Every finding on record at Lamar Healthcare & Rehabilitation Center

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure appropriate pain management when nursing staff failed to assess and manage pain prior to and during wound care for Resident #4 which resulted in the resident experiencing avoidable pain during wound care and failed to administer ordered pain medication for Resident #47 for two (2) of three (3) residents reviewed for pain management.Findings include: A review of the facility's policy, Pain – Clinical Protocol, undated, revealed, Assessment and Recognition.2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever this is a significant change in condition, and when there is onset of new pain or worsening of existing pain.4. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, wound care.Monitoring.2. The staff will evaluate and report the resident/patient's use of standing and PRN (as needed) analgesics. A. Depending on the characteristics of pain, the physician may start with PRN doses or supplement standing doses with PRN doses for breakthrough pain. Resident #4 A record review of the Order Summary Report revealed Resident #4 had a physician's order dated 12/9/25 for wound care to the left heel two times daily and an additional order dated 2/27/26 for wound care to the left heel two times daily. The record review further revealed an order dated 2/18/26 for Acetaminophen (Tylenol) 500 milligrams (mg) three times daily for pain. A record review of the electronic Medication Administration Record (eMAR) for March 2026 revealed Resident #4 was scheduled to receive Acetaminophen at 1:00 PM on 3/31/26, however, the eMAR was reviewed prior to observing wound care and Resident 4's Acetaminophen was not documented as administered at that time. On 3/31/26 at 1:45 PM, during an observation, Licensed Practical Nurse (LPN) #1 performed wound care to Resident #4's left heel. During the procedure, the resident vocalized that he was in pain, stated the treatment hurt, and began crying. The nurse continued the wound care procedure without stopping to assess pain or provide pain medication. On 3/31/26 at 2:00 PM, during an interview, LPN #1 reviewed the physician's orders and initially indicated the resident did not have pain medication ordered. Upon further review, she confirmed Resident #4 had a scheduled order for Acetaminophen at 1:00 PM and acknowledged the medication had not been administered prior to performing wound care. On 3/31/26 at 2:20 PM, during an interview, the Director of Nursing (DON) stated the expectation was for nursing staff to assess pain prior to wound care and administer pain medication before initiating treatment when pain was anticipated. On 4/1/26 at 4:30 PM, during an interview, the Administrator stated the expectation was for staff to follow the facility's pain management policy and ensure residents received appropriate pain control during treatments such as wound care. A record review of the admission Record revealed the facility admitted Resident #4 on 10/10/25 with diagnoses including Acute Kidney Failure. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/7/26 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident's cognition was severely impaired. Resident #47 A record review of the facility's investigation revealed Resident #47 complained of right lower extremity pain on 10/20/25 and was sent to the hospital on [DATE] and returned on 10/21/25 with a diagnosis of Deep Vein Thrombosis (DVT). The record review revealed the resident continued to complain of right leg and hip pain and a mobile X-ray obtained on 10/21/25 revealed an acute nondisplaced subcapital femoral neck fracture. A record review of the Progress Notes revealed on 10/20/25 at 4:37 PM, a Certified Nurse Aide (CNA) reported Resident #47 was experiencing pain throughout the shift when being changed. The nurse documented the resident yelled out and would not move his leg and the physician was notified and an X-ray was ordered. The progress note did not address how the resident's pain was managed. A progress note dated 10/20/25 at 8:15 PM revealed the resident continued to complain of pain with movement of the right leg and was sent to the emergency department. There was no documentation pain medication was administered. A progress note dated 10/21/25 at 11:48 PM revealed the resident continued to complain of pain to the right leg and hip and did not address how his pain was managed. A record review of the Order Summary Report revealed Resident #47 had a physician's order with a start date of 10/3/24 for Acetaminophen (Tylenol) 325 milligrams (mg) to be given every eight (8) hours as needed for pain. A record review of the Medication Administration Record (MAR) for October 2025 revealed Resident #47 was assessed for pain each shift and was documented as having a pain level of 0 on 10/20/25 and did not receive any documented pain medication, including Acetaminophen, during the month. On 4/1/26 at 10:03 AM, during an observation and interview, Resident #47 was observed lying in bed and was unable to answer questions. On 4/2/26 at 10:28 AM, during an interview, Licensed Practical Nurse (LPN) #5 confirmed she worked on 10/20/25 when Resident #47 complained of right leg pain. She stated she notified the physician and received an order for an X-ray. She reported she thought she had administered Tylenol but was unable to recall and confirmed there was no documentation to support that pain medication was administered. On 4/2/26 at 11:19 AM, during an interview, the Director of Nursing (DON) confirmed the resident complained of pain and there was no documentation that pain medication was administered despite an order being in place. She stated she expected nursing staff to provide pain relief when residents complained of pain. On 4/2/26 at 1:23 PM, during an interview, the Administrator stated it was the expectation that nursing staff provide pain relief to residents when they complained of pain. A record review of the admission Record revealed the facility admitted Resident #47 on 4/2/19 with diagnoses including Dementia. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/30/26 revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident's cognition was severely impaired.

Based on observation, interview, and record review, the facility failed to ensure a resident received necessary nutritional and hydration care and services to maintain nutritional status, including failing to offer alternative food items when meals were refused, failing to consistently document meal intake and weights, and failing to monitor, evaluate, and implement timely interventions, which contributed to a delay in identifying and addressing significant weight loss for one (1) of two (2) residents reviewed for nutrition. Resident #47Findings include:A record review of the admission Record revealed the facility admitted Resident #47 on 10/31/25 with diagnoses including Pressure Ulcer of Sacral Region, Stage 4.A record review of the Order Summary Report with active orders as of 4/2/26, revealed Resident #47 had a physician's order, dated 3/9/26, for double portions of ordered diet for lunch and supper tray. Mighty shakes or equivalent supplement to be added to each tray and as a bedtime snack. Add a magic cup to lunch and supper tray. There were physician's orders, dated 3/2/26 to document the percentage of meal intake at each meal and document total fluid intake at end of each shift. There was a physician's order, dated 3/12/26 to check the resident's weight each Thursday while RP (Responsible Party) in the room. A record review of the Weights and Vitals Summary revealed Resident #47's weight decreased from 128.0 pounds on 9/10/25 to 123 pounds on 1/22/26. It further decreased to 112.8 pounds on 2/26/26, and then to 94.4 pounds on 3/4/26 (six days later), representing a weight loss of 26.25% over six (6) months (9/10/25 to 3/4/26) and 16.46% within a 30-day period (2/26/26 to 3/4/26).A record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/30/26 revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident's cognition was severely impaired. A review of Section K revealed his weight was recorded as 123 pounds and did not indicate a significant weight loss.A record review of the Documentation Survey Report recorded by the Certified Nurse Aides (CNAs) for Resident #47 for February 2026 revealed documentation representing the amount eaten at each meal was not recorded for all meals on 2/2, 2/3, 2/6, 2/7, 2/8, 2/11, 2/14, 2/16, 2/17, 2/20, 2/21, 2/22, 2/25, 2/26, and 2/27 and for the supper meal on 2/12. This was a total of 46 times the resident's meal intake was not recorded for the month of February.A record review of the Medication Administration Record (MAR) for March 2026, revealed there was no documentation recording the percentage of meal intake for Resident #47 for 15 meals recorded by the nurses on 3/2 (lunch and dinner), 3/6 (breakfast, lunch and dinner), 3/11 (dinner), 3/13 (dinner), 3/16 (dinner), 3/17 (breakfast, lunch and dinner), 3/21 (dinner), 3/22 (lunch and dinner), and 3/29 (dinner). A record review of Progress Notes for Resident #47 revealed a Registered Dietician (RD) Assessment Summary, dated 02/28/2026 at 2:07 PM for . wt.: (weight) 123-January; February weight is pending . There was also an RD Assessment Summary, dated 03/05/2026 at 7:25 AM, for .wt.: 94 lb. weight is down -16.8% x 30 days, 23.6% x 90 days, and 26.6% x180 days .A record review of Resident #47's Progress notes revealed a nurses note dated 03/04/2026 at 4:02 PM, revealed, . dietician contacted to look at resident's weight decline and make any suggestions that may benefit resident . On 3/30/26 at 11:21 AM, during an observation, Resident #47 was observed lying in bed with a thin appearance and visible bony prominences.On 3/30/26 at 11:50 AM, during an observation and interview with Resident #47 and the resident's Responsible Representative (RR), the RR expressed concerns regarding Resident #47's weight loss and reported she had been visiting daily to assist with meals due to concerns that Resident #47 was not eating. She also expressed concerns that his weight was not being consistently monitored.On 3/30/26 at 12:01 PM, during an observation, CNA #4 was assisting Resident #47 with feeding. Resident #47 attempted to push staff away, refused food, and told staff to eat the food.On 3/30/26 at 2:00 PM, during an interview with CNA #4, she reported Resident #47 continued to refuse meals and demonstrated variable intake, sometimes eating and other times refusing. She reported Resident #47 could become combative during care and would push staff away during feeding attempts. CNA #4 reported that when Resident #47 refused meals, staff would encourage him to eat; however, she did not indicate that alternative food items were routinely offered following refusals.On 3/31/26 at 11:25 AM, during a follow up interview with CNA #4, she reported Resident #47 again refused lunch despite encouragement from staff and nursing. She reported Resident #47 was not offered an alternative meal or substitute food items after refusing the meal.On 3/31/26 at 11:55 AM, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed Resident #47 had experienced ongoing weight loss and frequently refused meals. She reported the facility had attempted interventions including supplements, appetite stimulants, and double portions. She confirmed weights were obtained by CNAs but were not obtained on consistent days, and she reported that all staff were able to the document meal intake of residents.On 4/1/26 at 3:30 PM, during an interview with the Dietary Manager, she reported Resident #47 had periods of refusing meals and had been provided supplements, including Ensure Plus. She reported the RD monitors residents with weight loss and wounds.On 4/1/26 at 4:30 PM, during an interview with the Director of Nursing (DON), she reported there was no staff member designated to consistently obtain weights and confirmed weights were not consistently obtained or entered into the medical record in a timely manner. She confirmed delays in documenting weights resulted in delayed identification of weight loss and delayed implementation of interventions. She reported interventions were initiated for Resident #47 after family concerns were raised. She confirmed Resident #47 had significant weight loss and acknowledged the lack of consistent monitoring contributed to delayed intervention.On 4/2/26 at 10:01 AM, during a phone interview with the facility's RD, she reported she had been coming to the facility for years and visits twice a month to review residents, including those with significant weight loss. She reported she accesses weights through the computer during her visits and explained that when she documents weights as pending, it indicates no weight has been entered into the record. She reported that weights have been hit and miss at the facility for several months. She explained the DON contacted her on 3/5/26 regarding Resident #47's weight loss, and after reviewing the medical record, she identified inconsistencies with both weights and meal intake documentation. She reported she reviewed Resident #47's weights and stated the amount of weight loss, including approximately 18 pounds in six (6) days, was not normal and would not be expected from refusal of some meals alone. She reported she communicated with the facility, including the DON and Dietary Manager, and recommended providing Ensure Plus to increase protein intake and to continue offering Magic Cup supplements for Resident #47.On 4/2/26 at 2:23 PM, during an interview with the Administrator, she reported she expects staff to obtain and document weights consistently and to notify the physician and RD of any significant weight loss in a timely manner.

Based on record review, facility policy review and staff interview, the facility failed to ensure the Director of Nursing (DON) did not function in the capacity of the charge nurse when the facility had more than 60 residents for four (4) of (15) days reviewed for staffing. (3/16/26, 3/17/26, 3/26/26, and 3/30/26).Findings Include:A review of the facility's policy, Staffing, Sufficient and Competent Nursing, Revision Date August 2022 revealed, Sufficient Staff.2 .c. The director of nursing services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer.A record review of the facility's daily assignment document revealed the DON was listed as the RN (Registered Nurse) Supervisor on 3/16/26 and the census was listed as 88. On 3/17/26, the DON was listed as the RN Supervisor and the census was 90, on 3/26/26 the DON was listed as the RN Supervisor and the census was 94, and on 3/30/26 the DON was listed as the RN Supervisor and the census was 93. On 04/02/2026 at 7:45 AM, in an interview with the DON, she stated that she was unaware she was unable to function in that role due to facility census. The DON stated that the facility has posted job openings and has tried to hire RNs. On 04/02/2026 at 1:17 PM, in an interview with the Administrator, she stated she did not know that due to the facility census being over 60 residents, that the DON could not function in the capacity of the charge nurse or RN Supervisor. The Administrator reported that the facility has placed job listings to recruit RNs.

