the observation of one (1) and one-half (1/2) hours. An interview on 11/20/17 at 9:30 AM, with CNA #2, revealed she had been seated in the day room where Resident #3 was present but she had not noticed Resident #3's helmet and had not checked on the resident. CNA #2 stated she was not assigned to Resident #3. An interview and observation on 11/20/17 at 9:35 AM, with LPN #1, confirmed she had been in and out of the day room area where Resident #3 was seated, but had not checked on Resident #3. LPN #1 stated CNA #1 was assigned to Resident #3. An interview on 11/20/17 at 9:40 AM, with CNA #1, who was assigned to Resident #3, confirmed that she had not checked on the resident in the one (1) and one half (1/2) hour period observed and was unaware she was to check the resident every 30 minutes. An interview on 11/21/17 at 9:21 AM,with the Director of Nursing (DON), revealed the CNAs should check Resident #3 every 30 minutes while she was wearing her helmet for circulation and positioning and release the helmet every two (2)hours. The DON stated that if the CNAs did not check the resident every 30 minutes, they did not follow the care plan. An interview on 11/21/17 at 1:25 PM, with the Minimum Data Set (MDS) Coordinator, revealed she wrote Resident #3's care plan and updated the care plan on 09/21/17 to include the restraint of a helmet. The MDS Coordinator stated that if the approach on the care plan that CNAs check the resident every 30 minutes for circulation was not done, the care plan was not followed. A review of the resident's record revealed no documentation that the resident had been checked every 30 minutes for circulation while wearing her helmet. A review of the facility's Identification and Summary Sheet, for Resident #3, revealed the resident was admitted by the facility on 06/28/05, with [DIAGNOSES REDACTED]. A review of the MDS, with an Assessment Reference Date (ARD) of 10/27/17, revealed the staff assessment of Resident #3's mental status indicated the resident had sever cognitive impairment.

Based on Observation, Staff Interview, Record Review, and Facility Policy Review, the facility failed to ensure monitoring of a resident with a restraint was completed, as ordered by the physician, for one (1) of four (4) residents with restraints reviewed, Resident #3. Findings Include: A review of the facility's policy titled Restraints, revised November 2016, revealed Physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to a resident's body, which the individual cannot remove easily, and that restricts freedom of movement or normal access to one's body. Nursing personnel will document observation and release and resident checks every 30 minutes and when the resident is released, repositioned, and range of motion are performed at least every two (2) hours or as ordered by the physician. Helmet-plastic or leather head covering. A review of Resident #3's Physician order [REDACTED]. Circulation checks every 30 minutes. Release and reposition every 2 hours. An observation on 11/20/17 from approximately 8:00 AM, until 9:30 AM, in the second floor day room of Building 28, revealed Resident #3 seated in a geriatric (geri) chair with a soft helmet on her head. A chin strap secured the helmet on her head. Resident #3 was seated in the day room with eight (8) other residents and all residents were watching a movie. During the observation, Resident #3 re-adjusted herself in the geri-chair turning to her right side and closed her eyes. Her re-adjustment caused the soft helmet to slide to the left on her head making the chin strap tighter on her neck. The resident did not appear to be uncomfortable and the resident's eyes were closed and she was breathing deeply. There was one (1) Certified Nursing Assistant, CNA #2, in the area with the residents and a Licensed Practical Nurse, LPN #1, was in and out of the area while doing medication administration. No staff was observed to check Resident #3, or positioning of her helmet, during the observation of one (1) and one-half (1/2) hours. During an interview on 11/20/17 at 9:30 AM, CNA #2 revealed that although she was seated in the area, she was not assigned to monitor Resident #3 and had only paid attention to the resident she was monitoring one on one (1:1). CNA #2 stated she had not noticed Resident #3's helmet and had not checked on the resident. An interview and observation on 11/20/17 at 9:35 AM, with LPN #1, confirmed she had been in and out of the day room area but had not noticed Resident #3 had re-adjusted herself in the geri-chair and her helmet had slid out of place on her head. LPN #1 confirmed the chin strap appeared a little tight and stated that the CNA assigned to the resident was supposed to check on the resident and monitor her. LPN #1 stated the CNA assigned to Resident #3 was CNA #1, and she should check the resident at least every two (2) hours to change her brief and would take the helmet off while the resident was being changed. An interview on 11/20/17 at 9:40 AM, with CNA #1 confirmed that she was assigned to Resident #3 and she had not checked the resident since approximately 8:00 AM, after breakfast. CNA #1 stated that she would check the resident again at approximately 10:00 AM, to change her brief and take her helmet off. CNA #1 stated she was not aware to check the resident every 30 minutes, only that she was to release the helmet and reposition the resident and check to see if she needed a change of brief every two (2) hours. CNA #1 stated that the Activities of Daily Living (ADL) sheet only had to check the resident's helmet and positioning every two (2) hours and the ADL sheet was where she looked to find out what she was supposed to do for each resident. CNA #1 stated she had been trained on how to put on the helmet by the CNA Supervisor. She stated the Supervisor told her in training to made sure to have the helmet on when the resident was out of bed and check on her every two (2) hours and take the helmet off to make sure skin was okay. CNA #1 stated if they didn't do that there could be skin irritation or bad circulation. A review of the November ADL sheets revealed Resident #3 had a category of Soft head helmet on while up. Resident with [MEDICAL CONDITION] [DIAGNOSES REDACTED]. A review of Resident #3's Comprehensive Care Plan revealed a care plan for Restraint-Soft helmet to be used while awake, updated and continued, with a problem onset date of 09/21/17. Approaches included: Circulation checks every 30 minutes, release and reposition every 2 hours, assigned to CNA. An interview on 11/20/17 at 12:35 PM, with RN #2, revealed it was her responsibility to transfer assignments for CNAs to the ADL sheets after a physician's orders [REDACTED].#2 stated orders for restraints are written and reviewed monthly per facility policy. RN #2 stated she had written on the ADL sheet for Resident #3 for the CNAs to put on a soft helmet while Resident #3 was up. RN #2 stated she failed to write on the sheet to check every 30 minutes for circulation and release the helmet every two (2) hours and had missed it on the physician's orders [REDACTED].#3 had worn a soft helmet in the past but it had been discontinued because the resident had stopped walking and there was no need for the helmet. RN #2 stated the helmet was ordered again in September because the resident started walking again periodically and due to her [MEDICAL CONDITION] disorder, the physician ordered the helmet to be worn while the resident was up. RN #2 stated the CNAs would not know to check for circulation every 30 minutes because it wasn't on the ADL sheet. RN #2 stated it was important to check to prevent any circulatory issues or skin breakdown. An interview on 11/21/17 at 7:55 AM, with the 1st and 3rd shift CNA Supervisors, revealed they trained CNA staff how to put on the soft helmet for Resident #3. The Supervisors stated CNAs were supposed to make sure the helmet strap was not too tight on the resident's neck. The CNA supervisors stated they taught the CNAs to make sure the helmet was on when the resident was out of bed but had not taught them to check the helmet every 30 minutes. The CNA Supervisors stated that they had been trained that restraints had to be checked every 30 minutes and released every two (2) hours but they had not considered the helmet to be a restraint because it wasn't on the ADL sheet to check every 30 minutes or release every two (2)hours. The CNA Supervisors stated that they thought the helmet was considered safety equipment. Both the CNA Supervisors stated Resident #3 was not able to remove the helmet on command and generally could not follow commands. Both CNA Supervisors agreed Resident #3 would not be able to scratch her head with the helmet on. Both CNA Supervisors stated they knew that if a resident could not remove the helmet it would be a restraint but resident #3 could remove the helmet, just not on command. The CNAs did not remember there being any discussion in restraint training that if a resident could not release a device on command, it was considered a restraint. An interview on 11/21/17 at 9:21 AM, with the Director of Nursing (DON), revealed the helmet ordered for Resident #3 was considered a restraint because the resident could not remove it on command. The DON stated the CNAs should check the resident every 30 minutes while she is wearing the helmet for circulation and positioning and release it every two (2) hours. The DON stated all CNAs and nurses received training on the restraint policy at orientation and annually thereafter. The DON stated she was unsure why the CNAs would not know the helmet was a restraint. An interview on 11/21/17 at 11:10 AM, with the Director of Staff Development, revealed she or the DON complete training on the facility's restraint policy with all staff upon hire and at least annually. She stated they use the restraint policy as their training material. The Director of Staff Development stated they use an example of bed rails during training and state that if a resident is unable to put the bed rail down, it is considered a restraint. She further stated that this principal applies to all equipment or devices, so if a resident could not remove a helmet, it would be considered a restraint. The Director of Staff development stated that the restraint policy may need to include that if the resident cannot remove on command, it is considered a restraint. A review of the training records for the facility confirmed all staff had been trained on the restraint policy. A review of the restraint policy confirmed there was no statement regarding if a resident could not remove a device or equipment on command, it was considered a restraint. A review of the facility's Identification and Summary Sheet for Resident #3 revealed the resident was admitted by the facility on 06/28/05, with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/27/17, revealed the staff assessed Resident #3 with severely impaired cognitive status.