Based on interview and record review, and facility policy review, the facility failed to ensure Registered Nurse (RN) staffing was adequate to meet the needs of residents and failed to designate a licensed nurse to serve as the designated charge nurse for each tour of duty for one (1) of four (4) days of survey. Findings include:A review of the facility's policy, Staffing, Sufficient and Competent Nursing, revised August 2022 revealed, .Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.Policy Interpretation and Implementation Sufficient Staff.2. A licensed nurse is designated as a charge nurse on each shift.b. A charge nurse is a licensed nurse with designated responsibilities that may include staff supervision, emergency coordination, provider or physician support and direct resident care.A record review of the Facility Assessment revealed, Staffing Hours per Resident Day data for October 1 through December 31, 2025, revealed Registered Nurse (RN) hours were reported as 0.173 hours per resident per day, which equals ten (10) minutes of RN time per resident per day. The report documented an average resident census of 88.6 residents, which equals 15.3 RN hours per day based on the facility's reported staffing levels.A record review of the facility's daily assignments revealed that on 3/30/26, there was no designated Charge Nurse or RN Supervisor for the 6PM or 6AM shift.On 3/31/26 at 3:43 PM, during an interview with the Director of Nursing (DON), she reported the facility did not have sufficient RN staffing to complete weekly wound assessments for residents with pressure ulcers. The facility relies on the outpatient wound clinic to complete these assessments. She explained there was no weekly wound documentation that include measurements or assessments describing wound characteristics available for residents with wounds. On 4/1/26 at 2:35 PM, during an interview, the DON explained she also served in the capacity of the Infection Preventionist and was responsible for staffing, scheduling, and daily facility operations. She reported she had not had time to complete infection surveillance, track infections, or conduct infection control rounds for several months because she was working the medication cart or functioning as the nursing supervisor.On 4/1/26 at 3:00 PM, during an interview, the Administrator stated that the DON had sufficient time to complete infection prevention duties in addition to her other responsibilities.On 04/02/2026 at 7:45 AM, during an interview with the DON, she confirmed there was no designated charge nurse indicated on the daily assignment sheets because it was known by the staff that the Licensed Practical Nurse (LPN) or cart nurse for the hall was in charge. The DON confirmed there was no charge nurse with specific duties including staff supervision, emergency coordinator, physician liaison and direct resident care. The DON said she was unaware she was unable to function in the role of Nursing Supervisor due to the facility's census. The DON stated that the facility has posted job openings and has tried to hire RNs. On 04/02/2026 at 1:17 PM, during an interview with the Administrator, she stated that the benefit to having a licensed nurse designated as the charge nurse is to cut down on confusion and to allow the staff to know who is in charge. She stated she did not know that due to the facility census being over 60 residents, that the DON could not function in the capacity of the charge nurse or RN Supervisor. The Administrator reported that the facility has placed job listings to recruit RNs.

Based on observation, interview, record review, and facility policy review, the facility failed to provide residents with alternate food options of similar nutritive value for one (1) of (19) sampled residents with the potential to affect all 89 residents in the facility. Residents #12Findings included:A review of the facility's policy Alternate Foods for Food Preferences with reviewed date of 12/23 revealed . Alternate foods and beverages are offered to residents who refuse offered off regular menu and is, served to meet individual . preferences, or requests. Procedure: . 4. The nursing assistant, on observing that a resident is refusing food, offers the always available alternate food to the resident.A record review of the facility's Always Available Menu revealed Grilled cheese, hamburger, chicken tenders, soup/salad (and/or) half of a sandwich, pimento cheese sandwich, peanut butter and jelly sandwich, and deli sandwich.A record review of the facility's menu, Fall/Winter 2025/2026 Week 1 Alternates and Modified Items revealed there were menu alternatives for each meal and each day of the week. The alternative menu included full meal options that included items such as sliced turkey, steak fingers, smoked sausage, but did not include the items listed on the Always Available Menu. The alternative menu was signed by the Registered Dietician (RD). Resident #12On 03/30/2026 at 11:55 AM, during an observation and interview, Resident #12 was eating the lunch meal which consisted of coleslaw, pulled pork, and baked beans. He reported that he doesn't always like what is served.On 03/31/2026 at 10:54 AM, during an interview, Certified Nurse Assistant (CNA) #4 stated that Resident #12 eats well depending on the menu. She reported that on the previous evening, the resident did not like the chicken alfredo served for dinner. CNA #4 explained the facility does not offer alternate meals, but that residents can get an item from the Always Available menu.A record review of Resident #12 admission Record revealed the facility admitted the resident on 7/22/24 with diagnoses including Unspecified Dementia.A record review of Resident #12's Order Summary Report revealed he had a physician's order, dated 7/22/24 for a regular diet, regular texture, and regular/thin consistency. A record review of Resident #12's Quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 1/30/26 revealed he had a Brief Interview for Mental Status (BIMS) Summary Score of 07, which indicated his cognition was severely impaired. On 04/01/2026 at 2:00 PM, during an observation, signage was posted outside of the main dining room that included the menu for breakfast, lunch, and dinner, but there was no alternative menu listed for lunch or dinner. On 04/01/2026 at 3:30 PM, during an interview, Dietary Manager #1 stated the facility does not offer alternative meals for lunch or dinner, because the facility has an Always Available menu in place. The Dietary Manager confirmed the always-available options included items such as soup, sandwiches, grilled cheese, burgers, salads, and chicken tenders.On 04/02/2026 at 10:01 AM, during a phone interview, the facility's RD stated she was not aware that alternative meals were not being prepared and offered per the alternate menu that she signs and approves for the facility. She reported that she knew the facility provided additional items to the residents from the Always Available menu but she was unaware that the facility had replaced the alternate menu she approves with the Always Available menu. She confirmed that selecting items from the Always Available menu alone may not provide equivalent nutritional value, as meals are required to include meat, starch, and vegetables to meet nutritional standards.On 04/02/2026 at 2:23 PM, during an interview with the Administrator, she reported that currently the facility did not prepare meals using both the regular menu and the alternate menu. She expected staff to honor residents' choices and offer other meal items from the Always Available menu when residents do not eat the meal provided.

Based on record review, staff interview, and facility policy review, the facility failed to develop and maintain a comprehensive facility assessment to determine the appropriate number of qualified staff needed to meet residents' needs, including sufficient licensed nursing staff coverage, affecting (89) of (89) residents in the facility. Findings include:A review of the facility's policy, Facility Assessment, revised June 2024, revealed, .Facility Assessment.4. The facility assessment is used to inform staffing decisions. a. The assessment is used to ensure there is enough staff with appropriate competencies and skill sets to meet the needs of the residents identified through the review of resident assessments and plans of care.b. The facility is used to develop and maintain a direct-care staff recruitment and retention plan.A record review of the Facility Assessment revealed Staffing Hours per Resident Day data for October 1 through December 31, 2025, documented Registered Nurse (RN) hours as 0.173 hours per resident per day, which equals ten (10) minutes of RN time per resident per day. The document further revealed an average resident census of 88.6 residents, which equals 15.3 RN hours per day based on the facility's reported staffing levels. The facility assessment did not include a breakdown of the number and type of direct care staff needed by shift did not include documentation of how resident acuity and care needs were used to determine staffing levels and did not include a documented recruitment and retention plan or a contingency plan to ensure licensed nurse coverage.On 4/2/26 at 1:17 PM, during an interview with the Administrator, she reported the facility considers census, staffing hours, and resident needs when compiling the facility assessment. She confirmed the facility assessment does not document specific staffing needs by shift and there was no documented recruitment or retention plan within the facility assessment.

Based on staff interview, record review, and facility policy review, the facility failed to establish and maintain an effective infection prevention and control program when the designated Infection Preventionist, who was the Director of Nursing (DON), did not have sufficient time to perform infection prevention and control duties, resulting in a failure to conduct infection surveillance, track and trend infections, and perform infection control rounds for three (3) of five (5) months reviewed, which had the potential to affect all (89) residents in the facility. Findings include:A review of the facility's policy, Surveillance for Infections, revised July 2016, revealed, .Policy Interpretation and Implementation.1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiological significant organism and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections.8. The Charge Nurse will notify the Attending Physician and the Infection Preventionist of suspected infections. a. The Infection Preventionist and the Attending Physician will determine if laboratory tests are indicated.b. The Infection Preventionist will determine if the infection is reportable.9. If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infection, the Infection Preventionist will collect date to help determine the effectiveness of such measures.A review of the facility's policy, Compliance Rounds, revised January 2012, revealed, .The Infection Preventionists shall conduct unannounced periodic infection control rounds. Policy Interpretation and Implementation.2. Infection control compliance rounds should be conducted at least quarterly or at a frequency determined by the IC (Infection Control) Committee or Quality Assurance and Assessment Committee.3. The 'Monitoring Compliance with Infection Control Checklist' should be completed during each periodic compliance round.A review of the facility's infection control records revealed there were no infection surveillance logs available to review that documented infection tracking or trending. There were also no infection control meeting minutes to review that documented infection control meetings were conducted for oversight.On 4/1/26 at 2:35 PM, during an interview, the Director of Nursing (DON) explained she also served as the Infection Preventionist and was responsible for staffing, scheduling, and daily facility operations. She reported she had not had time to complete infection surveillance, track infections, or conduct infection control rounds for several months because she was working the medication cart or functioning as the nursing supervisor.On 4/1/26 at 3:00 PM, during an interview, the Administrator explained she believed the DON had sufficient time to complete infection prevention duties in addition to her other responsibilities.

Based on observation, interview, record review, and facility policy review, the facility failed to conduct a thorough investigation related to a fracture of unknown origin for one (1) of four (4) residents reviewed for accidents. Resident #47.Findings include:A review of the facility's policy, Abuse Investigation and Reporting, revised July 2017, revealed, .All reports of resident abuse, neglect.injuries of unknown source.shall be.thoroughly investigated by facility management.Policy Interpretation and Implementation.Role of the Investigator: 1. The individual conducting the investigation will, as a minimum.j. Review all events leading up to the alleged incident.5. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator.On 4/2/26 at 9:00 AM, a record review of the facility's investigation revealed documentation identified Resident #47's diagnoses including Osteoporosis and Dementia and indicated the resident complained of right lower extremity pain on 10/20/25. The investigation documented the resident was sent to the hospital emergency room on [DATE] due to continued pain and returned on 10/21/25 with a diagnosis of Deep Vein Thrombosis (DVT). The investigation further documented the resident continued to complain of right leg and hip pain following return to the facility, and a mobile X-ray obtained on 10/21/25 revealed an acute nondisplaced subcapital femoral neck fracture of the right hip. The investigation indicated the physician and responsible party were notified and the resident was sent back to the hospital for evaluation. The investigation documentation did not include evidence of staff or resident interviews, witness statements, or a documented investigative summary identifying the possible cause of the injury.On 4/1/26 at 10:03 AM, during an observation and interview, Resident #47 was observed lying in bed and was unable to answer questions.On 4/1/26 at 3:10 PM, during an interview, the Social Worker (SW) explained incidents were discussed during daily clinical meetings and she conducted interviews with residents or staff when directed by the Director of Nursing (DON). She reported she was not directed to conduct interviews for the injury of unknown origin involving Resident #47 and was unable to explain why interviews were not completed.On 4/1/26 at 3:30 PM, during an interview, the DON stated the resident was interviewed at the time of the incident and reportedly indicated he fell but was unsure of details. The DON reported staff and other residents were interviewed but was unsure if documentation existed to support those interviews.On 4/2/26 at 10:28 AM, during an interview with Licensed Practical Nurse (LPN) #5, she confirmed she was working on 10/20/25 when Resident #47 complained of right leg pain. She explained she notified the physician and received an order for an X-ray. She reported the resident continued to complain of pain and was sent to the hospital where he was diagnosed with Deep Vein Thrombosis (DVT). She stated after the resident returned and continued to complain of pain, another X-ray was ordered, which revealed a fracture. She explained the facility was unable to determine how or when the fracture occurred and it could have occurred during transport or while at the hospital.On 4/2/26 at 11:19 AM, during a follow-up interview, the DON confirmed although staff and residents were reportedly interviewed, those interviews were not formally documented. After reviewing the facility policy, she acknowledged the facility did not follow their policy for investigating and documenting the injury.On 4/2/26 at 1:23 PM, during an interview, the Administrator reported she expected staff and resident interviews related to the injury of unknown origin for Resident #47 to be completed and documented and confirmed that documentation was not present.Record review of the admission Record revealed the facility admitted Resident #47 on 4/2/19 with diagnoses including Dementia.Record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/30/26 revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident's cognition was severely impaired.

Based on record review, staff interview, and facility policy review, the facility failed to notify the resident representative of the resident's transfer and failed to provide information regarding the bed-hold policy for two (2) of four (4) residents sampled for hospitalizations and closed record review. Residents #7 and #93. Findings include:A review of the facility's policy, Transfer or Discharge, Facility-Initiated, Revision Date October 2022, revealed, .Notice of Transfer or Discharge.4. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer.5. Notice of Facility Bed-Hold.policies provided to the resident and representative within 24 hours of emergency transfer.6. Notices are provided in a form and manner that the resident can understand. Resident #7 A record review of the admission Record revealed the Resident #7 was initially admitted by the facility on 10/3/2025 and she was readmitted on [DATE] and she had current diagnoses including Chronic Diastolic Heart Failure. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/26 revealed Resident #7 was discharged to an acute hospital and her return was anticipated. A record review of the facility's Order Summary Report revealed Resident #7 had a physician's order, dated 03/17/2026, to send the resident to a local hospital related to elevated BNP (brain natriuretic peptide) and tachycardia (increased heart rate). Review of the medical record showed no evidence the RR was notified of the transfer and no documentation that the bed-hold policy was provided at the time of transfer or within the required timeframe. Resident #93A record review of the admission Record revealed the facility admitted Resident #93 on 11/20/25 with diagnoses including Encounter for Surgical Aftercare following surgery on the Digestive System. A record review of the Discharge MDS with an ARD of 1/17/2026 revealed Resident #93 was discharged from the facility with return anticipated to a short-term general hospital. A record review of the Order Summary Report revealed Resident #93 had a physician's order, dated 01/17/2026, to send to the resident to a local hospital emergency room (ER) for evaluation. A record review of the facility's document Private Pay Bed-Holding Agreement, dated 01/23/2026, revealed the notice was completed six (6) days after the resident's transfer/discharge from the facility on 01/17/2026.On 04/02/2026 at 10:35 AM, during an interview, the Accounts Receivable Clerk (AR) confirmed she did not send a bed-hold notice or notice of transfer to Resident #7's Resident Representative (RR) following the resident's transfer to the hospital. The AR stated this occurred because the resident had been discharged from Part A coverage and she had been trained to handle Part A discharges in this manner. The AR also confirmed that for Resident #93, the bed-hold policy was not sent to the RR until six (6) days after the resident's transfer to the hospital. The AR stated she believed she was out of the facility during that time. She stated that when she is not present in the facility, there are no designated staff assigned to process or send bed-hold notifications, resulting in the letters remaining on her desk until her return. The AR acknowledged that it is her responsibility to ensure the required forms, including notification of transfer and bed-hold policy, are provided to the resident or RR at the time of transfer or within 24 hours in the case of an emergency transfer. The AR also stated that RR needs this information to be informed about the resident's status and bed-hold policy.On 04/02/2026 at 11:06 AM, during an interview, the Administrator stated that all hospital transfer notifications are to be sent to the RR regardless of payer source. She stated her expectation is for all residents and/or their RRs are to be notified of a hospital transfer and provided the bed-hold policy at the time of transfer or within 24 hours in the case of an emergency transfer. The Administrator stated that it is the responsibility of AR to communicate with families by preparing and sending all hospital transfer notifications and bed-hold policy letters. The Administrator reported that in the absence of the AR, the Accounts Payable Clerk is expected to assume these responsibilities to ensure timely notification.

Based on interviews, record review and facility policy review, the facility failed to implement comprehensive care plan interventions for three (3) of (19) sampled residents. (Resident #3, Resident #6, and Resident #25)Findings include:Review of the facility policy titled, Care Plans, Comprehensive Person-Centered with no date, revealed, Policy Statement. a comprehensive person- centered care plan that includes measurable objectives and timetables.developed and implemented for each resident.Policy interpretation and Implementation.7. The comprehensive, person-centered care plan.a. includes measurable objectives and timeframes.e. reflects currently recognized standards of practice for problem areas and conditions.Resident #3A record review of Resident #3's Care Plan Report revealed interventions for Seroquel, observe for s/s (signs and symptoms) of SE (side effects) of med (medication): dizziness, drowsiness, changes in cognition, and Remeron, observe for s/s of SE of med: dizziness, drowsiness, increased confusion. Both interventions had an initiation date of 5/22/25.During an interview on 03/31/2026 at 12:05 PM, with Licensed Practical Nurse (LPN) #1, she reported that Resident #3 has had no known side effects from taking antipsychotic and antidepressant medications. LPN #1 confirmed there was no documented evidence of monitoring for the medications side effects.A record review of Resident #3's admission Record revealed the facility admitted him on 05/09/2025 with diagnoses including Alzheimer's Disease. A record review of Resident #3's Order Summary Report with active orders as of 04/02/2026 revealed physician orders for Quetiapine Fumarate (Seroquel) Oral Tablet 25 mg to give 12.5 mg by mouth at bedtime related to Alzheimer's Disease, Unspecified (dated 2/10/26) and Remeron (Mirtazepine) Oral Tablet 15 mg Give 7.5 mg by mouth at bedtime (dated 2/10/26). No orders for monitoring the side effects of the medications were identified.A record review of Resident #3's medical records, including the Medication Administration Record (MAR), revealed there was no documentation that the resident was monitored for the side effects of antipsychotic and antidepressant medications. A record review of Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/13/2026 revealed he had a Brief Interview for Mental Status (BIMS) score of six (6), which indicated his cognition was severely impaired. A review of Section N revealed he was administered antipsychotic and antidepressant medications. Resident #6A record review of Resident #6's Care Plan Report revealed a care plan focus for Takes psychotropics meds with interventions for Celexa ,observe for s/s of SE (side effects) of med: increased confusion, drowsiness, weakness, dizziness, tremors and Xanax, observe for s/s of SE of med: Dizziness, drowsiness, lethargy, increased confusion, blurred vision.During an interview on 03/31/2025 at 11:40 AM, with LPN #1, she reported that to her knowledge the resident has not had any adverse side effects of her prescribed psychotropic medications. She confirmed there was no place in the medical record for nurses to document that monitoring for side effects occurred. A record review of Resident #6's admission Record revealed the facility admitted the resident on 10/10/25 with diagnoses including Bipolar Disorder, Depression, Unspecified, Anxiety Disorder, Unspecified, Other Psychoactive Substance Use, Unspecified with Psychoactive Substance-Induced Mood Disorder.A record review of Resident #6's Order Summary Report with active orders as 4/2/26, revealed physician orders for Abilify (Aripiprazole) Oral Tablet 5 (five) mg (milligram) Give 5 mg by mouth at bedtime relate to Bipolar Disorder Current Episode Manic Without Psychotic Features, Unspecified (dated 11/21/25) Alprazolam (Xanax) Tablet 0.25 mg Give 1(one) tablet by mouth three times a day for anxiety (dated 2/2/26) , Citalopram Hydrobromide (Celexa) Oral Tablet 10 mg Give 1 (one) tablet by mouth one a day related to Anxiety Disorder (dated 10/10/25), and Xanax Oral Tablet 0.25 MG Give 1 (one) tablet by mouth one time a day for anxiety related to Anxiety Disorder, Unspecified (dated 1/31/26). There were no orders identified for monitoring the side effects of the medications.A record review of Resident # 6's medical records, including the MAR, revealed there was no documentation for monitoring side effects of Antipsychotic, Antianxiety, and Antidepressant medications.A record review of Resident #6's Significant Change MDS with an ARD of 1/2/26 revealed she had a BIMS summary score of 15, which indicated her cognition was intact. A review of Section N revealed she received Antipsychotic, Antianxiety, and Antidepressant medications. Resident #25A record review of Resident #25's Care Plan Report revealed a care plan focus for High Risk for bruising/bleeding r/t (related to) Anticoagulant with intervention to observe for signs and symptoms of bleeding: unexplained bruising/spreading of an established bruise, frank bleeding, blood in urine/stool (tarry colored stool).During an observation and interview on 03/31/2026 at 10:55 AM, with Resident #25, she stated that she bruises easily and pointed to the top of her right hand, reporting that the discoloration was from a blood draw. During an interview on 03/31/2026 at 11:35 AM, with LPN #4, she stated that Resident #25 was prescribed Eliquis as an anticoagulant medication. She reported the resident was monitored for medication side effects; however, she was not aware of any documentation reflecting the monitoring. LPN #4 further stated that CNAs report any skin changes and that nurses complete weekly body audits for the residents.A record review of Resident #25's admission Record revealed the facility admitted her on 05/24/2024 with diagnoses including Chronic Atrial Fibrillation, Unspecified.A record review of Resident #25's Order Summary Report with active orders as of 04/02/2026 revealed a physician's order for Eliquis Oral Tablet 2.5 mg (Apixaban), dated 1/31/25, to give 1 (one) tablet by mouth every morning and at bedtime related to Chronic Atrial Fibrillation, Unspecified. There were no orders for monitoring for side effects of medications.A record review of Resident #25's medical records, including the MAR, revealed there was no documentation to monitor for bleeding or side effects of anticoagulant medication.A record review of Resident #25's Quarterly MDS with an ARD of 02/05/2026 revealed she had a BIMS Summary Score of 12, which indicated her cognition was moderately impaired. A review of Section N revealed she was administered anticoagulant medication. During an interview on 04/01/2026 at 4:04 PM, with the Director of Nursing (DON), she stated that the nurses are responsible for entering physician orders, including required parameters for monitoring medications. The DON confirmed that orders for medications, including anticoagulants and antipsychotics, should include monitoring for side effects and be reflected on the MAR for ongoing nurse oversight. The DON acknowledged that the care plan interventions for monitoring medication side effects were not implemented.During an interview on 04/02/2026 at 2:15 PM, with Registered Nurse (RN) #1, she reported that she expects all staff to follow the resident care plans. She acknowledged that the care plans include an intervention to observe; however, she confirmed there is no documentation to support that this intervention is being carried out.During an interview on 04/02/2026 at 2:23 PM, with the Administrator, she stated her expectation is for all staff to document care and duties required for their shift.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure appropriate monitoring and documentation of potential adverse consequences for psychotropic and high-risk medications, including anticoagulants, for three (3) of five (5) residents sampled for unnecessary medications. Resident #3, Resident #6, and Resident #25.Findings include:A review of the facility's policy Adverse Consequences and Medication Errors with the revision date of February 2023 revealed . The interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such are adverse drug reactions (ADRs) and side effects. Policy Interpretation and Implementation Adverse Consequences 1. An adverse consequence: refers to an unwanted, uncomfortable or dangerous effect that a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. An adverse consequence may include: a. Adverse drug/medication reaction. b. side effect . 3. Residents receiving medication are monitored for adverse consequences . Procedures . 4. Monitor the resident for medication-related adverse consequences .Resident #3On 03/31/2026 at 11:25 AM, during an observation and interview, Resident #3 was awake and lying in bed and he stated that he is sometimes forgetful. On 03/31/2026 at 12:05 PM, during an interview, Licensed Practical Nurse (LPN) #1 stated that Resident #3 has dementia and confusion but has not exhibited any type of behaviors or agitation. She reported that he has had no known side effects from taking antipsychotic medications. LPN #1 confirmed there was no documented evidence of the monitoring for the medication side effects. She stated she was aware of the potential side effects of the medications and that staff monitored his behaviors.A record review of Resident #3's admission Record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's Disease. A record review of Resident #3's Order Summary Report with active orders as of 04/02/2026 revealed physician orders for Quetiapine Fumarate (Seroquel) Oral Tablet 25 mg (milligrams) to give 12.5 mg by mouth at bedtime related to Alzheimer's Disease, Unspecified (dated 2/10/26) and Remeron (Mirtazepine) Oral Tablet 15 mg Give 7.5 mg by mouth at bedtime (dated 2/10/26). There were no orders for monitoring the side effects of the medications.A record review of Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/13/2026 revealed a Brief Interview for Mental Status (BIMS) score of six (6), which indicated his cognition was severely impaired. A review of Section N revealed he was administered antipsychotic and antidepressant medications. A record review of Resident #3's medical records, including the Medication Administration Record (MAR), revealed there was no documentation that the resident was monitored for the side effects of the medications. Resident #6On 03/31/2025 at 11:40 AM, during an interview with LPN #1, she reported that Resident #6 was currently out of facility with her boyfriend. LPN #1 reported that to her knowledge the resident has not had any adverse side effects of her prescribed psychotropic medications. She confirmed there was no place in the medical record for nurses to document that monitoring for side effects occurred. A record review of Resident #6's admission Record revealed the facility admitted the resident on 10/10/25 with diagnoses including Bipolar Disorder, Depression, Unspecified, Anxiety Disorder, Unspecified, Other Psychoactive Substance Use, Unspecified with Psychoactive Substance-Induced Mood Disorder.A record review of Resident #6's Order Summary Report with active orders as 4/2/26, revealed physician orders for Abilify (Aripiprazole) Oral Tablet 5 (five) mg (milligram) Give 5 mg by mouth at bedtime relate to Bipolar Disorder Current Episode Manic Without Psychotic Features, Unspecified (dated 11/21/25) Alprazolam (Xanax) Tablet 0.25 mg Give 1(one) tablet by mouth three times a day for anxiety (dated 2/2/26) , Citalopram Hydrobromide (Celexa) Oral Tablet 10 mg Give 1 (one) tablet by mouth one a day related to Anxiety Disorder (dated 10/10/25), and Xanax Oral Tablet 0.25 MG Give 1 (one) tablet by mouth one time a day for anxiety related to Anxiety Disorder, Unspecified (dated 1/31/26). There were no orders for monitoring the side effects of the medications.A record review of Resident #6's Significant Change MDS with an ARD of 1/2/26 revealed she had a BIMS summary score of 15, which indicated her cognition was intact. A review of Section N revealed she received Antipsychotic, Antianxiety, and Antidepressant medications. A record review of Resident # 6's medical records, including the MAR, revealed there was no documentation for monitoring side effects of Antipsychotic, Antianxiety, and Antidepressant medications.Resident #25On 03/31/2026 at 10:55 AM, during an interview and observation, Resident #25 was lying in bed. She stated that she bruises easily and pointed to the top of her right hand, reporting that the discoloration was from a blood draw. On 03/31/2026 at 11:35 AM, during an interview, LPN #4 stated that Resident #25 was prescribed Eliquis as an anticoagulant medication. She reported the resident was monitored for medication side effects; however, she was not aware of any documentation reflecting the monitoring. LPN #4 further stated that CNAs report any skin changes and that nurses complete weekly body audits for the residents.A record review of Resident #25's admission Record revealed the facility admitted her on 05/24/2024 with diagnoses including Chronic Atrial Fibrillation, Unspecified.A record review of Resident #25's Order Summary Report with active orders as of 04/02/2026 revealed a physician's order for Eliquis Oral Tablet 2.5 mg (Apixaban), dated 1/31/25, to give 1 (one) tablet by mouth every morning and at bedtime related to Chronic Atrial Fibrillation, Unspecified. There were no orders for monitoring for side effects of medications.A record review of Resident #25's Quarterly MDS with an ARD of 02/05/2026 revealed she had a BIMS Summary Score of 12, which indicated her cognition was moderately impaired. A review of Section N revealed she was administered anticoagulant medication. A record review of Resident #25's medical records, including the MAR, revealed there was no documentation to monitor for bleeding or side effects of anticoagulant medication.On 04/01/2026 at 4:04 PM, during an interview, the Director of Nursing (DON) stated that the nurses are responsible for entering physician orders, including required parameters for monitoring medications, and are trained to do so. The DON confirmed that orders for medications, including anticoagulants and antipsychotics, should include monitoring for side effects and be reflected on the MAR for ongoing nurse oversight. The DON acknowledged there are certain medications that require monitoring for side effects, which should be documented, with the physician notified of any adverse findings.On 04/02/2026 at 2:23 PM, during an interview, the Administrator stated her expectation is for all staff to document care and duties required for their shift.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure required cautionary signage was in place for a resident receiving oxygen therapy for one (1) of (1) resident reviewed for respiratory care. Resident #45.Findings Include:A review of the facility's policy, Oxygen Administration revised October 2010, revealed, .Equipment and Supplies.4. No smoking/oxygen in use signs.Steps in the Procedure.2. Place an oxygen in use sign on the outside of the room entrance door.3. Place an oxygen in use sign in a designated place on or over resident's bed.On 3/30/26 at 12:55 PM, during an observation, Resident #45 was in bed receiving oxygen at two (2) liters per minute via nasal cannula. No oxygen-in-use signage was observed on or near the resident's door or above the resident's bed.On 4/1/26 at 2:25 PM, an interview with Licensed Practical Nurse (LPN) #2 revealed the resident was placed on oxygen in January 2026 due to flu and pneumonia and stated that she received oxygen therapy continuously. LPN #2 confirmed that oxygen-in-use signage is required to be posted on the doors of residents receiving oxygen.On 4/2/26 at 1:42 PM, in an interview with the Director of Nursing (DON), she stated that it was her expectation that oxygen signage be posted on the doors for residents receiving oxygen therapy. She confirmed that nursing staff are responsible for ensuring the cautionary signage is present.A record review of the admission Record revealed the facility admitted Resident #45 on 10/15/18, with diagnoses including Alzheimer's Disease.A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/7/26, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated her cognition was severely impaired. A review of Section O indicated Resident #45 received oxygen therapy.A record review of the Order Recap Report revealed Resident #45 had a physician's order, dated 1/7/26, for oxygen at (2) liters via nasal cannula every shift for shortness of breath.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure weekly wound assessments that included wound dimensions and characteristics were completed and documented for one (1) of two (2) residents reviewed for pressure ulcers. Resident #47.Findings include:A review of the facility's policy, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018 revealed, . Assessment and Recognition . 2.the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .A record review of the Order Summary Report revealed a physician's order dated 2/19/26 to remove old dressing, cleanse with wound cleaner, apply Santyl to the sacral wound as the primary dressing, apply Calcium Alginate, gauze, and cover with Allevyn border dressing as the secondary dressing, to be completed daily and as needed.A record review of the Wound Care Visit, dated 3/10/26 revealed Resident #47 attended wound care at an outpatient provider. The visit documentation included assessment information that consisted of the wound dimensions, drainage, and wound characteristics and the Impression included that the wound had improved. A review of the next Wound Care Visit, dated 3/31/26 (three weeks later) revealed Resident #47 had another wound care visit at the outpatient provider. The documentation had wound information that included a complete assessment of the wound and documented the dimensions, drainage, and wound characteristics. The Impression included that the ulcer had improved.A record review of the medical record for Resident #47 revealed there was no wound assessment documented by the facility between the outpatient wound care visits on 3/10/26 and 3/31/26.On 3/30/26 at 11:24 AM, during an observation, Resident #47 was lying in bed on an air mattress with a positioning wedge in place between his knees.On 3/30/26 at 11:50 AM, during an observation and interview with Resident #47 and his Responsible Representative (RR), the RR expressed concerns regarding the resident's sacral pressure wound and reported she was unsure if the wound was being treated appropriately.On 3/31/26 at 11:55 AM, during an interview with Licensed Practical Nurse (LPN) #1, she reported Resident #47 had a longstanding sacral wound and stated the facility does not have a dedicated wound care nurse. She explained that medication cart nurses complete wound care and treatments daily for assigned residents. She confirmed Resident #47 attended outpatient wound care and reported the outpatient provider assessed the wound and provided treatment orders.On 3/31/26 at 3:43 PM, during an interview with the Director of Nursing (DON), she reported the facility did not have weekly wound reports that include measurements or assessments describing wound characteristics available. She confirmed there is no dedicated wound care nurse and that medication cart nurses completed treatments. She reported the facility relied on the outpatient wound care provider for wound assessments and monitoring. She acknowledged that pressure wounds should be assessed, measured, and documented weekly and explained that the facility did not have sufficient Registered Nurse (RN) staffing to complete weekly wound assessments.On 4/2/26 at 10:01 AM, during a phone interview with the Registered Dietician (RD), she reported she completed onsite visits to the facility twice monthly and reviewed residents with wounds. She explained that she often has to request information from the DON because there are no weekly wound reports available in the medical record.On 4/2/26 at 2:23 PM, during an interview with the Administrator, she reported she expected wound assessments to be completed as required.A record review of the admission Record revealed the facility admitted Resident #47 on 10/31/25 with diagnoses including Pressure Ulcer of Sacral Region, Stage 4.A record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/30/26 revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated his cognition was severely impaired. A review of Section M revealed he had unhealed pressure ulcers, including one (1) Stage 3 pressure ulcer.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide assistance with activities of daily living (ADLs) related to toenail care for one (1) of three (3) residents reviewed for ADL/Nail Care. Resident #76.Findings include:A review of the facility's policy, Fingernails/Toenails, Care of, dated 02/2018, revealed, .The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection.General Guidelines.6. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease.Documentation.6. If the resident refused the treatment, the reason(s) why and the intervention taken.On 3/30/26 at 2:39 PM, during an observation and interview, Resident #76's toenails were observed to be thick, long, curved, and excessive in length. The resident reported his toenails needed to be cut and stated he was unsure how long they had been in that condition.On 3/31/26 at 10:34 AM, during an interview with Certified Nurse Aide (CNA) #2, she reported Resident #76 required extensive assistance with Activities of Daily Living (ADLs) except feeding and that staff assisted with bed baths. She reported that CNAs are expected to notify nursing staff if nail care is needed and stated she had not noticed any concerns with the resident's toenails.On 3/31/26 at 11:10 AM, during an interview with Licensed Practical Nurse (LPN) #1, she reported the facility does not have an in-house podiatrist and residents must be sent out for podiatry services. She reported she had not been notified of any concerns regarding Resident #76's toenails.On 4/1/26 at 10:45 AM, during an observation and interview with LPN #5, Resident #76's toenails were observed to be long and thick. LPN #5 confirmed the toenails were abnormal and stated the condition should have been reported and followed through by nursing staff. Resident #76 stated that something needed to be done and stated willingness to see a podiatrist.On 4/1/26 at 11:05 AM, during an interview with the Director of Nursing (DON), she reported staff are expected to report changes in condition, including nail care, and ensure follow-up. She stated she had attempted to file the resident's toenails months prior, but the resident refused, and confirmed no follow-up was completed. She reported she was unsure whether a podiatry appointment had ever been scheduled.On 4/1/26 at 11:36 AM, during an interview with CNA #3/Transportation Aide, she reported she had recently been notified the resident needed a podiatry appointment; however, no appointment had been scheduled.On 4/2/26 at 2:50 PM, during an interview with the Administrator, she reported staff are expected to ensure residents' care needs are met.A record review of the admission Record revealed the facility admitted Resident #76 on 6/28/22 and readmitted on [DATE] with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Genitourinary System.A record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/29/26 revealed Resident #76 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. A review of Section GG revealed he required assistance with self-care, including bathing and personal hygiene.A record review of the Order Summary Report revealed Resident #76 had a physician's order, 9/8/22 for weekly head-to-toe body audits and to inform the supervisor or physician of any new skin concerns.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to have verbalized grievances addressed and resolved for one (1) of (19) sampled residents. Resident #25.Findings include:On 3/31/26 at 12:25 PM, during an observation and interview with the resident's Resident Representative (RR), she stated she was concerned regarding Resident #25's toenails. The RR removed the resident's socks, and her toenails were thick and had a yellow discoloration to both feet. The RR stated that she had been voicing her concerns for over a year to the facility staff, including Certified Nurse Aide (CNA) #1, that the resident needed to have a podiatry appointment, but nothing had been set up. On 4/1/26 at 2:14 PM, during an interview with Licensed Practical Nurse (LPN) #2, she reported she was aware that Resident #25's family requested for her to go to a podiatry appointment. She explained Resident #25's nails were thick and fungal in nature. On 4/1/26 at 2:22 PM, during an interview with CNA #1, she reported concerns regarding the resident's toenails were brought to her in late February 2026 by the RR and she was aware that the resident had thick, yellow toenails.On 4/2/26 at 9:26 AM, during an interview with CNA #3/Transportation staff, she reported she is responsible for making appointments for residents. She stated she was aware that the RR had requested for Resident #25 to receive podiatry services but confirmed that no appointment had been scheduled.On 4/2/26 at 1:42 PM, during an interview with the Director of Nursing (DON), she reported that when staff became aware of the RR's request, the nursing staff should have obtained a physician's order and scheduled a podiatry visit for Resident #25. A record review of the admission Record revealed the facility admitted Resident #25 on 5/24/24 with diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/5/26 revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident's cognition was moderately impaired.