Based on observation, staff interviews, record review, and policy review, the facility failed to verify the placement of a gastric tube prior to the administration of medications in water for one (1) of three (3) residents observed with gastric tube medications, Unsampled Resident B, and failed to follow proper medication administration procedures, to prevent the potential for harm, as evidenced by the LPN (Licensed Practical Nurse) left medications unattended with the resident, Unsampled Resident A, for 1 (one) of 10 residents observed during the medication pass. Findings Include: Review of the facility's letterhead statement, signed by the Administrator, dated 2/16/17, revealed the Lippincott Nursing Procedures Seventh Edition was the facility's evidenced based data guideline for nurses. Review of the Lippincott Nursing Procedures, Seventh Edition manual, revealed, Besides providing an alternate means of nourishment, a nasogastric (NG) tube or gastrostomy tube (GT) allows direct instillation of medication into the GI (Gastro-Intestinal) system of residents who can not ingest the drug orally/po/by mouth. Before instillation, the patency and positioning of the tube must be carefully checked because the procedure is contraindicated if: (1) the tube is obstructed or improperly positioned. Review of the facility's policy Safe Medication Administration Practices, General, page 678, revealed: To promote a culture of safety and to prevent medication errors, nurses must avoid distractions and interruptions when preparing and administering medications and adhere to the five rights of medication administration: identify the right patient by using at least two (2) patient specific identifiers; select the right medication and the right time; and administer the medication by the right route. Implementation: Avoid distractions, interruptions when preparing, and administrating medication to prevent medication errors. Review of a facility letter head statement, signed by the Administrator, dated 2/15/17, revealed the facility had no specific Medication Administration or Medication safety policy. Review of the Job descriptions of the Licensed Practical Nurse Under Examples of Work: Renders general nursing care to patients by administering prescribed medications and treatments in accordance with approved nursing techniques. Renders general nursing care to patients by administering prescribed medications and treatments in accordance with approved nursing techniques. Essential Functions: Administer prescribed medications and treatments. Examples of work: Renders general nursing care to patients by administering prescribed medications and treatments in accordance with approved nursing techniques. Resident #4: Observation on 02/15/2017 at 11:35 AM, revealed LPN (Licensed Practical Nurse) #4 prepared [MEDICATION NAME] 1 milligram (mg.) and [MEDICATION NAME] 20 mg, each mixed with 5 milliliters (ML) of water into individual dose cups. LPN #4 then placed the feeding pump on hold and explained the procedure to Unsampled Resident B. She uncapped the gastric-feeding tube and placed a 60 ML syringe into the port. LPN #4 then poured in 30 MLs of water, gave the first dose of medication followed by 10 MLs of water. She then gave the second dose of medication followed by another 30 MLs of water. LPN #4 removed the syringe and reattached the tube feeding formula. Interview on 2/16/2017 at 11:45 AM, with LPN #4, revealed the statement, referring to Resident #4, I forgot to verify placement. She stated she usually listened for air and stomach contents. She further stated that failure to verify placement could result in the gastric-tube not being in the right place and the stomach contents might be too full. Interview on 2/16/2017 at 12:50 PM, with the Director of Nursing, revealed the RNs (Registered Nurses) and LPNs were inserviced on medication administration yearly in February but have not had the annual training. The DON provided a signed statement, dated 2/16/17, which revealed LPN #4 had no in-service on Gastric Tubes in 2016, as she was on extended leave. Unsampled Resident #A: On 2/15/17 at 8:45 AM, an observation of Unsampled Resident #A revealed she was sitting in her wheelchair near the nursing station in a common area, wrapped in a white towel, with two (2) bottles of prescription eye drops. In the presence of Licensed Practical Nurse (LPN) #1, Unsampled Resident #A, when asked why she was holding the eye drops, she replied they were hers, because the nurse told her to keep them while the resident went to the restroom, and the nurse would return to administer the eye drops. Interview with LPN #2 on 2/15/17 at 8:50 AM, In the presence of the DON and LPN #1, revealed LPN #2 explained she had gotten distracted and forgotten to go back and administer the two (2) eye drops to Unsampled Resident #A, because when she was about to administer the eye drops, the resident needed to go to the bathroom. LPN #2 confirmed the eye drops, [MEDICATION NAME] eye drops and Liquid Tears eye drops, belonged to Unsampled Resident # A. Both LPN #1 and LPN #2 acknowledged it is never ok to leave medications in the care of a resident, despite the cognition of the resident. They stated it was a potential of possibility for harm to the prescribed resident and other residents who could take them away from Unsampled Resident #A and use in many other ways. The DON said there is always a potential for harm and medications are never to be left alone. The DON said it was against policy to leave medications with a resident and she, as the DON, was ultimately responsible. Review of the facility's face sheet revealed, the facility admitted the resident on 8/1/2001. Unsampled Resident #A's [DIAGNOSES REDACTED]. Review of Unsampled Resident #A's MDS, with an ARD of 1/13/17, revealed a BIMS of 15, indicating no cognitive impairment.

Based on staff interview, record review, and facility policy review the facility failed to develop a comprehensive care plan related to hospice care for one (1) of 14 care plans reviewed. (Resident # 13). Findings include: Review of the facility policy titled, Nursing Documentation, dated December 2016, revealed the purpose of this policy is to provide nurses with guidelines for documenting in the resident medical record. This policy applies to all licensed nursing staff at the facility. J. Care plans are initiated on admission, updated on readmission, and whenever resident care changes. Review of physician's orders, dated 2/8/17, revealed an order to admit Resident #13 to Hospice services. Review of Resident #13's current care plan revealed the absence of a care plan to address the resident's admission to Hospice Care on 2/8/17. Interview on 2/15/16 at 3:00 PM, with Registered Nurse (RN) #1, who serves as Minimum Data Set (MDS) Coordinator, stated the nurses update the care plans, then she types the changes. RN #1 confirmed there was no hospice care plan in place for Resident #13. During an interview on 2/15/17 at 4:30 PM, RN #3 stated she remembered discussing Resident #13's need for a hospice care plan but she was off the next day, due to her child being ill, and just did not get it done when she came back. RN #3 confirmed the resident did not have a care plan. RN #3 confirmed Resident #13 should have a care plan, that it was important to let the staff know how to care for the resident. Interview on 2/15/17 at 5:30 PM, with the Director of Nurses (DON,) revealed it is the responsibility of the charge nurses on the floor to initiate care plans. The facility admitted readmitted Resident #13 on 11/29/16, and readmitted the resident on 2/8/17, with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/7/16, revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognition.

Based on observation, staff interview and facility policy review the facility failed to provide privacy to ensure dignity for a resident while providing incontinent care for one (1) of (5) incontinent cares observed. (Resident #4). Findings include: Review of facility policy titled Dignity, dated January 2015, revealed the facility will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his/hers individuality. This policy applies to all residents and staff. All staff members will provide care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect. Staff members will monitor residents frequently to ensure their clothing, blankets, or sheets covers them while in bed or dayroom. Staff will protect the resident's privacy by always using privacy screens of curtains during bath times, brief changes and any treatment given by the nurse. Certified Nursing Assistants (CNAs) #1 and #2 were observed providing catheter and incontinent care for Resident #4, on 02/15/17, at 9:15 AM. CNA's #1 and #2 were observed pulling privacy curtains around the bed but left Resident #4 totally exposed and naked during catheter and incontinent care. During an interview, on 02/15/17 at 3:45 PM, Certified Nursing Assistant (CNA) #2 confirmed Resident #4 was exposed during the catheter/incontinent care. CNA #2 revealed the Resident could have gotten cold and possibly catch a cold. CNA #2 said she was just nervous. During an interview, on 02/16/17 at 09:15, the Director of Nursing (DON) stated that during resident care (bed bath, incontinent care, catheter care) the resident should be covered as much as possible; the only body parts that should be uncovered are the parts you're working on. The Facility admitted Resident #4 on 01/18/17, with [DIAGNOSES REDACTED]. Review of Resident #4's Minimal Data Set (MDS) with an Assessment Reference Date of 01/24/17, revealed Resident #4 scored 9 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment.

Based on observation, staff interview, record review, and facility policy review the facility failed to provide continuous one to one ordered supervised observation for Resident #1, resulting in a fall with injury, for one (1) of four (4) residents reviewed. Findings include: A review of the facility's policy entitled, "Resident Observation", reference date of December 2012, revealed "One-on-one observation is the constant observation of a resident by a staff member for the purpose of continuously monitoring the resident's behavioral and/or medical condition. One-on-one observation will require the assignment of a staff member to be in the immediate proximity such that the resident could not injure himself/herself or another resident or staff member." This policy/procedure stated the use of one-on-one observation, visual contact, or time check observation will be based upon the clinical assessment of the resident by the physician and will require a physician's orders [REDACTED]. Resident #1 A review of Resident #1's physician's orders [REDACTED]. May ambulate in Merri-Walker." A review of the Progress Notes for Resident #1 on 1/13/15 at 1:45 PM revealed Resident #1 was found on the floor of another resident's bedroom with a laceration to her left forehead. The laceration was approximately one and one-half inches long and was closed using a skin adhesive. Resident #1's primary doctor stated the Certified Nursing Assistant (CNA) assigned to provide one (1) to one (1) (1:1 Observation) was feeding another resident when Resident #1 apparently "slipped away from her". In a review of Resident #1's Nurses Notes on 1/13/15 at 3:35 PM revealed an entry stating Resident #1 was in room 205 on the floor in between two closets and sliding across the floor on her buttocks. Her Merri-Walker was found on the right side of the room with smeared blood. Also, a moderate amount of blood noted on the floor beside bed also. Bleeding was noted to the left forehead, 4 X 4 applied to area and cleaned with Normal Saline. Approximately one and one-half (1 ?) inch laceration to left forehead and hematoma noted. Laceration was bonded with Bond Glue by the building Medical Doctor (MD). In a phone interview on 2/4/15 at 11:25 AM, CNA #1 stated she was told by the CNA Supervisor to go upstairs and help feed the residents in the dining room that needed assistance and leave Resident #1. Resident #1 was the resident she was assigned to sit with on 1:1 observation. She admitted she was assisting another resident upstairs with dining when Resident #1 fell unsupervised and sustained a laceration and hematoma to the left side of her forehead. She stated she was assigned to Resident #1 to provide 1:1 observation on 1/13/15 at the time of the fall. CNA #1 admitted she knew she was to be within arms length of a resident on 1:1 observation but was told by her supervisor to go help in the dining room. In a phone interview on 2/5/15 at 8:20 AM, CNA #2 (CNA Supervisor) stated she was on a break at the time Resident #1 fell . She stated there was two residents left dining that needed assistance, but she had to leave for her break. She denied she asked CNA #1 to go to the dining room to assist with helping the other resident with dining. She stated if a CNA is assigned to 1:1 observation they have to stay within arms length all the time, and if they need to leave the resident, they have to get someone to relieve them. CNA #2 stated the last inservice on 1:1 observation had been "awhile". Review of Resident #1's January 2015, Activity of Daily Living (ADL) sheets, revealed an entry for, Resident on 1:1 observation. The ADL sheet also read that Resident #1 had a history of [REDACTED]. In an interview on 2/4/15 at 11:40 AM with the Staff Education nurse, she confirmed, "We do go over the 1:1 observation during orientation and they know to keep the resident within arms length and never to leave the resident unattended." On 2/3/15 at 3:30 PM, an observation of Resident #1 revealed a CNA present with the resident for 1:1 observation while the resident walked in a Merri-walker in the hallway. Resident #1 had a healed laceration to the left side of her forehead. The Identification and Summary Sheet indicated the facility admitted Resident #1 on 10/31/12 with [DIAGNOSES REDACTED]. In a review of Resident #1's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date of 11/14/14 revealed a Brief Interview for Mental Status (BIMS) of 0, which indicated Resident #1 was severely cognitively impaired. The 11/14/14 MDS also coded the resident as requiring the use of an assistive device (walker) and required supervision with ambulation.

Based on observation, interview, record review, and facility policy review, the facility failed to implement a resident's plan of care to provide care and services, as evidenced by failure to maintain constant ordered one-to-one (1:1) supervision resulting in a fall with injury, for one (1) of four (4) residents reviewed (Resident #1). Findings include: A review of the facility's policy entitled, "The Care Area Assessment (CAA) Process and Care Plan Completion", dated October 2014, stated the resident's plans of care would be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #1 Review of Resident #1's Plan of Care revealed a care plan for increased risk for falls, initiated 10/31/12. The care plan listed revisions and updates. A listed approach to protect the resident from falls was to monitor the resident with 1:1 observation. Record review of Resident #1's physician's orders [REDACTED]. May ambulate in Merri-Walker." Record review of January 2015 ADL (Activity of Daily Living) sheets for Resident #1 revealed, "Resident on 1:1 observation. Resident with a history of falls with injuries, and to monitor resident for wandering throughout the building and into other resident's rooms and belongings." During a phone interview on 2/4/15 at 11:25 AM with Certified Nursing Assistant (CNA) #1, admitted she left the 1:1 observation and was assisting another resident upstairs with dining when Resident #1 fell and sustained a laceration and hematoma to the left side of her forehead. She stated she was assigned to Resident #1 and was to provide 1:1 observation on 1/13/15 at the time she fell . She indicated a resident on 1:1 observation should be within arms length. She stated she was told by her supervisor to go help in the dining room to assist other residents with dining. Phone Interview on 2/5/15 at 8:20AM with CNA #2 (CNA Supervisor) revealed when asked if she had instructed CNA #1 to assist with dining, She stated, "No." On 2/4/15 at 11:40 AM during an interview with the Staff Education Nurse, she confirmed CNAs were taught to go by the ADL (Activities of Daily Living) sheets which comes from the care plan. She also explained that 1:1 observation procedures were covered during employee orientation. In an observation on 2/3/15 at 3:30 PM, Resident #1 was in the hallway in a Merri-walker with a CNA in attendance for 1:1 observation. Resident #1 was neatly dressed and constantly moving in hallway. Resident #1 has a healed laceration to left side of her forehead. Review of Resident #1's Identification and Summary Sheet revealed the facility admitted Resident #1 on 10/31/12 with [DIAGNOSES REDACTED]. In a review of Resident #1's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date of 11/14/14, indicated Resident #1 was severely cognitively impaired and required supervision with ambulation and use of a walker assistive device.

CI MS #9663 Based on observation, interview, record review and policy review the facility failed to implement policies and procedures that prohibited neglect and to provide adequate supervision to prevent one (1) of six (6) residents, Resident #1, from leaving the facility unsupervised and without staff knowledge. Resident #1 had been assessed and care planned as a wander risk with a history of wandering and had no implemented interventions monitoring her specific wander risk. Two (2) nurses in Building 34, (Licensed Practical Nurse (LPN) #1 and LPN #2, were not aware of Resident #1's wandering risk. Resident #1 left Building 34 on 8/10/11 at approximately 4:45 p.m. without staff knowledge and was seen by another resident, Resident #2, who reported Resident #1's exit from the building. Resident #1 was found by LPN #1 and Certified Nursing Assistant (CNA) #1 behind Building 34 getting into an unlocked car which was approximately 175 paces from the facility's front door where she had exited. The estimated time that Resident #1 was outside the building was less than five (5) minutes. Resident #1 was returned to Building 34 by LPN #1 and CNA #1 with no injuries. The lack of the implementation to supervise and ensure that measures were put into place to prevent Resident #1 from leaving the building unsupervised and unassisted was deemed Substandard Quality of Care and an Immediate Jeopardy (IJ) on 8/18/11 at 9:00 a.m. The Administrator was notified of the IJ at that time. The IJ began on 8/10/11 and was determined to be removed on 8/18/11. The facility submitted a credible Allegation of Compliance (AoC) on 8/19/11. Based on the facility's implementation of corrective actions and an acceptable credible AoC, the IJ was removed on 8/18/11 and lowered to a "D" level which constitutes no actual harm with potential for more than minimal harm. Findings Include: Cross refer to F-323 for the facility's failure to ensure that Resident #1 did not leave the facility without staff knowledge and supervision and for the facility's failure to ensure that staff was aware of residents who were at risk for wandering/elopement. "Credible Allegation of Compliance" "On 8/10/11 at 4:45 p.m. Resident #2 reported to LPN #1 that Resident #1 was outside and was walking down the sidewalk. CNA #1 and LPN #1 after being told by Resident #2 exited the front door and Staffing Coordinator #1 exited the rear of the building and saw Resident #1 sitting in the backseat of a parked car closing the door. CNA #1 and LPN #1 escorted Resident #1 back to the building at approximately 4:51 p.m. on 8/10/11. It was estimated that Resident #1 was off the building for four (4) to five (5) minutes. LPN #1 examined Resident #1 and found no visible injuries. RN #1 was notified by LPN # 2 at approximately 4:50 p.m. on 8/10/11. RN #1 assessed Resident #1 at approximately 5:00 p.m. on 8/10/11 and found no visible injuries. Resident #1 was admitted to facility on 5/11/11 and assessed to be a wanderer and no documented checks were in place specific to wandering behavior. Facility investigation revealed that Vehicle Safety Policy was violated by Pantry Worker #1. On 8/16/11 at approximately 11:30 a.m. disciplinary action was issued that included a written reprimand to her personnel file. This written reprimand indicated that the employee failed to follow Vehicle Safety Policy. On 08/10/11 at 5:15 p.m., Resident #1 was placed on visual contact by the Medical Officer of the Day #1. Medical Officer of the Day is the attending physician on campus on call after hours. Visual Contact is defined as continuous observation of residents by one staff member for the purpose of monitoring behavioral and/or medical conditions. There is no defined distance between the observer and resident, but the observer must be able to visualize the actions of the resident assigned to them. On 08/10/11 at approximately 6:30 p.m., RN #1 began in-servicing all facility staff on duty at this time, which included Nursing and Pantry on the following policies: *JNH J500-15 Wandering/Elopement/Abduction. The purpose of this policy is to establish procedures when a resident of Jaquith Nursing Home is determined to be at risk for wandering or elopement. Specific elements of this policy that were covered included placing this resident on thirty minute time checks but in this case it was upgraded to visual contact. JNH J500-48 Missing Residents. The purpose of this policy is to establish procedures to be followed when a resident of Jaquith Nursing Home is determined to be missing from the Mississippi State Hospital (MSH) grounds, or when a resident does not return from an approved pass. Specific elements of this policy that were covered include to begin a search immediately and report the missing resident to all necessary disciplines i.e Floor Nurse, RN Supervisor and MSH Campus Police if resident is missing longer than ten minutes. MSH POL 184-05 Vehicle Safety. The purpose of this policy is to provide the fundamental rules for the operation of private and state motor vehicles on the premises of Mississippi State Hospital (MSH). Specific elements of this policy that were covered include: All car doors should be locked upon exiting the vehicle at all times. MSH POL 210-78 Patient/Resident Daily Accountability. The purpose of this policy is to establish procedures for patient/resident accountability 24 hours a day and maintaining written documentation of these checks. Specific elements of this policy that were covered include: building checks and resident accountability forms. No staff was allowed to work until he/she was in-serviced and no changes to the policy were made. On 08/10/11 at approximately 5:20 p.m., RN #1 updated the care plan of Resident #1 to include visual contact until further notice. This implementation of visual contact is documented every 15 minutes on MSH Form 31A by assigned staff. On 08/11/11 at approximately 1:30 p.m., RN #2 began in-servicing all facility staff that were on duty at the time which included Nursing, Pantry, Housekeeping, Laundry, Social Services, Psychology and Recreation on the following policy: JNH J530-55 Injury, Abuse, Neglect, Mistreatment or Exploitation of Residents. The purpose of this policy is to affirm that Jaquith Nursing Home (JNH) resident have a right to be free from abuse, neglect, sexual battery, mistreatment, exploitation, and misappropriation of property and to outline procedures for complying with Centers for Medicare Medicaid Services (CMS) and the Mississippi Vulnerable Adults Act of 1986 as annotated. Specific elements included definitions of injury, abuse and neglect and how failure to return resident to a safe environment could result in neglect. No staff was allowed to work until he/she was in-serviced and no changes to the policy were made. On 08/11/11 at 2:30 p.m. JNH QA meeting was held to discuss the incident of Resident #1 exiting the building without supervision on 8/10/11 and actions taken thus far. The QA committee consisted of DON #1, NHA #1, Building Doctor #1, RN #3, RN #2, Accreditation and Licensure Coordinator #1, RN #4, CUO #1, Administrative Assistant #1, Nurse executive #1, JNH Psychology Supervisor #1. Additional recommendations and actions were taken as a result of the QA meeting: -Development and implementation of Vehicle Monitoring. Facility supervisory staff will conduct random checks of vehicles parked in the immediate proximity once daily to ensure doors were locked. Any unlocked vehicles will be reported to MSH Campus Police and referred to Personnel Officer for possible disciplinary action. -Continue visual contact of Resident #1 by assigned nurses and cna's. -Contact family to discuss possibility of relocating Resident #1 to a locked unit. -Review all residents to identify any additional residents who are at risk for wandering. -Review and update care plans as needed. On 8/11/11 at approximately 3:15 p.m. DON #1 reviewed all facility residents to identify any additional residents at risk. No other residents were identified to be at risk for wandering except the two (2) that were previously noted to be at risk, Resident #1 and Resident #3. Measures were in place for Resident #3 that included time checks every 15 minutes. No episodes of exit seeking behavior or elopements have occurred for Resident #3. On 8/11/11 at 4:00 p.m., NHA #1 or designee began random checks of five (5) or more vehicles in the surrounding area daily to ensure that car doors remain locked. Documentation of these checks has been recorded on the Vehicle Monitoring Log. No concerns were found since 8/11/2011. On 8/12/11 at approximately 11:45 a.m. RN #2 updated Activities of Daily Living (ADL) records for resident #1 to further identify her at risk for wandering. This information was communicated to facility staff at the change of each shift which occurs at approximately 7:15 a.m., 3:15 p.m. and 11:15 p.m. On 8/16/11 at 9:30 a.m. incident and actions taken thus far were discussed at Quarterly QA meeting which was attended by JNH Medical Director. Facility Staff present included four (4) DON'S, four (4) NHA'S, JNH Director, JNH Nurse Administrator, JNH Psychology Supervisor, JNH Social Services Director, JNH Recreational Supervisor, MSH Infection Prevention Director, Quality Management Coordinator. No further actions were recommended at this time. On 8/16/11 at approximately 10:30 a.m., NHA #1 spoke with DON #2 regarding the possible transfer of Resident #1 to a locked facility. Resident #1 has been approved for transfer to locked facility based upon availability. On 8/17/11 at approximately 7:30 a.m., RN #2 added a photo sheet identifier on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 8/17/11 at approximately 7:45 a.m., RN #2 placed a neon orange sheet of paper in the front of the "shift change report notebook" that states - the following residents are at risk for wandering, then the two (2) identified residents were listed, Resident #1 and Resident #3. On 8/17/11 at approximately 1:00 p.m., RN #2 began in-servicing facility staff (Nursing staff and CNA staff) to alert staff of the location of these identifiers for residents at risk for wandering. Nurses are to report during shift change to any new staff or agency staff the location of identifying information for residents at risk for wandering. On 8/17/11 at approximately 3:00 p.m., RN #2 began in-servicing facility staff (Nursing staff) on updating resident care plans as incident occur or with any changes in behavior such as increased wandering, medication changes and notifying physician. No staff was allowed to work until he/she was in-serviced. On 8/17/11 at approximately 4:30 p.m., RN #3 added additional updates to the care plan of Resident #1 and Resident #3 to include monitoring efforts. The monitoring efforts include accounting for resident on Accountability Sheet at 7:00 a.m., 9:00 a.m., 11:00 a.m., 3:00 p.m., 5:00 p.m., 7:00 p.m. and 11:00 p.m., offering resident fluids every two (2) hour. Updates to the care plan also included placing a photo sheet identifier on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"shift change report notebook" that states the resident is at risk for wandering. Resident's Activities of Daily Living (ADL) indicates that resident is at risk for wandering. Daily Assignment Sheets also indicate that the resident is at risk for wandering. On 8/17/11 at approximately 3:30 p.m., an additional QA meeting was held to review all actions that have been put into place at this time. These actions include education on the following policies and procedures, Wandering/Elopement/Abduction, Missing Residents, Vehicle Safety, Patient/Resident Daily Accountability, Care Plan/Updates and Injury, Abuse, Neglect, Mistreatment or Exploitation of Residents. ? Resident #1 was placed on visual contact while doors are unlocked. ? Implementation of Vehicle Monitoring ? Placed a photo sheet identifier on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. ? Placed a neon orange sheet of paper in the front of the "shift change report notebook" that states Resident #1 and Resident #3 are at risk for wandering. ? Resident's Activities of Daily Living (ADL) indicates Resident #1 and Resident #3 are at risk for wandering. ? Resident's Daily Assignment Sheets also indicate Resident #1 and Resident #3 are at risk for wandering. ? Resident #1 has been approved for transfer to locked facility based upon availability. Facility Staff present include: NHA #1, RN #2, RN#3, and JNH Medical Director #1. No additional actions were recommended at this time. Any noted deficient practice is reported to the Nursing Home Administrator or Designee and to QA for any further actions necessary." Verification of the AoC: Random interviews with Nursing Staff (RNs and LPNs), Certified Nursing Assistants (CNAs), and Administrative staff along with observations on 8/16/11 through 8/19/11 revealed