Based on interview and record review, the facility failed to revise a comprehensive care plan for one (1) of (19) resident care plans reviewed. Resident #47Findings include:A record review of the Care Plan Report revealed Resident #47 had an individual care plan with Focus of Impaired Skin Integrity.Stage III wound to sacrum-Healing Stage IV wound. The care plane included an intervention initiated on 1/28/26 to Remove old dressing, cleanse with wound cleanser, apply plurogel to wound to sacrum, use polymem AG (alginate) as the primary dressing, use allevyn border dressing as the secondary dressing, the order is to be carried out daily and PRN. This was inconsistent with the current physician order for wound treatment dated 2/19/26. A record review of the admission Record revealed the facility admitted Resident #47 on 10/31/25 with diagnoses including Pressure Ulcer of Sacral Region, Stage 4.A record review of the Order Summary Report with active orders as of 04/02/2026, revealed Resident #4 had a physician's order, dated 2/19/26, to Remove old dressing, cleanse with wound cleaner, apply Santyl to wound to sacrum as the primary dressing, apply Calcium Alginate, gauze and cover with Allevyn border dressing as the secondary dressing, the order is to be carried out daily and PRN (as needed). A record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/30/26 revealed Resident #47 had a Brief Interview for Mental Status (BIMS) Summary Score of 04, which indicated his cognition was severely impaired. A review of Section M revealed he had unhealed Pressure Ulcers/Injuries including one (1) Stage 3 Pressure Ulcer. On 04/02/2026 at 2:10 PM, during an interview, Registered Nurse (RN) #1 stated she updates care plans with each new order and believed she had done so for Resident #47's wound care order. RN #1 reviewed the physician orders and care plan for Resident #47 and confirmed the care plan had not been updated and reflected outdated wound care orders.On 04/02/2026 at 2:23 PM, during an interview with the Administrator, she reported that she expects resident care plan to be revised as needed.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions regarding incontinence care for two (2) of 17 care plans reviewed. (Resident #8 and Resident #34) Findings Include: Record review of the facility's policy, Care Plans, Comprehensive Person Centered revised March 2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation .3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan .b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #8 Record review of the Self-Care Deficit care plan with a start date of 4/1/24 for Resident #8 revealed .Resident is .total/depended with assist of 2 with hoyer lift .Ext/Max (extensive/maximum) assist with . toileting .Intervention Assist with ADL's (Activities of Daily Living) as needed . The role listed as Nursing Assistant. On 06/24/24 at 10:24 AM, Resident #8 was lying in bed and there was a strong odor of urine and feces. She was alert and oriented and stated she had informed Certified Nursing Assistant (CNA) #1 earlier in the morning that she had an accident with urine and a bowel movement (BM). CNA #1 told her she would be back, but she had not returned. Resident #8 explained she had to be transferred with a Hoyer lift (a type of mechanical lift) and it required two (2) staff members to provide care, therefore, she normally received care once during a shift. On 06/24/24 at 2:00 PM, during an observation and interview, Resident #8 stated she had not received incontinence care all day. The room continued to have a strong, foul odor. On 06/24/24 at 2:08 PM, during an observation, CNA #1 and CNA #2 were providing incontinence care to Resident #8. Her brief and bedding were saturated with urine and feces. During an interview on 06/24/24 at 2:25 PM with CNA #1 and CNA #2, both CNAs said they had to do rounds together for all the other residents on the hall and were unable to check on Resident #8 until now. During an interview on 06/25/24 at 11:00 AM, the Director of Nursing (DON) confirmed the CNAs failed to follow the comprehensive care plan by not providing incontinence care when it was needed. The DON said the CNAs should have checked on the residents every two (2) hours and she should have been cleaned before lunch. A record review of the Face Sheet revealed the facility admitted Resident #8 on 3/5/10 with current diagnoses including Hemiplegia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/19/24 revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Section GG revealed she was dependent on staff for toileting hygiene. Resident #34 Record review of the Urinary Incontinence and bladder incontinence care plan with a start date of 4/1/24 for Resident #34 revealed . Intervention . Assist with perineal cleansing as needed . On 06/24/24 at 11:00 AM, during an observation, Resident #34's family member informed Registered Nurse (RN) #3 the resident had urinated and needed assistance. During an observation with RN #3 on 06/24/24 at 2:34 PM, Resident #34 continued to wear a heavily saturated brief. During an interview on 06/26/24 at 11:42 AM, the DON confirmed the staff failed to implement the care plan intervention to provide perineal care as needed. During an interview on 06/27/24 at 10:52 AM, RN #3 explained the care plan was used to guide the resident's care. She expected the staff to follow the care plan by providing incontinence and perineal care as needed by the residents in a timely manner. A record review of the Face Sheet revealed the facility admitted Resident #34 on 6/29/18 with current diagnoses including Alzheimer's Disease. A record review of the Quarterly MDS with an ARD of 5/17/24 revealed Resident #34 had a BIMS score of 3, which indicated her cognition was severely impaired. Section GG revealed she required maximum assistance with toileting hygiene.