that staff was aware of the policy to lock their car doors. Review of the "Car Lock Monitoring Log" that was provided by the Administrator revealed that cars were checked daily by administrative staff and any unlocked cars were being reported to security. Random interviews 8/16/11 through 8/19/11 revealed that staff had been in-serviced on Abuse/Neglect, Missing Residents, Wandering/Elopement/Abduction, Vehicle Safety, and Patient/Resident Daily Accountability, and Care Plans/Updates. It was verified through random interviews with the nursing staff and review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Random interviews with Nursing staff on 8/18/11 and 8/19/11 revealed that they were aware of which residents were at risk for wandering and how the residents were monitored for their wandering behavior. Nursing staff interviews on 8/18/11 and 8/19/11 verified that the residents identified at risk for wandering was reported to the oncoming shift during shift report. Random nursing interviews also verified that the neon sheet was in front of the shift report book which had the names of the two (2) residents at risk for wandering. Random nursing interviews and review of care plans on 8/18/11 and 8/19/11 revealed that the residents at risk for wandering had an updated care plan that included monitoring that was specific to their wandering risk which included visual contact for Resident #1 and every 15 minute time checks for Resident #3. Review of documentation and observations on 8/16/11 through 8/19/11 revealed that visual contact and every 15 minute documentation was provided for the two (2) residents at risk for wandering. Interview with LPN # 4 (an agency nurse) on 8/17/11 at 5:15 p.m. revealed that he had been inserviced about identifiers placed in the resident's record and shift change report book that identified residents at risk for wandering. Interviews with the Administrator on 8/16/11 at 3:00 p.m. revealed that the Quality Assurance (QA) Committee had met and discussed the elopement issue for Resident #1 on 8/11/11 and 8/16/11 with recommended interventions that were put into place. The signature pages were reviewed for both QA meetings. After verification of the facility's corrective actions that was validated by staff interviews, observation and in-service reviews, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 8/18/11 to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be further reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

CI MS #9663 Based on observation, interview, record review and policy review the facility failed to ensure that care plans were reviewed and revised and had specific interventions in place to monitor residents at risk for wandering/elopement for one (1) of six (6) residents reviewed (Resident #1) for Building 34. Resident #1 had a history of [REDACTED]. Resident #1 exited Building 34 on 8/10/11 at approximately 4:45 p.m. and got into an unlocked vehicle behind the building. The lack of implementations that care plans were updated and measures were put into place to prevent Resident #1 from leaving the building unsupervised and unassisted was deemed an Immediate Jeopardy (IJ) on 8/18/11 at 9:00 a.m. The Administrator was notified at that time. The IJ began on 8/10/11 and was determined to be removed on 8/18/11. The facility submitted a credible Allegation of Compliance (AoC) on 8/19/11. Based on the facility's implementation of corrective actions and an acceptable credible AoC, the Immediate Jeopardy was removed on 8/18/11 and lowered to a "D" level which constituted no actual harm with potential for more than minimal harm. Findings Include: Cross refer to F-323 for the facility's failure to have a care plan with monitoring interventions specific to Resident #1's wandering/exit seeking behavior and failure to supervise to prevent Resident #1 from exiting the building without staff knowledge. "Credible Allegation of Compliance" "On 8/10/11 at 4:45 p.m. Resident #2 reported to LPN #1 that Resident #1 was outside and was walking down the sidewalk. CNA #1 and LPN #1 after being told by Resident #2 exited the front door and Staffing Coordinator #1 exited the rear of the building and saw Resident #1 sitting in the backseat of a parked car closing the door. CNA #1 and LPN #1 escorted Resident #1 back to the building at approximately 4:51 p.m. on 8/10/11. It was estimated that Resident #1 was off the building for four (4) to five (5) minutes. LPN #1 examined Resident #1 and found no visible injuries. RN #1 was notified by LPN # 2 at approximately 4:50 p.m. on 8/10/11. RN #1 assessed Resident #1 at approximately 5:00 p.m. on 8/10/11 and found no visible injuries. Resident #1 was admitted to facility on 5/11/11 and assessed to be a wanderer and no documented checks were in place specific to wandering behavior. Facility investigation revealed that Vehicle Safety Policy was violated by Pantry Worker #1. On 8/16/11 at approximately 11:30 a.m. disciplinary action was issued that included a written reprimand to her personnel file. This written reprimand indicated that the employee failed to follow Vehicle Safety Policy. On 08/10/11 at 5:15 p.m., Resident #1 was placed on visual contact by the Medical Officer of the Day #1. Medical Officer of the Day is the attending physician on campus on call after hours. Visual Contact is defined as continuous observation of residents by one staff member for the purpose of monitoring behavioral and/or medical conditions. There is no defined distance between the observer and resident, but the observer must be able to visualize the actions of the resident assigned to them. On 08/10/11 at approximately 6:30 p.m., RN #1 began in-servicing all facility staff on duty at this time, which included Nursing and Pantry on the following policies: *JNH J500-15 Wandering/Elopement/Abduction. The purpose of this policy is to establish procedures when a resident of Jaquith Nursing Home is determined to be at risk for wandering or elopement. Specific elements of this policy that were covered included placing this resident on thirty minute time checks but in this case it was upgraded to visual contact. JNH J500-48 Missing Residents. The purpose of this policy is to establish procedures to be followed when a resident of Jaquith Nursing Home is determined to be missing from the Mississippi State Hospital (MSH) grounds, or when a resident does not return from an approved pass. Specific elements of this policy that were covered include to begin a search immediately and report the missing resident to all necessary disciplines i.e Floor Nurse, RN Supervisor and MSH Campus Police if resident is missing longer than ten minutes. MSH POL 184-05 Vehicle Safety. The purpose of this policy is to provide the fundamental rules for the operation of private and state motor vehicles on the premises of Mississippi State Hospital (MSH). Specific elements of this policy that were covered include: All car doors should be locked upon exiting the vehicle at all times. MSH POL 210-78 Patient/Resident Daily Accountability. The purpose of this policy is to establish procedures for patient/resident accountability 24 hours a day and maintaining written documentation of these checks. Specific elements of this policy that were covered include: building checks and resident accountability forms. No staff was allowed to work until he/she was in-serviced and no changes to the policy were made. On 08/10/11 at approximately 5:20 p.m., RN #1 updated the care plan of Resident #1 to include visual contact until further notice. This implementation of visual contact is documented every 15 minutes on MSH Form 31A by assigned staff. On 08/11/11 at approximately 1:30 p.m., RN #2 began in-servicing all facility staff that were on duty at the time which included Nursing, Pantry, Housekeeping, Laundry, Social Services, Psychology and Recreation on the following policy: JNH J530-55 Injury, Abuse, Neglect, Mistreatment or Exploitation of Residents. The purpose of this policy is to affirm that Jaquith Nursing Home (JNH) resident have a right to be free from abuse, neglect, sexual battery, mistreatment, exploitation, and misappropriation of property and to outline procedures for complying with Centers for Medicare Medicaid Services (CMS) and the Mississippi Vulnerable Adults Act of 1986 as annotated. Specific elements included definitions of injury, abuse and neglect and how failure to return resident to a safe environment could result in neglect. No staff was allowed to work until he/she was in-serviced and no changes to the policy were made. On 08/11/11 at 2:30 p.m. JNH QA meeting was held to discuss the incident of Resident #1 exiting the building without supervision on 8/10/11 and actions taken thus far. The QA committee consisted of DON #1, NHA #1, Building Doctor #1, RN #3, RN #2, Accreditation and Licensure Coordinator #1, RN #4, CUO #1, Administrative Assistant #1, Nurse executive #1, JNH Psychology Supervisor #1. Additional recommendations and actions were taken as a result of the QA meeting: -Development and implementation of Vehicle Monitoring. Facility supervisory staff will conduct random checks of vehicles parked in the immediate proximity once daily to ensure doors were locked. Any unlocked vehicles will be reported to MSH Campus Police and referred to Personnel Officer for possible disciplinary action. -Continue visual contact of Resident #1 by assigned nurses and cna's. -Contact family to discuss possibility of relocating Resident #1 to a locked unit. -Review all residents to identify any additional residents who are at risk for wandering. -Review and update care plans as needed. On 8/11/11 at approximately 3:15 p.m. DON #1 reviewed all facility residents to identify any additional residents at risk. No other residents were identified to be at risk for wandering except the two (2) that were previously noted to be at risk, Resident #1 and Resident #3. Measures were in place for Resident #3 that included time checks every 15 minutes. No episodes of exit seeking behavior or elopements have occurred for Resident #3. On 8/11/11 at 4:00 p.m., NHA #1 or designee began random checks of five (5) or more vehicles in the surrounding area daily to ensure that car doors remain locked. Documentation of these checks has been recorded on the Vehicle Monitoring Log. No concerns were found since 8/11/2011. On 8/12/11 at approximately 11:45 a.m. RN #2 updated Activities of Daily Living (ADL) records for resident #1 to further identify her at risk for wandering. This information was communicated to facility staff at the change of each shift which occurs at approximately 7:15 a.m., 3:15 p.m. and 11:15 p.m. On 8/16/11 at 9:30 a.m. incident and actions taken thus far were discussed at Quarterly QA meeting which was attended by JNH Medical Director. Facility Staff present included four (4) DON'S, four (4) NHA'S, JNH Director, JNH Nurse Administrator, JNH Psychology Supervisor, JNH Social Services Director, JNH Recreational Supervisor, MSH Infection Prevention Director, Quality Management Coordinator. No further actions were recommended at this time. On 8/16/11 at approximately 10:30 a.m., NHA #1 spoke with DON #2 regarding the possible transfer of Resident #1 to a locked facility. Resident #1 has been approved for transfer to locked facility based upon availability. On 8/17/11 at approximately 7:30 a.m., RN #2 added a photo sheet identifier on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 8/17/11 at approximately 7:45 a.m., RN #2 placed a neon orange sheet of paper in the front of the "shift change report notebook" that states - the following residents are at risk for wandering, then the two (2) identified residents were listed, Resident #1 and Resident #3. On 8/17/11 at approximately 1:00 p.m., RN #2 began in-servicing facility staff (Nursing staff and CNA staff) to alert staff of the location of these identifiers for residents at risk for wandering. Nurses are to report during shift change to any new staff or agency staff the location of identifying information for residents at risk for wandering. On 8/17/11 at approximately 3:00 p.m., RN #2 began in-servicing facility staff (Nursing staff) on updating resident care plans as incident occur or with any changes in behavior such as increased wandering, medication changes and notifying physician. No staff was allowed to work until he/she was in-serviced. On 8/17/11 at approximately 4:30 p.m., RN #3 added additional updates to the care plan of Resident #1 and Resident #3 to include monitoring efforts. The monitoring efforts include accounting for resident on Accountability Sheet at 7:00 a.m., 9:00 a.m., 11:00 a.m., 3:00 p.m., 5:00 p.m., 7:00 p.m. and 11:00 p.m., offering resident fluids every two (2) hour. Updates to the care plan also included placing a photo sheet identifier on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"shift change report notebook" that states the resident is at risk for wandering. Resident's Activities of Daily Living (ADL) indicates that resident is at risk for wandering. Daily Assignment Sheets also indicate that the resident is at risk for wandering. On 8/17/11 at approximately 3:30 p.m., an additional QA meeting was held to review all actions that have been put into place at this time. These actions include education on the following policies and procedures, Wandering/Elopement/Abduction, Missing Residents, Vehicle Safety, Patient/Resident Daily Accountability, Care Plan/Updates and Injury, Abuse, Neglect, Mistreatment or Exploitation of Residents. ? Resident #1 was placed on visual contact while doors are unlocked. ? Implementation of Vehicle Monitoring ? Placed a photo sheet identifier on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. ? Placed a neon orange sheet of paper in the front of the "shift change report notebook" that states Resident #1 and Resident #3 are at risk for wandering. ? Resident's Activities of Daily Living (ADL) indicates Resident #1 and Resident #3 are at risk for wandering. ? Resident's Daily Assignment Sheets also indicate Resident #1 and Resident #3 are at risk for wandering. ? Resident #1 has been approved for transfer to locked facility based upon availability. Facility Staff present include: NHA #1, RN #2, RN#3, and JNH Medical Director #1. No additional actions were recommended at this time. Any noted deficient practice is reported to the Nursing Home Administrator or Designee and to QA for any further actions necessary." Verification of the AoC: Random interviews with Nursing Staff (RNs and LPNs), Certified Nursing Assistants (CNAs), and Administrative staff along with observations on 8/16/11 through 8/19/11 revealed that staff was aware of the policy to lock their car doors. Review of the "Car Lock Monitoring Log" that was provided by the Administrator revealed that cars were checked daily by administrative staff and any unlocked cars were being reported to security. Random interviews 8/16/11 through 8/19/11 revealed that staff had been in-serviced on Abuse/Neglect, Missing Residents, Wandering/Elopement/Abduction, Vehicle Safety, and Patient/Resident Daily Accountability, and Care Plans/Updates. It was verified through random interviews with the nursing staff and review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Random interviews with Nursing staff on 8/18/11 and 8/19/11 revealed that they were aware of which residents were at risk for wandering and how the residents were monitored for their wandering behavior. Nursing staff interviews on 8/18/11 and 8/19/11 verified that the residents identified at risk for wandering was reported to the oncoming shift during shift report. Random nursing interviews also verified that the neon sheet was in front of the shift report book which had the names of the two (2) residents at risk for wandering. Random nursing interviews and review of care plans on 8/18/11 and 8/19/11 revealed that the residents at risk for wandering had an updated care plan that included monitoring that was specific to their wandering risk which included visual contact for Resident #1 and every 15 minute time checks for Resident #3. Review of documentation and observations on 8/16/11 through 8/19/11 revealed that visual contact and every 15 minute documentation was provided for the two (2) residents at risk for wandering. Interview with LPN # 4 (an agency nurse) on 8/17/11 at 5:15 p.m. revealed that he had been inserviced about identifiers placed in the resident's record and shift change report book that identified residents at risk for wandering. Interviews with the Administrator on 8/16/11 at 3:00 p.m. revealed that the Quality Assurance (QA) Committee had met and discussed the elopement issue for Resident #1 on 8/11/11 and 8/16/11 with recommended interventions that were put into place. The signature pages were reviewed for both QA meetings. After verification of the facility's corrective actions that was validated by staff interviews, observation and in-service reviews, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 8/18/11 to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be further reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

CI MS #9663 Based on observation, interview, record review and policy review, the facility failed to ensure that residents received adequate supervision consistent with resident needs to prevent leaving the facility without supervision for one (1) of six (6) residents reviewed, Resident #1. Resident #1 was assessed and care planned as a risk for wandering and exiting the building without supervision. There was no care plan or monitoring interventions in place that were specific to Resident #1's wandering and exit seeking behavior. Resident #1 left Building 34 without staff knowledge on 8/10/11 and ambulated to the back of the building which was approximately 175 paces. Resident #1 was seen by Certified Nursing Assistant (CNA) #2 getting into the back seat of an unlocked car. Resident #2 reported that he had seen Resident #1 exit the building. Two (2) nurses, Licensed Practical Nurse (LPN) #1 and LPN #2, and two (2) Certified Nursing Assistants (CNAs), CNA #1 and CNA #5, who worked in Building 34 were unaware that Resident #1 was a wander risk. The lack of implementation to supervise and ensure that measures were put into place to prevent Resident #1 from leaving the building unsupervised and unassisted was deemed Substandard Quality of Care and an Immediate Jeopardy on 8/18/11 at 9:00 a.m. The Immediate Jeopardy began on 8/10/11 and was determined to be removed on 8/18/11. The Administrator was notified of the Immediate Jeopardy on 8/18/11 at 9:00 a.m. The facility submitted a credible Allegation of Compliance (AoC) on 8/19/11. Based on the facility's implementation of corrective actions and an acceptable credible AoC, the Immediate Jeopardy was removed on 8/18/11 and lowered to a "D" level which constituted no actual harm with potential for more than minimal harm. Findings Include: The facility reported the following information to the state agency: "On 08/10/11 at 4:45 p.m. resident (Resident #1) reported to (LPN #1), that resident (Resident #1) was outside and was walking down the sidewalk. Staff immediately exited the front and rear of the building and saw (Resident #1) sitting in the backseat of a parked car closing the door. (CNA #1) and (LPN #1), escorted (Resident #1) back to the building. It was estimated that (Resident #1) was off the building for four to five minutes. (LPN #1), examined (Resident #1) and found no visible injuries. (RN #1), RN Supervisor, was notified and assessed (Resident #1) and found no visible injuries. Review of the facility's "Investigative Findings" dated August 15, 2011 revealed "BUILDING 34 ELOPEMENT LESS THAN TWO HOURS: (RESIDENT #1)." "On 8/10/11, (Resident #1) was noted missing from Building 34. Upon searching the grounds, (Resident #1) was located outside of Building 34. (Resident #1) was sitting in a parked vehicle which belonged to pantry worker (Pantry Worker #1). (Resident #1) was removed from the vehicle by staff and escorted back into Building 34. (Resident #1) sustained no injuries during this incident." "After completing this investigation there is no indication of neglect involving (Resident #1) when she left Building 34 and was immediately discovered in a parked vehicle outside of the building. This finding is based on the following: 1) No documentation was found which indicated (Resident #1) was assigned 1:1 observation, visual contact observation, or was on time checks at the time of the incident. 2) Building staff immediately began to search for (Resident #1). 3) (Resident #1) was discovered within five minutes or less after leaving the building and was immediately returned to Building 34 without incident; upon return, (Resident #1) was examined and discovered to have no injuries. 4) Documentation indicates that (Resident #1) frequently seeks "exits" in order to leave the building; documentation also indicates (Resident #1) has a history of wandering. 5) Building 34 is not a locked building. This matter warrants no further investigation by the Department of Safety and Investigative Services and is closed..." Two (2) residents, Resident #1 and Resident #3, were at risk for wandering/exiting the building without assistance that were housed in Building 34, which is not a locked unit and has no Wander Guard (WG) system. There were four (4) residents at risk for elopement in building 28, which is a locked unit with a WG system. There were no concerns noted for Building 28 in regards to elopement and protocol was followed for monitoring the residents at risk for wandering. Observation on 8/16/11 at 11:30 a.m. revealed that the distance between the front door of Building 34 and the location where Resident #1 was found on 8/10/11 was approximately 175 paces. This location was at the back of Building 34 where vehicles were parked. The terrain was fairly level with a smooth path. There was gravel in the parking lot where the cars were and a small tree that had roots on top of the ground nearby the path. There were six (6) locked cars in the parking lot at the time. Resident #1: Observation and interview with Resident #1 on 8/16/11 at 11:20 a.m., revealed that she was ambulatory in the hallway with LPN #5. She was alert and verbally responsive and answered some questions appropriately but was very slow to process them. When asked about leaving the facility, Resident #1 just smiled and showed her bracelet on her arm with her name on it and a black and white arm band. Resident #1 was observed throughout the survey 8/16/11-8/19/11 ambulating with a steady gait and staff within sight of her, documenting on paper of her whereabouts every 15 minutes while the building doors were unlocked. There were no attempts observed of Resident #1 exiting the building. Resident #1 was observed to have a black and white band on her right wrist at all times during the survey. Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's initial Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/17/11 revealed that she was independent with transfer and ambulation. Resident #1 scored 11 of 15 on a Brief Interview for Mental Status (BIMS) which indicated that Resident #1 had moderate cognitive impairment. (A score of 8-12 is moderate cognitive impairment). There were no behaviors coded for Resident #1. Review of a quarterly MDS with an ARD of 8/5/11 revealed a score of 12 of 15 BIMS and Resident #1 continued to be independent with ambulation and transfer. There were no behaviors coded for Resident #1. Review of a "Nursing Assessment", dated 5/11/11 at 9:10 a.m., revealed that Resident #1 had a chief complaint of confusion (dementia) with impaired recent memory, remote memory, attention span and judgment. Review of a "Psychology General Assessment", dated 5/12/11 at 11:50 a.m., revealed that Resident #1 had no behaviors other than wandering noted with medications of Effexor XR (Antidepressant) and Risperdal (Antipsychotic). Another psychology note dated 5/12/11 at 11:10 a.m. revealed that Resident #1 was prone to wander. Resident explained: "I was getting lost in my neighborhood and couldn't find my house". Review of a "Social History and Assessment" for Resident #1, dated 5/12/11, revealed that the resident's husband had noted some little things and then the resident began wandering away from home in the neighborhood and knocking on doors. The facility treatment team felt like the resident would benefit from a supervised setting. An "Interdisciplinary Notes" (Social Work Note) for Resident #1 dated 5/26/11 revealed that the treatment team met with the family to discuss another building, Building 28, that was equipped to maintain wanderers. The family declined transfer to Building 28 on 5/26/11. On 5/27/11 the family toured Building 31 and declined transfer for Resident #1. A Social note dated 6/20/11 revealed that Resident #1's family had toured Building 48 and Resident #1 would remain in Building 34 until there was availability in Building 48. Review of (Physician's) "Progress Notes" for Resident #1 revealed the following dates and information in regards for her wandering/exit seeking behavior: 5/11/11 at 12:10 p.m. - early onset of Dementia. 5/20/11 at 2:20 p.m. - Resident having a good deal of sundowning, becomes agitated in the evenings-delusions, frequently tearful-benefit from the addition of Zoloft (Antidepressant)-will taper Effexor. There was no documented evidence that the physician addressed the resident's wandering/exit seeking at this time. 5/24/11 at 12:00 noon - Resident has been exit seeking frequently in the afternoons-has gotten out the door at least once but quickly redirected by staff. To have the social worker call family to meet about possible transfer to a building with Wander Guard. 