MS CI #25290 Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure residents dignity, physical, mental or psychosocial needs were met as evidenced by residents not receiving assistance with incontinence care in a reasonable timeframe for two (2) of 17 sampled residents. (Resident #8 and Resident #34) Findings include: Review of the facility's policy, Routine Resident Checks revised July 2013, revealed Staff shall make routine resident checks to help maintain resident safety and well-being. Policy Interpretation and Implementation .2. Routine resident checks involve entering the resident's room .identify whether the resident has any concerns, and see if the resident .needs toileting or assistance . Review of the facility's policy, Residents rights revised February 2021, revealed, Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence b. be treated with respect, kindness, and dignity . Record review of the facility policy Dignity revised February 2021 revealed .Policy Interpretation and Implementation .5 e. provided with a dignified dining experience . Resident #8 During an observation and interview on 06/24/24 at 10:24 AM, Resident #8 was lying in bed and there was a strong odor of urine and feces. She was alert and oriented and stated she had informed Certified Nursing Assistant (CNA) #1 earlier in the morning that she had an accident with urine and a bowel movement (BM). CNA #1 told her she would be back, but she had not returned. Resident #8 explained she had to be transferred with a Hoyer lift (a type of mechanical lift) and it required two (2) staff members to provide care, therefore, she normally received care once during a shift. On 06/24/24 at 12:15 PM, during an observation, CNA #2 took a lunch meal tray into Resident #8's room. On 06/24/24 at 12:20 PM, Resident #8 explained that she still had not been changed. She was tearful and stated that she did not care for eating lunch with urine and feces on her because it was humiliating. On 06/24/24 at 12:45 PM, during an observation, CNA #2 removed Resident #8's lunch meal tray from her room. Resident #8 asked the CNA if they were going to clean her up and she responded that she would be back. On 06/24/24 at 1:00 PM, during an observation, both CNAs assigned to Resident #8 were on a lunch break. During an observation and interview on 06/24/24 at 2:00 PM, with Resident #8, she revealed she had not received incontinence care all day. The room continued to have a strong foul odor. On 06/24/24 at 2:05 PM, during an interview and observation, Resident #8 was lying in bed with a heavily soiled brief, in which feces were spilling over the top and sides of the brief. Resident #8 stated, This is what I deal with every day. She stated that she was soiled most of the time and she depended on staff for assistance to get her out of bed. Resident #8 became tearful and stated she felt degraded and nasty. She reiterated that she did not want to eat her meals while wearing a brief that was soiled. During an observation on 06/24/24 at 2:08 PM, CNA #1 and CNA #2 were providing incontinence care to Resident #8. Her brief and bedding were saturated with urine and feces. During an interview on 06/24/24 at 2:25 PM with CNA #1 and CNA #2, CNA #1 stated she was assigned to Resident #8 and had checked on her earlier this morning and she was clean with no urine or feces at that time. Both CNAs said they had to do rounds together for all the other residents on the hall and was unable to check on Resident #8 until now. CNA #2 confirmed that she gave the resident her lunch tray and picked it up. Both CNAs explained they are not allowed to clean a resident up during lunch time because they were told that it was an issue with cross contamination, and therefore, residents had to eat their meals when they were wet and soiled. In an interview on 06/24/24 at 3:00 PM, with Registered Nurse (RN) #1, she explained the CNAs should check on the residents every two (2) hours and that residents should not have to eat meals while lying in feces and urine. The nurse confirmed the staff does not clean the residents up during meals to prevent cross contamination, but CNAs should check on the resident's before meals and provide care at that time. During an interview on 06/25/24 at 11:00 AM, with the Director of Nursing (DON), she explained the CNAs should check on the residents every two (2) hours and confirmed Resident #8 should have been cleaned up before lunch. The DON confirmed the staff was trained to not provide care during meals to prevent cross contamination. A record review of the Face Sheet revealed the facility admitted Resident #8 on 3/5/10 with current diagnoses including Hemiplegia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/19/24 revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Further review revealed she was dependent on staff for toileting hygiene. Resident #34 During an observation 06/24/24 at 11:00 AM, Resident #34's family member informed RN #3 that the resident had urinated and needed assistance. During an observation on 06/24/24 at 12:31 PM, revealed Resident #34 was lying in bed eating her lunch and the staff had not provided incontinence care that was requested at 11:00 AM, which was prior to lunch. On 06/24/24 at 2:34 PM, during an observation with RN #3, Resident #34 continued to wear a heavily saturated brief. During an interview on 06/24/24 at 3:36 PM, with RN #3, she confirmed Resident #34's brief was saturated with urine. RN #3 said she had reported to CNA #1 and Licensed Practical Nurse (LPN) #1 that the family member had requested for the resident to be cleaned at 11:00 AM. RN #3 also confirmed she did not check back to ensure the staff had provided the requested care. During an interview on 06/24/24 at 3:39 PM, with LPN #1, she stated the CNAs informed her the resident had said she did not want to be bothered at that time and she did not follow up with the resident. She said she expected the CNAs to go back later and see if the resident had changed her mind. During an interview on 06/26/24 at 11:42 AM, with the DON, she stated the CNAs should have reported the resident's refusal to the nurse when she first refused, and they should have followed up to see if the resident had changed her mind. During an interview on 06/27/24 at 12:28 PM, with the Administrator, she stated she expected the staff to provide care when the resident needs it, and the residents should be treated with dignity and respect. A record review of the Face Sheet revealed the facility admitted Resident #34 on 6/29/18 with current diagnoses including Alzheimer's Disease. A record review of the Quarterly MDS with an ARD of 5/17/24 revealed Resident #34 had a BIMS score of 3, which indicated her cognition was severely impaired. Section GG revealed she required maximum assistance with toileting hygiene.

Based on staff interview, record review and facility policy review, the facility failed ensure that the Infection Preventionist was present in the QAPI (Quality Assurance and Performance Improvement) Committee for 12 of the 12 months of meetings reviewed. July 2023 through June 2024. This had the potential to affect the quality of healthcare for all residents residing in the facility. Findings include: A review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership, revised March 2020, revealed, .The Quality Assurance and Performance Improvement Program is overseen and implemented by the QAPI Committee .The following individuals serve on the committee: a. Administrator, or designee who is in a leadership role; b. Director of Nursing Services; c. Medical Director; d. Infection Preventionist .The committee meets at least quarterly (or more often as necessary) . Record review of the facility's QAPI Committee meeting sign in logs for the 12 meetings held from July 2023 through June 2024, documentation revealed the Infection Preventionist was not present for any of the 12 meetings. On 6/27/24 at 12:30 PM, during an interview with the Administrator, she acknowledged the facility's QAPI committee meets monthly, but did not have the Infection Preventionist present at all the meetings. The Administrator stated the importance of the IP being present is to improve the quality of healthcare for the residents. She stated that going forward, she will expect that the IP be present at the QAPI meetings.

Based on observation, resident and staff interview, and resident council minutes review, the facility failed to resolve resident repeated concerns of cold food served to the residents rooms for three (3) of six (6) months reviewed. January 2024, April 2024, and May 2024. Findings Include: Observation and interview on 06/25/24 1:00 PM with the Resident Council revealed 12 residents attended the meeting. Residents were comfortable and multiple residents vocalized concerns with the temperature of food served in their rooms. Residents denied issues with food temperatures served in dining room. Resident #70 stated the food temperature of eggs and other food delivered to his room are cold. Resident #54 confirmed his food was cold as well. Other residents stated this is an ongoing issue with cold food. Resident #54 stated the council had complained to staff multiple times for several months about the food without improvement. Review of the monthly grievance log minutes revealed complaints related to the temperature of their food for the following months: [DATE] April 2024 May 2024 Review of January 2024 minutes revealed, Food that comes to rooms still seems to be inconsistent in temperature. Majority (residents) say it is cold. The May 7, 2024 minutes revealed residents suggested heated carts for food transport to rooms. There was no evidence of attempts by the facility to resolve the grievance. Observation and interview 06/25/24 2:10 PM of the kitchen revealed single runner stacked open metal carts with a clear plastic cover. The Dietary Manager (DM) confirmed these carts are used to deliver food to the halls. The DM said the trays are served according to hall, starting with 100, 200, 300, then 400 halls. The DM stated she was aware the facility residents have complained about food temperatures. She explained temperatures are checked on the food holding table in the kitchen prior to plating the food. Interview on 06/25/24 2:50 PM with the facility Administrator revealed the facility is monitoring and talking to residents and are aware of the cold food concerns. The Administrator stated she had talked to the DM about serving trays to 100 hall then 300 hall, then 200 and 400 shorter halls. The Administrator went on to say that CMS (Centers for Medicare and Medicaid Services) did not pay the facility enough to buy insulated or heated carts for delivery of food to the halls. She stated she would have to start back at square one to address the cold food complaints.

Based on observation, staff interview, and facility policy review, the facility failed to follow the COVID-19 Infection Control Guidelines to prevent the spread of the [MEDICAL CONDITION] which likely led to the death of three (3) residents who had not been outside the facility, Residents #25, #26 and #27 and prevent the possible spread of the COVID-19 virus between positive and negative COVID-19 residents. This concern was identified for Residents #1, #2, #12, #13, #14, #15, #18, #19, #20 and #23, as evidenced by the facility's failure to change gloves and wash hands or use hand sanitizer between resident rooms, failure to change Person Protective Equipment (PPE) between positive and negative Covid-19 residents, and wear full PPE in positive Covid-19 residents rooms. The facility staff also failed to clean an oxygen concentrator before transferring the machine from a contaminated room to a non-contaminated room, and then placed the oxygen mask on the resident's face. The concerns was identified for 13 of 68 residents in the facility. On [DATE], the State Agency (SA) surveyor made observations of the facility's staff members failure to perform hand hygiene, change PPE when entering and exiting positive COVID-19 residents and then entering and exiting negative resident rooms with the same PPE on. The facility staff also failed to clean an oxygen (O2) concentrator that was in a positive COVID-19 resident's room prior to transferring the machine to a negative COVID-19 resident room, and then placed the oxygen mask on the resident's face. Record review revealed the facility had a total of three (3) COVID-19 related deaths. Two of the deaths occurred in the hospital and one in the facility. The Immediate Jeopardy (IJ) was determined to exist on [DATE], at the time of Resident #27's death, who was one of the three COVID-19 deaths in the facility and one of those three residents who had not left the building except for their transfer to the hospital related to COVID-19. The facility's failure to follow appropriate COVID-19 infection control guidelines for not wearing PPE, sanitizing hands, changing PPE between positive and negative residents and cleaning an oxygen concentrator when transferring from a contaminated room to non-contaminated room has caused, or likely to cause serious injury, harm, impairment or death to residents who tested positive for the COVID-19 virus while residing solely in the facility. The affected three (3) of 60 Covid-19 positive Residents who had not been out of the facility. Resident # 25, #26 and #27 expired due to, or as consequence of COVID-19, as indicated on the certificate of death or physician documentation. Findings include: Review of the facility's policy titled, Isolation Policy, with a revision date of [DATE] revealed: Transmission precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection the infection to other residents. Masks, gloves, gowns and goggles will be worn when entering a Residents room. Review of the facility's policy titled, For Suspected or Confirmed Coronavirus (COVID-19), revised ,[DATE], revealed; the facility leadership and clinical staff are implementing all reasonable measures to protect the health and safety of residents and staff during the current outbreak of coronavirus disease (COVID-19). The response to the current outbreak of coronavirus disease is based on the most current recommendations from health policy officials, state agencies and the federal government. Infection prevention and control measures are based on established guidelines governing all communicable diseases. Residents with suspected or confirmed COVID-19 infection are placed in a separate room or cohorted with other residents with the same infection status. Residents who cannot be treated adequately or safely separated from other residents will be transferred. Standard precautions are utilized when caring for all residents. Contact and droplet precautions are implemented for any residents with symptoms of respiratory infection. Current CDC guidelines will be followed for infection prevention and control of residents diagnosed with [REDACTED]. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised [DATE], revealed; the resident -care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard. Durable Medical Equipment (DME) such as oxygen concentrators must be cleaned and disinfected before removing from a contaminated area and moved to a non-contaminated area for reuse by another or same resident. During the facility's initial observation tour, on [DATE] at 10:10 AM, observations revealed the facility did not have a designated COVID-19 unit. The facility had COVID-19 positive Residents located on each of the halls in the building, hall 100, 200, 300 and 400. The facility had precaution signs on the doors and PPE carts placed outside all of the positive COVID-19 residents rooms. The positive COVID-19 residents also had two barrels in their room for linen and trash. The facility held a license for 120 beds. Review of the Resident Census and Condition report, dated [DATE] revealed a census of 68. Review of the facility's census printed, on [DATE] at 10:05 AM, revealed there was four (4) positive COVID-19 residents and 14 negative COVID-19 residents on the 400 hall; one (1) positive COVID-19 and 12 negative COVID-19 residents on the 300 hall; one (1) positive COVID-19 and 19 negative COVID-19 residents on the 200 hall and 11 positive COVID-19 and five (5) negative COVID-19 residents on the 100 hall. During an interview, on [DATE] at 10:00 AM, the Administrator (ADM) and Director of Nursing (DON) revealed the DON confirmed the facility had positive COVID-19 residents all over the building. The DON said the facility tried to make the 300 hall a designated COVID-19 hall, but the facility had several hospital returns in which they had to place them on 14-day quarantine. The facility was unable to keep the wing closed for positive COVID-19 residents because there were more positive residents than negative. The DON said the facility decided to put positive residents in the room together and negative residents together. The Administrator and DON reported the facility had a total of 60 Residents and 15 staff members to test positive with COVID-19. The DON said as of [DATE], there was 18 residents that are currently COVID-19 positive. An observation, on [DATE] at 10:30 AM, revealed Certified Nursing Assistant (CNA) #2 transferred Resident #1's oxygen (O2) concentrator from room [ROOM NUMBER], a room with a positive COVID-19 Resident (#2) across the hall to room [ROOM NUMBER], where a negative COVID-19 resident resided and then placed the oxygen mask on the Resident #1's face. CNA #2 did not clean the O2 concentrator prior to moving it out into the hall and transport it from room [ROOM NUMBER] to room [ROOM NUMBER]. CNA #2 did not cover the O2 concentrator either prior to transferring it from room [ROOM NUMBER] to room [ROOM NUMBER]. During an interview, on [DATE] at 2:40 PM, CNA #2 confirmed she failed to clean the oxygen concentrator. CNA #2 confirmed she transferred Resident #1's contaminated oxygen concentrator from room [ROOM NUMBER] down the hallway to room [ROOM NUMBER] without cleaning it. CNA #2 said she was told at the last minute to transfer Resident #1 from room [ROOM NUMBER] to room [ROOM NUMBER]. CNA #2 said she was not thinking when she removed the oxygen concentrator. CNA #2 confirmed she was trained to clean the concentrator before removing it from one room to another. CNA #2 said she had been in-serviced on COVID-19 and infection control several times. Record review of the facility's Face Sheet for Resident #1, revealed, Resident #1 was admitted by the facility, on [DATE], with [DIAGNOSES REDACTED]. Resident #1 resided in Room ,[DATE]. Resident #1 tested for COVID-19 on [DATE] and the results on [DATE] was negative. Record review of the facility's Face Sheet for Resident #2, revealed, Resident #2 was admitted by the facility on [DATE], with the included [DIAGNOSES REDACTED]. Resident #2 resided in room ,[DATE]. Resident #2 was tested for COVID-19 on [DATE] and the results on [DATE] was positive. Review of the facility's census list, dated [DATE] at 10:05 AM, revealed the resident in Room ,[DATE] was identified by the Director of Nurses (DON) as a negative COVID-19 resident. The DON identified the positive COVID-19 residents with a yellow highlight marker. Review of the facility's Training Sign In Sheets revealed CNA #2 attended in-service training that addressed COVID-19 and infection control [DATE], [DATE] and [DATE]. During an interview, on [DATE] at 10:40 AM, the Medical Director (MD) confirmed the facility had an outbreak of COVID-19 positive residents in [DATE]. The MD said he thinks the outbreak started with a [MEDICAL TREATMENT] resident on the 300 hall that was a dementia resident. The MD said the [MEDICAL TREATMENT] resident was on the same hall as Resident #27. The MD said both residents were confused and refused to wear a mask appropriately. Resident #27 was non-compliant and traveled all over the facility with his mask off and under his chin. The MD also said he recommended the facility designate the 300 hall as the COVID-19 hall and to only use recovered staff on that hall. An observation, on [DATE] at 12:00 PM, revealed CNA #1 was sitting on Resident #4's bed feeding her lunch with full PPE on. After feeding Resident #4 her lunch, CNA #1 proceeded to remove the Styrofoam lunch trays from the 400 hall. Rooms 401 to 414 by placing them in a large black garbage bag sitting in a wheelchair. CNA #1 failed to change her PPE when she entered and exited a positive COVID-19 resident's room. CNA #1 left the 400 hall and placed the garbage bag in the biohazard room. CNA #1 failed to change her PPE gown or gloves or perform hand hygienge at any time during this observation. A review of the facility's census list printed on [DATE] at 10:05 AM, revealed the Director of Nurses (DON) identified four (4) COVID-19 positive residents resided on the 400 hall by highlighting the names with a yellow marker. The positive residents on the 400 Hall resided in rooms (407) Resident #12, (,[DATE]) Resident #14, (,[DATE]) Resident #15 and (412) Resident #19. Further review of the facility's census printed, on [DATE] at 10:05 AM, revealed there was 14 negative COVID-19 residents on the 400 hall. The observation of CNA #1 revealed she entered the COVID-19 negative rooms as follows: Resident #13 (room [ROOM NUMBER]), Resident #18 (room [ROOM NUMBER]) and Resident #20 (room [ROOM NUMBER]), on [DATE] at 12:00 PM to remove the Styrofoam lunch trays from the residents' rooms. During an interview, on [DATE] at 2:00 PM, CNA #1 confirmed she failed to change her gown and gloves when entering positive COVID-19 residents' rooms. CNA #1 said she did not think about it to change her PPE after entering the positive residents' rooms because she was only picking up lunch trays. CNA #1 said she was in-serviced to change PPE when providing care to COVID-19 positive Residents. CNA #1 confirmed by going into positive resident rooms to remove their lunch trays could possibly cause negative residents to become positive. Review of the facility's Training Sign In Sheets revealed CNA #1 attended in-service training that addressed COVID-19 and infection control on [DATE], [DATE] and [DATE]. Review of the facility's Face Sheet for Resident #12 revealed Resident #12 was admitted by the facility on [DATE], with the included [DIAGNOSES REDACTED]. Review of Resident #12's lab reports revealed the resident was tested for COVID-19 on [DATE] and the results returned on [DATE] to be positive. Review of the facility's Face Sheet for Resident #14 revealed Resident #14 was admitted by the facility on [DATE], with the included [DIAGNOSES REDACTED]. Resident #14 was tested for COVID-19 ON [DATE] and the results returned positive on [DATE]. Review of the facility's Face Sheet for Resident #15 revealed Resident #15 was admitted by the facility on [DATE], with the included [DIAGNOSES REDACTED]. Resident #15 was tested for COVID-19 on [DATE] and the results were reported to be positive on [DATE]. Record review of the facility's Face Sheet for Resident #19 revealed the facility admitted Resident #19, on [DATE], with the included [DIAGNOSES REDACTED]. Resident #19 was tested for COVID-19 on [DATE] and the results was reported on [DATE] to be positive. During an interview, [DATE] at 2:50 PM, the DON confirmed as of [DATE], the facility has 18 positive covid-19 residents in the building. The DON said the facility did not have any positive residents until the facility was tested , on [DATE], when the facility was tested by the outbreak team. The DON said 30 out of 70 residents tested positive. The DON said most of the residents that was positive was on the 200 Hall. There were no positive residents on the 100 Hall. The DON also said he believed the residents on the 100 Hall became positive due to an asymptomatic employee. The DON confirmed the facility has had a total of 60 positive residents and 15 positive staff. The DON said there was two (2) staff still on quarantine due testing positive at this time. The DON also confirmed that one (1) resident died in the facility and two (2) residents died at the hospital related to COVID-19. The DON confirmed CNA #1 failed to follow the facility policy by not changing PPE and sanitizing her hands after each positive