5/26/11 at 10:40 a.m. - Resident's family agrees to move to Bldg 28 with a Wander Guard system. 5/26/11 at 11:30 a.m. - Resident's family declined move to Bldg 28 (no other alternatives documented). 6/10/11 at 3:20 p.m. - Resident continues to exit seek at times but can be usually redirected by staff, tearfulness. Increase Zoloft and try to find more activities. 7/29/11 at 10:00 a.m. - No recent exit seeking behavior reported. 8/11/11 at 3:15 p.m. - Resident wandered outside yesterday afternoon and sat in backseat of a car-another resident saw her and notified the nurse. No injuries-surprised since she'd done so well lately-will keep her on VC (visual contact) awhile. Review of a "Treatment Team Meeting Minutes", dated 5/26/11, revealed that Resident #1 had behavior problems of "Attempting to leave building unassisted". Review of Resident #1's Activity of Daily Living (ADL) records revealed a sheet located in front of Resident #1's ADL documents of (Resident #1' name), A Shift bath, Resident able to feed self, ambulatory, Resident had dementia and is confused, has a history of wandering, resident is independent with ADL's. and assist as needed. On the August 2011 ADL sheet, page 4, there was a handwritten note dated 8/12/11 at 11:45 a.m. which revealed "Change VC (Visual Contact) to VC @ (at) all times that doors are not locked" and "Resident has potential for wandering". There was no documented evidence of monitoring efforts prior to 8/12/11 on Resident #1's ADLs. Review of "Nurse Notes" for Resident #1 revealed the following dates and information in regards to her wandering/exit seeking behavior: 5/16/11 at 7:00 p.m. -resident has had three episodes where she attempted to walk out the door. The door was locked. 5/17/11 at 9:30 p.m. -crying and pacing corridor and going from up and down the stairs repeatedly. 5/18/11 at 7:00 p.m. -agitated, pacing hallway and going up and down the elevator repeatedly. 5/18/11 at 7:40 p.m. - pacing hallway, going up and down stairs, attempting to go out front door of the building and going in and out of other resident's rooms repeatedly. 5/19/11 at 9:00 p.m. - agitated for no apparent reason, pacing corridor, going up and down the elevator with attempts of exit first floor front door, crying loudly, going from her room to another room repeatedly. 5/22/11 at 1:30 p.m. - another resident alerted nurses that this resident had exited the front door of building. Nurse found resident standing on walkway near door crying. When asked what was wrong resident grabbed writer's hand and started walking away from the building. Informed resident that she shouldn't leave the building without staff for fear of her getting lost-resident voiced okay and yes-will continue to monitor. (No documentation of how resident was to be monitored.) 5/23/11 at 10:00 a.m. -"Go home". Nurse explained to resident that this is where she lives now and resident screamed "no". 5/23/11 at 1:35 p.m. - Resident noted by nurse going out of front door of building. Nurse assisted resident back into the building without problems. Assisted back upstairs. Will monitor. (No documentation of how monitored.) 5/26/11 10:45 a.m. (Late Entry) - Special TX (treatment) team was called today concerning possible elopement of resident on unlocked unit with family and TX team. MD and family present. TX team explained to family that resident is confused and becomes more confused in evenings and that resident has made multiple attempts to leave building unescorted. It was the TX team that see this is being a future problem. As an alternative the family was offered to move resident to a locked Bldg (building) for her safety. The family was allowed to tour Bldg 28 for possible placement there. Family was against the move and refused to move resident to Bldg 28. Will continue to monitor resident for elopement issue. Resident remains on 2 weeks pass. (There was no documented alternative monitoring interventions put into place at this time once the family refused a move to another building). 6/4/11 at 3:20 p.m. - Resident has been slightly agitated this shift, crying and several times leaving of bldg and going down side walk. States "(name of husband) here". 8/10/11 at 4:45 p.m. - Nurse downstairs alerted this nurse that resident went outside unassisted. (Another resident) alerted nurse that he saw resident get into employee's car. Resident returned to building. RN supervisor notified. MD notified and an order received for VC (visual contact) until further notice. 8/10/11 at 4:53 p.m. - writer (RN Supervisor) was notified by (LPN #1) that Resident #1 was outside and walking up the sidewalk. (CNA #2) reportedly discovered the resident sitting in the pantry worker's car behind the building (Bldg 34). (CNA #1) and (LPN #1) escorted Resident #1 back into the building, no injuries were visible. The resident cannot verbalize what her intentions were at the time. The resident has a history of wandering. 8/10/11 at 5:14 p.m. - Resident placed on visual contact per MD until further notice. 8/10/11 at 6:00 p.m. - Resident #1's family notified-"he had been expecting this to happen". Care plan was updated to include new intervention for visual contact. Review of a care plan for Resident #1, dated 5/11/11, revealed a problem: "Resident at risk for wandering off building unescorted by staff due to (d/t) cognitive status". The approaches included: "* Black and white identification band to be worn on resident at all times (to identify resident at risk for wandering) with name, building number and ID number. * If resident discovered to be missing notify nurse and staff is to search the immediate area if resident is not found within 10 minutes call security immediately and all available staff to begin search of campus grounds and follow JNH Policy #J500-48. * Notify MD of any episodes of wandering. * If resident attemps (attempts) to leave bldg (building) unescorted follow resident and encourage resident to come back to unit using diversional tech. (technique) ie offer snack, watch TV or participate in activity of choice. * Resident teaching done regarding leaving building unescorted without staff prn (as needed)". There was no documented evidence that interventions/approaches that indicated how often, who was responsible and how Resident #1 was to be monitored for wandering behavior. Review of an updated care plan dated 8/10/11 at 4:45 p.m., revealed that Resident #1 wandered outside of Building 34 through the front door, walked around the side of the building and got into the back seat of an employee's car. The approaches included: Placed on visual contact. NHA (Nursing Home Administrator), DON (Director of Nursing) notified. Correspondent (name) notified. Safety & Investigative Services was notified. There were no additional approaches documented on Resident #1's care plan for 8/10/11. Review of "physician's orders [REDACTED]. A further order dated 8/12/11 at 11:45 a.m. revealed an order to change VC to VC at all times that doors are not locked". Review of the "Daily Assignment Sheet", dated 8/10/11, did not have documented information that Resident #1 was at a risk for wandering/elopement. Review of the assignment sheet dated 8/16/11 did not have Resident #1 designated at risk for elopement or with VC (visual contact) monitoring. Review of the "Shift Change Report Book", from May 2011 through August 10, 2011, did not have documentation on each shift report or even daily that Resident #1 was at risk for wandering/elopement. Interview with the DON on 8/16/11 at 11:10 a.m. revealed that Resident #1 had been admitted in May 2011 and was assessed and care planned as a wander risk but had settled down and had not been exit seeking for the past couple of months. The DON stated that Resident #1 had been placed on the second floor so that she wouldn't readily see the front door and was on regular protocol of every two (2) hour monitoring which is the accountability checks and bed checks. The DON stated that Resident #2 had told LPN #1, an agency nurse, that he had seen Resident #1 on the sidewalk on 8/10/11. The DON stated that Resident #1 was seen in an employees car out back of building (34). She stated that the weather was pretty warm that evening. She stated that Resident #1 was out of the building less than five (5) minutes and was placed on visual contact upon return. Further Interview with the DON on 8/16/11 at 2:55 p.m. revealed that Resident #1 was not on any type of time checks prior to her exit from the building on 8/10/11. The DON stated that there had not been any attempts for Resident #1 to leave the building after the first few weeks after admission to the facility. She stated that the family had declined moving the resident to the building with a Wander Guard system. When asked what measures were put in place for Resident #1 after the family had declined the move, the DON stated that Resident #1 had a black and white (b/w) striped arm band for identification as a wanderer and she had a care plan for the risk. The DON was shown the policy that indicated any resident at risk for wandering would have every 30 minute time checks. The DON stated that Resident #1 was not getting 30 minute time checks, that Resident #1 had not shown any signs of exiting the building recently. The DON was reminded that Resident #1 was still care planned for the risk of wandering and that there had been no updates or interventions done since 5/11/11. Also, there were documented nurse's notes where Resident #1 had exited the building on 5/22/11 and the DON stated that there was a team meeting on 5/26/11 to discuss the issue and the family refused to move the resident to another building. The DON stated that once there was an availability in Building 48 that the family will allow the resident to be moved. Again the DON was asked what other measures were put into place to help prevent Resident #1 from elopement and were measures care planned? The DON stated that Resident #1 was on the second floor, had the b/w identification bracelet, staff aware of her risk, and every two (2) hour observation with whereabouts documented. The DON stated that the CNAs didn't have a care plan for Resident #1's wander risk but provided fluids every two (2) hours that alternated with the accountability checks. Interview with Resident #2 on 8/16/11 at 11:25 a.m., revealed that he was alert and oriented to person, place and time. Resident # 2 stated that he was walking toward the building (on 8/10/11) and saw Resident #1 walking away from the building down the sidewalk toward the back. Resident #2 stated that he had thought about going after Resident #1 but decided to go and tell the nurse. Resident #2 stated that the nurses (names unknown) came out to look for Resident #1. He stated that he had not seen Resident #1 come out before but didn't think she was supposed to be outside. Review of Resident #2's medical record revealed that he was cognitively intact. Resident #2's initial MDS with an ARD of 6/21/11 had a 15 of 15 BIMS score. (A score of 13-15 means no cognitive impairment). Interview with RN #2, Head Nurse of Building 34, on 8/16/11 at 3:05 p.m. revealed that she had been informed of Resident #1's exit from Building 34 the next day. RN #2 stated that Resident #1 was on every two (2) hour observational checks prior to her exit of the building on 8/10/11. RN #2 stated that staff had observed Resident #1 with multiple attempts to leave the building (prior to 8/10/11) but had redirected her. RN #2 stated that Resident #1 had no recent attempts to leave the building. RN #2 stated that Resident #1 had attempted to leave the building after she had been initially admitted . RN #2 was shown the policy for Wandering/Elopement/Abduction which indicated that residents who were assessed as a wander risk should have every (Q) 30 minute time checks. RN #2 stated that Q 30 minute time checks had not been performed for Resident #1 prior to her exit from the building. Interview with RN #2, Head Nurse, on 8/16/11 at 3:20 p.m. revealed that Resident #1's husband had said that Resident #1 was going to neighbor's houses in the middle of the night and that he couldn't handle her anymore. RN #2 stated that Resident #1's husband had brought Resident #1 to the facility because he couldn't keep up with her. RN #2 stated that Resident #1 was care planned for a potential wander risk. She stated that Resident #1 was placed upstairs and a black and white (b/w) band was placed on her arm. RN #2 stated that when an incident occurred the nurse on duty should update the care plan with interventions. RN #2 stated that if something got overlooked that she would update the care plan after the stand up meetings that were held Monday through Friday. At this time, RN #2 looked at Resident #1's care plan dated 5/11/11 and couldn't find any updates about Resident #1's exit seeking behavior or leaving the building prior to 8/10/11. RN #2 stated that she guessed the Q 30 minute time checks, according to policy, got over looked. Further interview with RN #2, Head Nurse, on 8/16/11 at 4:05 p.m. revealed that Resident #1 had not been listed as a wander risk on the staff "Assignment Sheet"on 8/10/11 or as of today, 8/16/11 and it should have been. RN #2 stated that after Resident #1 was admitted to the facility that she had placed a sheet in front of Resident #1's ADL sheet. This sheet indicated that Resident #1 was at risk for wandering. Interview with CNA #2 on 8/16/11 at 3:10 p.m., revealed that she was downstairs on 8/10/11 and was told that the lady from upstairs was missing and had left the building. CNA #2 stated that she had gone out the back door and saw Resident #1 in the back of a car with the door open. CNA #2 stated that Resident #1 closed the car door when she (Resident #1)saw her. CNA #2 stated that the car belonged to (Pantry Worker #1). CNA #2 stated that there was a policy on locked doors here. CNA #2 stated that she was not aware that Resident #1 would do that. CNA #2 stated that she had known that Resident #1 had made attempts to leave the building when first admitted . Further interview with CNA #2 on 8/18/11 at 4:20 p.m. revealed that Resident #1 had not been out of the building more than four (4) to five (5) minutes on 8/10/11. CNA #2 stated that Resident #1 had no evidence of a fall and that the weather was sunny and warm. Interview with LPN #1, an agency nurse, on 8/16/11 at 3:35 p.m. revealed that she had worked the B shift (3:00 p.m.