resident. The DON said all the staff has been in-serviced on donning and doffing PPE. The DON said he would provide more education to CNA #1. The DON also confirmed CNA #2 should have cleaned the oxygen concentrator and placed a bag over it prior to moving it to another room. The DON said he was going to re-in-service the staff. Record review, of the Face Sheet for Resident #25, revealed Resident #25 was admitted by the facility on [DATE] and readmitted on [DATE], with the included [DIAGNOSES REDACTED]. Resident #25 resided on the 100 Hall. Resident #25 tested positive for COVID-19 on [DATE]. Resident #25 expired at the facility on [DATE]. Review of Resident #25's Death Certificate revealed the resident expired, on [DATE] at 1:55 PM, due to [MEDICAL CONDITION] due to COVID-19. Record review, of the Face Sheet for Resident #26, revealed Resident #26 was admitted by the facility, on [DATE], with the included [DIAGNOSES REDACTED]. Resident #26 resided on the 200 Hall. Resident #26 tested positive for COVID-19 on [DATE] at the facility. Resident #26 was sent to the emergency room (ER), on [DATE]. The Departmental Notes dated [DATE] at 3:42 PM, revealed Resident #26 was exhibiting hypoxemia and lethargy. The resident would not keep his oxygen (O2) on even with the nurse continuing to apply the O2, Resident #26's oxygen saturation (O2 sat) was low as 70 to 78 percent (%) with O2 at five liters per minute (5L/M). An order was received from the physician to send Resident #26 to the emergency room (ER). Emergency Response Services (EMS) arrived at 3:10 PM and the resident was transferred out to the hospital at 3:20 PM per the EMS. Previous Departmental Notes documented by Social Services (SS) at 2:33 PM and 2:34 PM, revealed the SS staff was performing a Minimal Data Set (MDS) evaluation for the resident's mood and memory. Resident #26 expired, on [DATE], at the hospital. Review of the hospital's Discharge Summary, for Resident #26, with a date of service [DATE], and signed by the physician on [DATE], revealed Resident #26 was admitted on [DATE] and discharged on [DATE] due to the resident expired on [DATE] at 11:36 PM. The discharge [DIAGNOSES REDACTED]. Record review, of the Face Sheet, for Resident #27, revealed Resident #27 was admitted by the facility, on [DATE], with the included [DIAGNOSES REDACTED]. Resident #27 resided on the 300 Hall. Resident #27 tested positive for COVID-19 on [DATE]. Resident #27 was sent to the emergency room (ER) on [DATE]. Review of the Departmental Notes with a late entry at [DATE] at 1:18 AM, revealed on [DATE] at 10:45 PM, Resident #27 was noted to be coughing with congestion and wheezing. Vital Signs (V/S) was blood pressure (B/P) ,[DATE], Pulse (P)-100, O2 sat 90%, Respirations (R)-18 and a temp of 101.3 degrees Fahrenheit (F). The physician was notified and a new order to transfer the resident to the ER was received. Resident #27 was transferred to the ER per (Name of Transport) at 11:00 PM. The Resident #27 was noted to be coughing with congestion and wheezing, oxygen saturation (O2 sat) 90%, temperature 101.3 degrees Fahrenheit. Review of the hospital's Discharge Summary, for Resident #27, revealed the resident was admitted , on [DATE], with the [DIAGNOSES REDACTED]. The Discharge Summary stated Resident #27 expired, on [DATE] at 8:45 PM, and the Primary [DIAGNOSES REDACTED]. The summary was signed by the physician on [DATE] at 8:54 PM. On [DATE] at 10:48 AM, an observation revealed the Registered Occupational Therapist (ROT) and Physical Therapist Assistant (PTA) entered Resident #23's room wearing masks/shields and gloves, but no gowns on. Further observation revealed the ROT and PTA assisted Resident #23 to drink water from a cup and then the ROT and PTA both left the room. On [DATE] at 10:52 AM, an interview with the ROT and PTA as they were exiting Resident #23's room revealed they did not have PPE gowns on during their visit to Resident #23 because they were only helping the resident do drink some water. Review of Resident #23's lab reports revealed she tested positive for COVID-19 on [DATE]. On [DATE] at 11:36 AM, an interview with the Medical Doctor (MD) revealed if a resident in the facility is COVID-19 positive then that resident would be required to be on contact/droplet precautions and whoever enters the room should wear full PPE with gowns, if they are 6 (six) feet or closer proximity to the resident. On [DATE] at 1:45 PM, an interview with the ROT revealed she did not have to wear a PPE gown while she was in Resident #23's room because she was not providing care for Resident #23, she was only giving her water to drink. She stated since she was not providing direct resident care, she only had to wear gloves and mask/shield that she did not have to wear a gown. This surveyor asked if she was 6 (six) feet in proximity to Resident #23, and she replied yes, she was within 6 (six) feet of Resident #23. On [DATE] at 1:55 PM, an interview with the PTA revealed she did not have to wear a PPE gown when entering Resident #23's room because she was not providing care, only giving her water to drink. This surveyor asked if she was closer than 6 (six) feet to Resident #23, and she replied she was at Resident #23's bedside. The PTA stated since she was not providing Resident #23 direct patient care, she did not have to don a gown before entering Resident #23's room. The facility submitted an acceptable Immediate Jeopardy (IJ) Removal Plan, on [DATE]. Review of the Removal Plan revealed the facility took the following actions to remove the Immediate Jeopardy. 1. On [DATE] at 11:55 AM, the state agency notified the facility of an Immediate Jeopardy due to facility failure to follow Centers for Disease Control (CDC) and Centers for Medicare & Medicaid Services (CMS) guidelines for infection control practices during the COVID-19 pandemic. The facility failed to follow infection control guidelines to prevent the spread of COVID-19. Certified Nursing Assistant (C.N.A.) #1 failed to change her Personal Protective Equipment (PPE) gown while entering COVID positive and negative resident rooms from rooms 401 to 414 with four (4) positive COVID-19 residents. Certified Nursing Assistant (C.N.A.) #2 failed to clean oxygen concentrator between contaminated resident's room [ROOM NUMBER] to a non-contaminated room [ROOM NUMBER] across the hallway. On [DATE], the Occupational Therapist (OTR) and the Physical Therapy Assistant (PTA) entered a positive resident's room [ROOM NUMBER] without Personal Protective Equipment (PPE). As of [DATE], the facility had a total of 60 residents who had tested positive for COVID-19. The facility has 120 licensed beds with a census of 68. As of [DATE], the facility had a total of 18 out of 68 residents who had tested positive for COVID- 19 with 2 COVID deaths in the facility. 2. The facility held a Quality Assurance and Assessment Committee meeting at 12:45 PM, on [DATE], with the Medical Director, Infection Preventionist, Administrator, Director of Nursing, Director of Rehab, Social Services Director, Director of Housekeeping & Laundry, Dietary Service Manager, Business Office Manager, and Minimum Data Set Coordinator to discuss the findings of: 1. Failure to change Personal Protective Equipment (PPE), specifically gowns, from a positive COVID resident room to a negative COVID resident room and 2. Failure to clean equipment transferred from a positive COVID resident room to a negative COVID resident room. Additionally discussed was in-service training for all staff related to CDC Guidelines for COVID-19 regarding use of Personal Protective Equipment (PPE) and in-service training for all staff related to disinfecting equipment from contaminated area to uncontaminated area. Policy revisions for Personal Protective Equipment- Using Gowns and Cleaning and Disinfection of Resident-Care Items and Equipment were discussed and revisions approved: o Droplet precautions were changed to include gloves, gowns, and goggles in addition to masks when entering from gloves, gown, and goggles if there is a risk of spraying secretions. o Durable Medical Equipment (DME) was changed to durable medical equipment (DME) such as oxygen concentrators must be cleaned and disinfected before removing from a contaminated area and moved to a non-contaminated area for reuse by another resident or same resident from Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 3. As of [DATE], all 60 Covid-19 positive residents care plans were updated by Registered Nurse(RN) #1 and Licensed Practical Nurse(LPN) #2 on [DATE]. Daily temperature checks and oxygen levels are being done on 8 negative residents. Care plans for risk of exposure to COVID- 19 by negative residents have been addressed by the Director of Nursing (DON). 4. On [DATE], the facility Director of Nursing (DON) initiated in-service training on revised policy and procedures on CDC Guidelines for COVID-19 use of Personal Protective Equipment (PPE) of when to use, when to remove, and when to dispose properly. The following staff received this in-service: 1 of 5 RN 9 of 16 LPN 12 of 26 CNA 5 of 8 Dietary 1 of 2 Laundries 4 of 4 Housekeeping 5 of 5 Therapies 1 of 1 Business Office Manager 1 of 1 Admissions liaison 1 of 1 Receptionist 1 of 1 Marketing 1 of 2 Activities 1 of 1 Administrator 1 of 1 Social Worker No staff will be allowed to work until participation of in-service CDC Guidelines for COVID-19 use of Personal Protective Equipment of when to use, when to remove, and when to dispose properly. 5. On [DATE], the facility Director of Nursing(DON) initiated in-service training on updated policy and procedures based on CDC Guidelines for COVID-19 on when to disinfect equipment from a contaminated area to an uncontaminated area. The following staff received this in-service: 1 of 5 RN 9 of 16 LPN 12 of 26 CNA 5 of 8 Dietary 1 of 2 Laundries 4 of 4 Housekeeping 5 of 5 Therapies 1 of 1 Business Office Manager 1 of 1 Admissions Liaison 1 of 1 Receptionist 1 of 1 Marketing 1 of 2 Activities 1 of 1 Administrator 1 of 1 Social Worker No staff will be allowed to work until participation of in-service CDC Guidelines for COVID-19 on when to disinfect equipment from a contaminated area to an uncontaminated area. 6. On [DATE], the facility Administrator was in-serviced by the Director of Nursing (DON) on CDC Guidelines for COVID-19 use of Personal Protective Equipment {PPE) of when to use, when to remove, and when to dispose properly and CDC guidelines for COVID-19 on when to disinfect equipment from a contaminated area to an uncontaminated area. The Director of Nursing (DON) was in-serviced by the Administrator on CDC Guidelines for COVID-19 use of Personal Protective Equipment (PPE) of when to use, when to remove, and when to dispose properly and CDC Guidelines for COVID-19 on when to disinfect equipment from a contaminated area to an uncontaminated area. The Infection Preventionist, MD, in-serviced the Administrator and the Director of Nursing (DON) on [DATE] at 5:45 PM. on CDC Guidelines for COVID-19 use of Personal Protective Equipment (PPE) of when to use, when to remove, and when to dispose properly and CDC Guidelines for COVID-19 on when to disinfect equipment from a contaminated area to an uncontaminated area. 7. The facility Director of Nursing (DON) will monitor daily adherence to infection prevention practices and infection control requirements through daily monitoring of staff for hand hygiene, environmental cleaning and disinfection, injection and medication safety, use of appropriate personal protective equipment (e.g. gloves, gowns, and facemasks), respiratory hygiene and cough etiquette, and reprocessing of re-usable medical equipment between each patient. The Director of Nursing (DON) and Administrator will continue to track and report new cases of COVID-19. The facility Director of Nursing(DON) and Administrator will communicate status of COVID-19 positive cases and COVID-19 negative cases to staff daily in order to mitigate infection risk and stop transmission of infections. 8. The facility alleges that the Immediate Jeopardy was removed on [DATE]. The State Agency (SA) validated the facility's Immediate Jeopardy Removal Plan through observation, interview, record review and review of sign-in-sheets. 1. The SA validated through observations that no further issues were observed regarding staff not changing PPE when exiting COVID-19 positive residents rooms on the 400 Hall. 2. The SA validated through interviews and review of the facility's in-service sign-in sheets that in-service education was provided by the facility to all of the staff in the form of lectures and films. 3. The SA validated through interviews and review of monitoring tools the facility utilized to perform visual inspections of nursing staff for proper hand hygiene and PPE use, and cleaning Durable Medical Equipment. 4. The SA validated through record review that all residents in the facility was assessed for signs and symptoms of COVID-19. 5. The SA validated a Quality Assessment and Assurance Committee meeting was held on Tuesday, [DATE] by interview of persons who attended and review of sign in sheets. 6. The SA validated facility wide testing for staff and residents was done on [DATE], [DATE], [DATE]. 7. The SA validated that all of the facility's IJ Removal Plan's corrective actions were completed and the IJ was removed as of [DATE] and validated by the SA's exit on [DATE].