-11:00 p.m.) on 8/10/11. LPN #1 stated that she was sitting at the nurse's station when one of the other residents, Resident #2, came and reported that Resident #1 was out on the sidewalk. LPN #1 stated that she went outside and behind the building and saw CNA #1 and CNA #2 getting Resident #1 out of the back of a car. LPN #1 stated that she had not been aware that Resident #1 was at risk for wandering/exiting the building. LPN #1 stated that the nurse upstairs who was assigned to Resident #1 had looked at the chart and care plan after the incident. With permission from LPN #1, RN #2 listened to the phone conversation and LPN #1 repeated that she had not known that Resident #1 had been at risk for wandering until after the incident. Further interview with LPN #1 on 8/17/11 at 12:30 p.m. revealed that she wasn't sure what kind of arm band that Resident #1 had on when she exited the building on 8/10/11. LPN #1 was not aware of a black and white arm band for Resident #1. LPN #1 stated that during shift report the nurse would give information about anything significant but that she had never been told that Resident #1 was a wander risk. Interview with CNA #1 on 8/16/11 at 3:45 p.m., revealed that she had worked downstairs on B shift on 8/10/11 and heard Resident # 2 say that Resident #1 was outside on the sidewalk. CNA #1 stated that she and CNA # 2 had gone out the door that led to the back of the building while the nurse went out the front. CNA #1 stated that she saw a car door open and Resident #1 sitting in the back seat. CNA #1 stated that Resident #1 was taken upstairs and her CNA, (CNA #4), was told about the incident. CNA #1 stated that CNA #4 said that she'd just seen the resident in her room. CNA #1 stated that the incident had happened somewhere between 4:30 p.m. and 4:45 p.m. CNA #1 stated that she had not been aware that Resident #1 was at risk for wandering/elopement before she (Resident #1) left the building. CNA #1 stated that they usually discuss information in shift report but that she had not been told of Resident #1's wander risk. CNA #1 stated that "Resident Accountability Sheets" are documented for resident whereabouts every two (2) hours and bed checks are documented every 30 minutes after 7:00 p.m. Interview with LPN #2, an agency nurse, on 8/16/11 at 4:10 p.m., revealed that she had been working the 3:00 p.m.-11:00 p.m. (B) shift on 8/10/11 when Resident #1 had went outside. LPN #2 stated that she had been assigned to the upstairs unit and that Resident #1 had come to the desk three (3) times after 3:00 p.m. LPN #2 stated that she had not been aware that Resident #1 was a risk for wandering at the time the incident happened. LPN #2 stated that Resident #1 had not shown any signs of exit seeking behavior during the times that she had worked. LPN #2 stated that after being told that Resident #1 had gone outside, she had looked in the resident's chart and saw that Resident #1 had a care plan for the risk of wandering. LPN #2 stated that there were also nurse's notes in May and June 2011 which documented Resident #1's wandering behavior . LPN #2 stated that staff usually reported any concerns during the shift report and that there was not a list at the station that indicated Resident #1 was at risk for wandering. LPN #2 stated that the incident happened somewhere between 4:30 p.m. and 4:45 p.m. and that Resident #1 came back into the facility with no injuries. Resident #1 was placed on visual contact that evening. Interview with CNA #4 on 8/16/11 at 4:25 p.m., revealed that she had been in another resident's room and was told that Resident #1 had been outside. CNA #4 stated that just before she went into another residents room she had seen Resident #1. CNA #4 stated that she had been aware that Resident #1 was a wander risk. CNA #4 stated that she usually checked on the residents about every 30 minutes. CNA #4 stated that she documented on the accountability sheets every two (2) hours and bed checks every 30 minutes. (The bed checks start after 7:00 p.m.). CNA #4 stated that she was not aware of any documentation on the ADL or Assignment Sheet about Resident #1 being at risk for wandering prior to her exit from the building. CNA #4 stated that Resident #1 was now on Visual Contact (VC). Interview with RN #2 (Head Nurse) on 8/16/11 at 4:40 p.m., revealed that she was not aware that the nurses didn't know that Resident #1 was at risk for wandering. RN #2 stated that she thought everyone had known. RN #2 stated that the information should have been discussed in shift report about Resident #1's wander risk. RN #2 stated that Resident #1 had the black and white ID band and a care plan for the risk of wandering. Interview with RN #3 on 8/16/11 at 5:15 p.m., with RN #2 present, stated that agency nurses are given report at shift change and should have been notified that Resident #1 was at risk for wandering. RN #3 stated that information is reported by word of mouth as to where things are located in the building, such as list of wanderers, where equipment is located, orientation of supplies such as tube feeding and treatment rooms. Further interview with RN #3 on 8/18/11 at 9:45 a.m., revealed that the nurses on the unit who take an order or witness an issue should update the care plan, but this doesn't always happen. RN #3 stated that she updated the care plans with the MDS. RN #3 stated that Resident #1's care plan should have been updated by the Head Nurse after the team meeting of 5/26/11 for her wandering and exit seeking behavior. Interview with the Nursing Home Administrator (NHA) for Building 34 on 8/17/11 at 8:30 a.m., revealed that staff was "working toward" getting Resident #1 identified as not a wander risk because her behavior had settled down with no attempts to exit the building since June. The NHA stated that he had read the part of the policy about every 30 minute time checks for residents at risk for wandering. The NHA agreed that staff was not checking Resident #1 per policy. Discussion with the administrator included the numerous attempts of wandering/exit seeking behavior that was documented for Resident #1, no increased measures implemented, the care plan not updated and that staff were not knowledgeable about Resident #1 being at risk for elopement. The NHA agreed that other measures should have probably been put into place for Resident #1. Interview with RN #2 on 8/17/11 at 9:35 a.m. revealed that she had put an orange sheet that listed Resident #1 and Resident #3 as a wander risk in front of the "shift change report book" that morning as part of the corrective action that informed staff of residents at risk for wandering. RN #2 stated that information had only been reported through word of mouth during shift report for the kind of monitoring or observation of residents. Interview with LPN #3 on 8/17/11 at 9:40 a.m., revealed that Resident #1 would get agitated, cry for her husband and look for him. LPN #3 stated that she had never seen Resident #1 go outside by herself, that she had witnessed her go toward the door and that she would follow Resident #1 outside. LPN #3 stated that if residents were pacing or going toward the front door then they would be considered a risk and usually they would be put on time checks or visual contact. LPN #3 stated that it had been discussed that Resident #1 was at risk for wandering because she had a history of [REDACTED]. LPN #3 stated that she had not been aware of any documentation of shift report or a list of residents at risk for elopement prior to 8/10/11. LPN #3 stated that she had not been aware of any special identification bracelets for wander risk, but knows they do now. LPN #3 did not recall Resident #1 having a black and white band on when she went outside on 6/4/11. Interview with DON #3, DON of another building, on 8/17/11 at 10:30 a.m., revealed that there was a "Nurse Orientation Handbook" that had policies and procedures. There was no policy/procedure for wandering or elopement found in the handbook. This was confirmed by DON #3 who stated that she had checked with the Head Nurse and Building 34 had no other specific policy/procedures for agency. DON #3 stated that the handbook was specifically for agency staff and that the RN Supervisors go over the handbook with agency nurses and the nurses sign that they have reviewed the book. DON #3 could not find where LPN #2 had signed the form for reviewing the handbook. DON #3 stated that during shift change pertinent information should be shared and residents at risk for wandering should be part of that. DON #3 stated that when agency staff comes to a building for the first time they should be oriented to the building and where things are kept and who is at risk for certain things. Interview with RN #1, RN Supervisor, on 8/17/11 at 12:45 p.m., revealed that he had been paged to Building 34 (on 8/10/11) by LPN #1. RN #1 was told by LPN #1 that Resident #2 had reported that Resident #1 was outside the building. RN #1 stated that Resident #1 had been found in a parked worker's car. RN #1 stated that this was around 5:00 pXXX

CI MS #9663 Based on observation, interview and record review, the facility failed to ensure that agency and other staff were effectively trained and knowledgeable of residents that were deemed a wandering/elopement risk for the building (Building 34) for one (1) of six (6) residents reviewed, Resident #1. Resident #1 was assessed and care planned as a wander risk on admission and two (2) agency nurses, LPN #1 and LPN #2 and two (2) Certified Nursing Assistants (CNAs), CNA #1 and CNA #5, who were on duty 8/10/11 were not aware of the risk. Resident #1 exited the building without staff knowledge on 8/10/11 and was found in an unlocked car behind the building approximately four (4) to five (5) minutes after staff was notified by another resident, Resident #2. The lack of implementation that staff was aware of residents at risk for elopement and that measures were put into place to prevent Resident #1 from leaving the building unsupervised and unassisted was deemed an Immediate Jeopardy on 8/18/11 at 9:00 a.m. The Administrator was notified at that time. The Immediate Jeopardy began on 8/10/11 and was determined to be removed on 8/18/11. The facility provided a credible Allegation of Compliance (AoC) on 8/19/11. Based on the facility's implementation of corrective actions and an acceptable credible AoC, the Immediate Jeopardy was removed as of 8/18/11 and lowered to a "D" level which constitutes no actual harm with potential for more than minimal harm. Findings Include: Cross refer to F-323 for the facility's failure to ensure that staff was trained and knowledgeable about residents who were at risk for wandering/elopement behavior. Resident #1 was assessed and care planned for the risk of wandering. Resident #1 exited the building without staff knowledge on 8/10/11 and was found in an unlocked car. Staff on duty was not aware of Resident #1's wandering risk. "Credible Allegation of Compliance" "On 8/10/11 at 4:45 p.m. Resident #2 reported to LPN #1 that Resident #1 was outside and was walking down the sidewalk. CNA #1 and LPN #1 after being told by Resident #2 exited the front door and Staffing Coordinator #1 exited the rear of the building and saw Resident #1 sitting in the backseat of a parked car closing the door. CNA #1 and LPN #1 escorted Resident #1 back to the building at approximately 4:51 p.m. on 8/10/11. It was estimated that Resident #1 was off the building for four (4) to five (5) minutes. LPN #1 examined Resident #1 and found no visible injuries. RN #1 was notified by LPN # 2 at approximately 4:50 p.m. on 8/10/11. RN #1 assessed Resident #1 at approximately 5:00 p.m. on 8/10/11 and found no visible injuries. Resident #1 was admitted to facility on 5/11/11 and assessed to be a wanderer and no documented checks were in place specific to wandering behavior. Facility investigation revealed that Vehicle Safety Policy was violated by Pantry Worker #1. On 8/16/11 at approximately 11:30 a.m. disciplinary action was issued that included a written reprimand to her personnel file. This written reprimand indicated that the employee failed to follow Vehicle Safety Policy. On 08/10/11 at 5:15 p.m., Resident #1 was placed on visual contact by the Medical Officer of the Day #1. Medical Officer of the Day is the attending physician on campus on call after hours. Visual Contact is defined as continuous observation of residents by one staff member for the purpose of monitoring behavioral and/or medical conditions. There is no defined distance between the observer and resident, but the observer must be able to visualize the actions of the resident assigned to them. On 08/10/11 at approximately 6:30 p.m., RN #1 began in-servicing all facility staff on duty at this time, which included Nursing and Pantry on the following policies: *JNH J500-15 Wandering/Elopement/Abduction. The purpose of this policy is to establish procedures when a resident of Jaquith Nursing Home is determined to be at risk for wandering or elopement. Specific elements of this policy that were covered included placing this resident on thirty minute time checks but in this case it was upgraded to visual contact. JNH J500-48 Missing Residents. The purpose of this policy is to establish procedures to be followed when a resident of Jaquith Nursing Home is determined to be missing from the Mississippi State Hospital (MSH) grounds, or when a resident does not return from an approved pass. Specific elements of this policy that were covered include to begin a search immediately and report the missing resident to all necessary disciplines i.e Floor Nurse, RN Supervisor and MSH Campus Police if resident is missing longer than ten minutes. MSH POL 184-05 Vehicle Safety. The purpose of this policy is to provide the fundamental rules for the operation of private and state motor vehicles on the premises of Mississippi State Hospital (MSH). Specific elements of this policy that were covered include: All car doors should be locked upon exiting the vehicle at all times. MSH POL 210-78 Patient/Resident Daily Accountability. The purpose of this policy is to establish procedures for patient/resident accountability 24 hours a day and maintaining written documentation of these checks. Specific elements of this policy that were covered include: building checks and resident accountability forms. No staff was allowed to work until he/she was in-serviced and no changes to the policy were made. On 08/10/11 at approximately 5:20 p.m., RN #1 updated the care plan of Resident #1 to include visual contact until further notice. This implementation of visual contact is documented every 15 minutes on MSH Form 31A by assigned staff. On 08/11/11 at approximately 1:30 p.m., RN #2 began in-servicing all facility staff that were on duty at the time which included Nursing, Pantry, Housekeeping, Laundry, Social Services, Psychology and Recreation on the following policy: JNH J530-55 Injury, Abuse, Neglect, Mistreatment or Exploitation of Residents. The purpose of this policy is to affirm that Jaquith Nursing Home (JNH) resident have a right to be free from abuse, neglect, sexual battery, mistreatment, exploitation, and misappropriation of property and to outline procedures for complying with Centers for Medicare Medicaid Services (CMS) and the Mississippi Vulnerable Adults Act of 1986 as annotated. Specific elements included definitions of injury, abuse and neglect and how failure to return resident to a safe environment could result in neglect. No staff was allowed to work until he/she was in-serviced and no changes to the policy were made. On 08/11/11 at 2:30 p.m. JNH QA meeting was held to discuss the incident of Resident #1 exiting the building without supervision on 8/10/11 and actions taken thus far. The QA committee consisted of DON #1, NHA #1, Building Doctor #1, RN #3, RN #2, Accreditation and Licensure Coordinator #1, RN #4, CUO #1, Administrative Assistant #1, Nurse executive #1, JNH Psychology Supervisor #1. Additional recommendations and actions were taken as a result of the QA meeting: -Development and implementation of Vehicle Monitoring. Facility supervisory staff will conduct random checks of vehicles parked in the immediate proximity once daily to ensure doors were locked. Any unlocked vehicles will be reported to MSH Campus Police and referred to Personnel Officer for possible disciplinary action. -Continue visual contact of Resident #1 by assigned nurses and cna's. -Contact family to discuss possibility of relocating Resident #1 to a locked unit. -Review all residents to identify any additional residents who are at risk for wandering. -Review and update care plans as needed. On 8/11/11 at approximately 3:15 p.m. DON #1 reviewed all facility residents to identify any additional residents at risk. No other residents were identified to be at risk for wandering except the two (2) that were previously noted to be at risk, Resident #1 and Resident #3. Measures were in place for Resident #3 that included time checks every 15 minutes. No episodes of exit seeking behavior or elopements have occurred for Resident #3. On 8/11/11 at 4:00 p.m., NHA #1 or designee began random checks of five (5) or more vehicles in the surrounding area daily to ensure that car doors remain locked. Documentation of these checks has been recorded on the Vehicle Monitoring Log. No concerns were found since 8/11/2011. On 8/12/11 at approximately 11:45 a.m. RN #2 updated Activities of Daily Living (ADL) records for resident #1 to further identify her at risk for wandering. This information was communicated to facility staff at the change of each shift which occurs at approximately 7:15 a.m., 3:15 p.m. and 11:15 p.m. On 8/16/11 at 9:30 a.m. incident and actions taken thus far were discussed at Quarterly QA meeting which was attended by JNH Medical Director. Facility Staff present included four (4) DON'S, four (4) NHA'S, JNH Director, JNH Nurse Administrator, JNH Psychology Supervisor, JNH Social Services Director, JNH Recreational Supervisor, MSH Infection Prevention Director, Quality Management Coordinator. No further actions were recommended at this time. On 8/16/11 at approximately 10:30 a.m., NHA #1 spoke with DON #2 regarding the possible transfer of Resident #1 to a locked facility. Resident #1 has been approved for transfer to locked facility based upon availability. On 8/17/11 at approximately 7:30 a.m., RN #2 added a photo sheet identifier on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 8/17/11 at approximately 7:45 a.m., RN #2 placed a neon orange sheet of paper in the front of the "shift change report notebook" that states - the following residents are at risk for wandering, then the two (2) identified residents were listed, Resident #1 and Resident #3. On 8/17/11 at approximately 1:00 p.m., RN #2 began in-servicing facility staff (Nursing staff and CNA staff) to alert staff of the location of these identifiers for residents at risk for wandering. Nurses are to report during shift change to any new staff or agency staff the location of identifying information for residents at risk for wandering. On 8/17/11 at approximately 3:00 p.m., RN #2 began in-servicing facility staff (Nursing staff) on updating resident care plans as incident occur or with any changes in behavior such as increased wandering, medication changes and notifying physician. No staff was allowed to work until he/she was in-serviced. On 8/17/11 at approximately 4:30 p.m., RN #3 added additional updates to the care plan of Resident #1 and Resident #3 to include monitoring efforts. The monitoring efforts include accounting for resident on Accountability Sheet at 7:00 a.m., 9:00 a.m., 11:00 a.m., 3:00 p.m., 5:00 p.m., 7:00 p.m. and 11:00 p.m., offering resident fluids every two (2) hour. Updates to the care plan also included placing a photo sheet identifier on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"shift change report notebook" that states the resident is at risk for wandering. Resident's Activities of Daily Living (ADL) indicates that resident is at risk for wandering. Daily Assignment Sheets also indicate that the resident is at risk for wandering. On 8/17/11 at approximately 3:30 p.m., an additional QA meeting was held to review all actions that have been put into place at this time. These actions include education on the following policies and procedures, Wandering/Elopement/Abduction, Missing Residents, Vehicle Safety, Patient/Resident Daily Accountability, Care Plan/Updates and Injury, Abuse, Neglect, Mistreatment or Exploitation of Residents. ? Resident #1 was placed on visual contact while doors are unlocked. ? Implementation of Vehicle Monitoring ? Placed a photo sheet identifier on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. ? Placed a neon orange sheet of paper in the front of the "shift change report notebook" that states Resident #1 and Resident #3 are at risk for wandering. ? Resident's Activities of Daily Living (ADL) indicates Resident #1 and Resident #3 are at risk for wandering. ? Resident's Daily Assignment Sheets also indicate Resident #1 and Resident #3 are at risk for wandering. ? Resident #1 has been approved for transfer to locked facility based upon availability. Facility Staff present include: NHA #1, RN #2, RN#3, and JNH Medical Director #1. No additional actions were recommended at this time. Any noted deficient practice is reported to the Nursing Home Administrator or Designee and to QA for any further actions necessary." Verification of the AoC: Random interviews with Nursing Staff (RNs and LPNs), Certified Nursing Assistants (CNAs), and Administrative staff along with observations on 8/16/11 through 8/19/11 revealed that staff was aware of the policy to lock their car doors. Review of the "Car Lock Monitoring Log" that was provided by the Administrator revealed that cars were checked daily by administrative staff and any unlocked cars were being reported to security. Random interviews 8/16/11 through 8/19/11 revealed that staff had been in-serviced on Abuse/Neglect, Missing Residents, Wandering/Elopement/Abduction, Vehicle Safety, and Patient/Resident Daily Accountability, and Care Plans/Updates. It was verified through random interviews with the nursing staff and review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Random interviews with Nursing staff on 8/18/11 and 8/19/11 revealed that they were aware of which residents were at risk for wandering and how the residents were monitored for their wandering behavior. Nursing staff interviews on 8/18/11 and 8/19/11 verified that the residents identified at risk for wandering was reported to the oncoming shift during shift report. Random nursing interviews also verified that the neon sheet was in front of the shift report book which had the names of the two (2) residents at risk for wandering. Random nursing interviews and review of care plans on 8/18/11 and 8/19/11 revealed that the residents at risk for wandering had an updated care plan that included monitoring that was specific to their wandering risk which included visual contact for Resident #1 and every 15 minute time checks for Resident #3. Review of documentation and observations on 8/16/11 through 8/19/11 revealed that visual contact and every 15 minute documentation was provided for the two (2) residents at risk for wandering. Interview with LPN # 4 (an agency nurse) on 8/17/11 at 5:15 p.m. revealed that he had been inserviced about identifiers placed in the resident's record and shift change report book that identified residents at risk for wandering. Interviews with the Administrator on 8/16/11 at 3:00 p.m. revealed that the Quality Assurance (QA) Committee had met and discussed the elopement issue for Resident #1 on 8/11/11 and 8/16/11 with recommended interventions that were put into place. The signature pages were reviewed for both QA meetings. Based on verification of the facility's corrective actions that was validated by staff interviews, observation and in-service reviews, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 8/18/11 to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be further reviewed and evaluated by the facility's QA Committee.