Based on observation, record review, staff interview, and facility policy review, the facility failed to provide weekend activity interventions to meet the needs of residents on the Memory Care/Alzheimer's Unit for three (3) of five (5) sampled residents reviewed, Resident #1, #4 and #5, and the remaining 12 of 15 unsampled residents on the Memory Care/Alzheimer's Unit Unsampled Residents A, B, C, D, E, F, G, H, I, J, K, and L for a total of 15 of 15 residents on the Memory Care/Alzheimer's Unit. The facility failed to provide scheduled activities for the residents of the Memory Care/Alzheimer's Unit. Resident #1 left the faciity on Sunday, 10/18/15 at 1:58 PM by removing a window in the dining/activity room during a scheduled activity time without supervision and walked approximately four tenths (.4) of a mile down a three lane highway. The facility was unaware of any residents missing until a member of the community notified the facility on 10/18/15 at 2:10 PM of an elderly person walking along the highway. The facility discovered Resident #1 was missing and returned the resident to the facility on [DATE] at 2:18 PM. The facility's activity calendar listed a group activity for 10/18/15 at 2:00 PM. Video review revealed the facility held no activity on Sunday, 10/18/15 at 2:00 PM for the Memory Care/Alzheimer's Unit. The facility's failure to provide scheduled activities to ensure the well being of Resident #1 who resided on the Memory Care/Alzheimer's Unit, placed Resident #1 in a situation that was likely to cause serious harm, impairment, or death and lead to other residents on the unit being placed in a situation likely to cause serious harm, impairment, or death. This was determined to be an Immediate Jeopardy (IJ) that began on 10/12/15 with Resident #1's admission. The State Agency notified the facility Administrator on 10/28/15 of an Immediate Jeopardy (IJ). An acceptable credible Allegation of Compliance (AOC) was received on 10/30/15 in which the facility alleged removal of the IJ on 10/29/15. The State Agency validated the AOC and determined the IJ was removed prior to exit. The scope and severity for the IJ at 42 CFR 483.15 (f) (1) Activities to Meet the Needs of Each Resident (F248) was lowered to an F while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic change. Findings include: Review of the facility policy entitled, Activity Programs, revised 01/11, revealed, Policy Statement, Activity programs designed to meet the needs of each resident are available on a daily basis. Review of the facility policy entitled, Activity Programming, dated 08/28/07, for the Memory Care/Alzheimer's Unit revealed Procedure: 4. Activity staff will develop a schedule to out-line the daily routine based upon the Day at a Glance out-lined in the Programming Guide. Review of the Intent of the Daily Programming, undated, revealed, Organizational Strategies: Organize the schedule so that the day flows from one activity to another without lapses between events. This will reduce wandering away from the activity room. Also on the Intent of the Daily Programming was Consistency of Programming, Activity staff will provide nursing staff with tools and information related to each resident's interests and with tools and instruction to conduct groups so that programming can be effectively carried on during the week-ends and evenings when activity staff is not on the secure unit. Review of the Sample Daily Events Schedule Day at a Glance, undated, revealed activities, which included ADL care (Activities of Daily Living such as dressing, grooming, eating and toileting), were scheduled every 30 minutes from 6:00 AM to 6:00 PM. Some of the sample daily activities included mental/cognitive stimulation, physical, outdoor time, sing-along, and reminiscence. Review of the facility policy entitled, Resident Interest and Routines, dated 8/28/07, for the Memory Care/Alzheimer's Unit revealed 3. Behaviors-Does the resident have any behaviors that the staff should be aware of? If so, answer the following: What is the behavior? Are there any warning signs or things that cause the behavior to occur? Are there any successful ways to respond or calm? Review of the Activity Calendar for the Memory Care/Alzheimer's unit revealed there were three (3) activities per day scheduled for seven (7) days from 10/01/15 to 10/18/15, and there were four (4) activities per day scheduled for 11 days from 10/01/15 to 10/18/15 (a total of 65 activities for 10/01/15 to 10/18/15). The documentation revealed that of the 65 scheduled activities, the facility held three (3) scheduled activities from 10/01/15-10/18/15. These three (3) scheduled activities were attended by four (4) residents on 10/09/15 at 9:00 AM; two (2) residents at 9:30 AM on 10/09/15; and on 10/16/15 at 9:00 AM six (6) residents attended. Review of the Activity Participation Sheets for the Memory Care/Alzheimer's Unit revealed the following: 1. For the month of July 2015, there were no activities recorded for the weekends of 07/04/15 to 07/05/15, 07/11/15 to 07/12/15, or 07/18/15 to 07/19/15. There were also no activities for 07/20/15 (Monday), 07/22/15 (Wednesday), 07/23/15 (Thursday) and 07/31/15 (Friday). 2. For the month of August 2015, there were no activities recorded for the weekends of 08/01/15 to 08/02/15, 08/08/15 to 08/09/15, 08/15/15 to 08/16/15, and 08/22/15 to 08/23/15. There were also no activities recorded for 08/03/15 (Monday), 08/18/15 (Tuesday), 08/20/15 (Thursday), 08/25/15 (Tuesday) and 08/31/15 (Monday). 3. For the month of September 2015, there were no activities recorded for 09/01/15 (Tuesday), 09/02/15 (Wednesday), 09/05/15 (Saturday) to 09/07/15 (Monday/Holiday), the weekend of 09/12/15 to 09/13/15, 09/15/15 (Tuesday) to 09/20/15 (Sunday), and 09/23/15 (Wednesday) to 09/30/15 (Wednesday). 4. For the month of October 2015, there were no activities documented for 10/01/15 (Thursday) to 10/08/15 (Thursday), 10/10/15 (Saturday) to 10/15/15 (Thursday), and the weekend of 10/17/15 to 10/18/15. (Resident #1 eloped on 10/18/15). Documentation review revealed Resident #1 had attended one (1) scheduled group activity from 10/12/15-10/18/15. The Facility admitted Resident #1 on 10/12/15, and Resident #1 eloped on 10/18/15. Interview, on 11/30/15 at 3:35 PM, with a family member who wished to remain anonymous revealed this family member came to the facility at least weekly, usually on weekdays but sometimes on weekends. The family member stated, I don't see any activities when I'm up there. The family member reported the Resident has a calendar in her room for activities, but I very seldom see them doing things. The family member added these observations occurred both on the weekdays and on the weekends, and stated, Most of the time when I come, people are lying down in bed. The family member also stated, Some of those ladies, I've never seen them up except to eat. I thought they could take them outside, but mom says they never do that. Interview, on 12/02/15 at 12:00 PM, with the facility Administrator revealed, Activities are going on at all times and added some of the activities might have been as simple as walking down the hall. The administrator also stated the facility did not feel the need to document every single move for activities. The Administrator also stated there were no forms completed for the documentation being monitored, but that the Activity Director checked the logs as they were turned in. Interview, on 12/02/15 at 12:15 PM, with the Activity Director confirmed there was no documentation of the Activity Participation Sheets having been monitored. She also stated the activity participation was to have been documented daily, but the documentation might not have been done because I got busy, but stated We do something all the time over there. Interview, on 10/27/15 at 3:10 PM, with Certified Nurses Assistant (CNA) #4 revealed she did not remember seeing any activity staff on the Memory Care/Alzheimer's Unit the day Resident #1 eloped (10/18/15). Interview, on 10/27/15 at 3:15 PM, with CNA #2 confirmed there had been no activity staff on the Memory Care/Alzheimer's Unit on 10/18/15 even though an activity had been scheduled for 2:00 PM on 10/18/15. CNA #2 also stated if no Activity staff were present for activities, We let them watch TV (television). Interview, on 10/28/15 at 11:30 AM, with the Activities Director revealed there is one (1) person scheduled for activities for both the Memory Care/Alzheimer's Unit as well as the other long-term care residents. The Activity Director stated the Certified Nursing Assistants (CNAs) usually assisted with the activities on the weekends on the Memory Care/Alzheimer's Unit. Interview, on 10/28/15 at 2:50 PM, with Licensed Practical Nurse (LPN) #1 revealed she had not seen anyone from activities assigned to the Memory Care/Alzheimer's Unit on the weekends. Interview, on 10/29/15 at 3:40 PM with Activities Staff #1 revealed the activity employee scheduled for weekends did the activities for the other long-term care residents and did not know if the activities were done on the Memory Care/Alzheimer's Unit. Interview, on 10/29/15 at 4:20 PM, with Activities Staff #2 revealed the facility previously employed an Activities staff member for the Memory Care/Alzheimer's Unit, but there had not been an Activity staff member assigned to the Unit since 05/15 or 06/15. Activities Staff #2 also stated for a while, Activities Staff started the activities on the Unit and then returned to the long-term care residents to perform activities. Activities Staff #2 stated the last time she assisted with activities on the weekends on the Memory Care/Alzheimer's Unit was around 07/15. Interview per phone, on 11/05/15 at 3:50 PM, with the Activity Director revealed when asked about the completion of the Resident Interest and Routines form she stated, I've heard of it. What I use is the Evaluation form and complete a Progress Note. Interview, on 12/01/15 at 12:45 PM, with the facility Administrator revealed the Activity Participation Sheets were implemented in 07/15 as part of an action plan because the facility did not have the documentation of activities to their satisfaction. Resident #1 Observation and interview of Resident #1, on 10/28/15 at 2:50 PM revealed the resident was able to ambulate without assistance and stated, I like to be doing something, not doing nothing. Resident #1 also stated she liked to have a job and something to do and stated she worked at the facility. Review of the Activities Calendar for the Memory Care/Alzheimer's Unit revealed the following scheduled group activities for 10/18/15, the day Resident #1 eloped from the facility: 9:30 AM spiritual music, 10:30 AM Bible story, 2:00 PM games, and 3:00 PM coffee/snack. Review of the facility surveillance video of Resident #1's elopement on Sunday, 10/18/15 revealed there were no facility staff members or other residents present in the Dining Room, where activities were usually held at the time of the elopement. Resident #1's Responsible Party returned a phone call on 12/07/15 at 11:45 AM, the interview with Resident #1's Responsible Party (RP) revealed the RP did not recall having seen residents in activities prior to Resident #1's elopement on 10/18/15. The RP stated she usually observed residents seated in the dining room watching television. Review of Resident #1's Activities Evaluation, dated 10/12/15, revealed the entry was a [DIAGNOSES REDACTED]. The behavior disturbances were not identified. The Evaluation was completed by the Minimum Data Set (MDS)/Care Plan Licensed Practical Nurse (LPN), and signed on 10/15/15. Review of Resident #1's Activity Progress Notes, revealed the first entry was dated 10/20/15, and signed by the Activity Director. The note included that Resident #1 liked to stay busy. Review of the Social Service Progress Notes, dated 10/14/15 and completed by the Licensed Social Worked (LSW), revealed a history of wandering at home prior to Resident #1's admission to the facility. There was no documentation of warning signs or ways to respond or calm the resident. Review of the Activity Participation Sheet revealed between Resident #1's admission on 10/12/15 and elopement on 10/18/15, the facility documented one (1) activity attended by Resident #1 on 10/16/15 at 9:00 AM for Arts and Crafts. Interview, on 10/29/15 at 3:40 PM with the Activities Director confirmed there had been no documentation of activities performed on the Memory Care/Alzheimer's Unit for 10/13/15 to 10/15/15 and 10/17/15 and stated some of the Activities staff had been sick. Interview on 10/28/15 at 11:20 AM with the Activity Director revealed the facility had no monitoring to ensure staff provided activities on the weekends. Review of Resident #1's Face Sheet revealed the facility admitted Resident #1 on 10/12/15 with diagnoses, which included Dementia and Anxiety. Review of the Interim Care Plan revealed the Resident had memory loss. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/19/15 which reviewed Resident #1's status from 10/13/15 to 10/19/13, revealed the BIMS score was seven (07), which indicated moderate cognitive impairment. Review of the facility's video and staff interviews confirmed no group activity for 10/18/15 at 2:00 PM for any of the 15 residents residing on the facility's Memory Care/Alzheimer's Unit. The following residents also resided on the Memory Care/Alzheimer's Unit on 10/18/15: Resident #4 Review of the Activity Participation Sheets for Resident #4 revealed 23 documented activities in July 2015, 19 in August 2015, 5 in September 2015, and there were 3 activities for 10/1/15 and 10/18/15. Review of the Face Sheet revealed the facility readmitted Resident #4 on 05/02/12 with diagnosis, which included Parkinson. Resident #4 resided on the Memory Care/Alzheimer's Unit. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/21/15, revealed Resident #4 scored three (3) of 15 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. Resident #5 Review of the Activity Participation Sheets for Resident #5 revealed the documented activities in July 2015 was 18, in August 2015 was 11, in September 2015 was six (6) and there were zero (0) activities documented from 10/1/15 through 10/18/15. Review of the Face Sheet revealed the facility admitted Resident #5 on 09/04/14 with diagnosis, which included [MEDICAL CONDITION]. Resident #5 resided on the Memory Care/Alzheimer's Unit. Review of the annual MDS, with an ARD of 08/19/15, revealed Resident #5 had severely impaired decision-making skills. Unsampled Resident A Review of the Activity Participation Sheets for Unsampled Resident A revealed 7 documented activities in July 2015, 4 in August 2015, 5 in September, and zero (0) activities documented for October 1 to 18, 2015. Review of the Face Sheet revealed the facility admitted Unsampled Resident A on 02/10/14 with diagnosis, which included [MEDICAL CONDITION], Major [MEDICAL CONDITION]. Unsampled Resident A resided on the Memory Care/Alzheimer's Unit. Review of the quarterly MDS, with an ARD of 10/08/15, revealed Unsampled Resident A scored 11 of 15 on the BIMS, which indicated moderate cognitive impairment. Unsampled Resident B Review of the Activity Participation Sheets for Unsampled Resident B revealed 7 documented activities in July 2015, 4 in August 2015, 5 in September 2015, and 0 activities documented for October 01 to 18, 2015. Review of the Face Sheet revealed the facility admitted Unsampled Resident B on 02/01/15 with diagnosis, which included [MEDICAL CONDITION]. Unsampled Resident B resided on the Memory Care/Alzheimer's Unit. Review of the quarterly MDS, with an ARD of 08/27/15, revealed Unsampled Resident B scored 11 of 15 on the BIMS, which indicated moderate cognitive impairment. Unsampled Resident C Review of the Activity Participation Sheets for Unsampled Resident C revealed documentation for participation in activities 6 times in July 2015, 5 times in August 2015, 4 times in September 2015 and 0 times from October 01 to 18, 2015. Review of the Face Sheet revealed the facility admitted Unsampled Resident C on 01/31/14 with diagnosis, which included [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder. Unsampled Resident C resided on the Memory Care/Alzheimer's Unit. Review of the quarterly MDS, with an ARD of 09/21/15, revealed Unsampled Resident C scored 13 of 15 on the BIMS, which indicated the Resident was cognitively intact. Unsampled Resident D Review of the Activity Participation Sheets for Unsampled Resident D revealed participation was documented in July 2015 19 times, 13 times in August 2015, 4 in September 2015, and 0 from October 1 to 18, 2015. Interview, on 11/30/15 at 12:55 PM, with Unsampled Resident D revealed he/she only participated in activities when a game was played or for birthday parties. Unsampled Resident D preferred to pursue activities in his/her room. Review of the Face Sheet revealed the facility admitted Unsampled Resident D on 05/29/15 with diagnosis, which included Unspecified Dementia. Unsampled Resident D resided on the Memory Care/Alzheimer's Unit. Review of the quarterly MDS, with an ARD of 08/28/15, revealed Unsampled Resident D scored eight (8) of 15 on the BIMS, which indicated moderate cognitive impairment. Unsampled Resident E Review of the Activity Participation Sheets for Unsampled Resident E revealed documentation of participation in activities 20 times for July 2015, 13 times in August 2015, 4 times in September 2015, and 2 times for October 1 to October 18, 2015. Review of the Face Sheet revealed the facility admitted Unsampled Resident E on 05/29/15 with diagnosis, which included [MEDICAL CONDITION] and [MEDICAL CONDITION]. Unsampled Resident E resided on the Memory Care/Alzheimer's Unit. Review of the quarterly MDS, with an ARD of 08/28/15, revealed Unsampled Resident E scored four (4) of 15 on the BIMS, which indicated severe cognitive impairment. Unsampled Resident F Review of the Activity Participation Sheets for Unsampled Resident F revealed documentation for activities for July 2015 was 21 times, August 2015 was 15 times, September 2015 was 13 times, and for October 1 to 18, 2015 was 1 time. Review of the Face Sheet revealed the facility admitted Unsampled Resident F on 02/10/14 with diagnosis, which included [MEDICAL CONDITION]. Unsampled Resident F resided on the Memory Care/Alzheimer's Unit. Review of the quarterly MDS, with an ARD of 10/05/15, revealed Unsampled Resident F had severely impaired decision-making skills. Unsampled Resident G Review of the Activity Participation Sheets for Unsampled Resident G revealed documentation for activities in July 2015 was 27 times, August 2015 was 19 times, September 2015 was 11 times and October 1 to 18, 2015 was 1 time. Review of the Face Sheet revealed the facility admitted Unsampled Resident G on 05/01/14 with diagnosis, which included [MEDICAL CONDITION]. Unsampled Resident G resided on the Memory Care/Alzheimer's Unit. Review of the quarterly MDS, with an ARD of 10/06/15, revealed Unsampled Resident G scored nine (9) of 15 on the BIMS, which indicated moderate cognitive impairment. Unsampled Resident H Review of the Activity Participation Sheets for Unsampled Resident H revealed documentation for 8 activities in July 2015, 5 activities for August 2015, 6 times for September 2015, and 0 for October 1 to 18, 2015. Review of the Face Sheet revealed the facility admitted Unsampled Resident H on 11/14/13 with diagnosis, which included Dementia. Unsampled Resident H resided on the Memory Care/Alzheimer's Unit. Review of the 30 day MDS, with an ARD of 09/24/15, revealed Unsampled Resident H had severely impaired decision-making skills. Unsampled Resident I Review of the Activity Participation Sheets for Unsampled Resident I revealed documentation for activities for July 2015 was 7 times, August 2015 was 3 times, September 2015 was 2 times and from October 1 to 18, 2015 was 0 times. Review of the Face Sheet revealed the facility readmitted Unsampled Resident I on 05/02/12 with diagnosis, which included Dementia. Unsampled Resident I resided on the Memory Care/Alzheimer's Unit. Review of the quarterly MDS, with an ARD of 08/19/15, revealed Unsampled Resident I scored five (5) of 15 on the BIMS, which indicated severe cognitive impairment. Unsampled Resident J Review of the Activity Participation Sheets for Unsampled Resident J revealed participation in activities for July 2015 was 17 times, for August 2015 was 12 times, for September 2015 was 9 times, and for October 1 to 18, 2015 was 0 times. Review of the Face Sheet revealed the facility admitted Unsampled Resident J on 01/31/14 with [DIAGNOSES REDACTED]. Unsampled Resident J resided on the Memory Care/Alzheimer's Unit. Review of the quarterly MDS, with an ARD of 09/10/15, revealed Unsampled Resident J scored three (3) of 15 on the BIMS, which indicated severe cognitive impairment. Unsampled Resident K Review of the Activity Participation Sheets for Unsampled Resident K revealed documentation of activities for July 2015 was 15 times, for August 2015 was 9 times, for September 2015 was 9 times, and for October 1 to 18, 2015 was 1 time. Review of the Face Sheet revealed the facility admitted Unsampled Resident K on 03/12/14 with diagnosis, which included [MEDICAL CONDITION]. Unsampled Resident K resided on the Memory Care/Alzheimer's Unit. Review of the quarterly MDS, with an ARD of 10/29/15, revealed Unsampled Resident K scored two (2) of 15 on the BIMS, which indicated severe cognitive impairment. Unsampled Resident L Review of the Activity Participation Sheets for Unsampled Resident L revealed documentation of activities for July 2015 was 25 times, for August 2015 was 20 times, for September 2015 was 9 times, and for October 1 to 18, 2015 was 1 time. Review of the Face Sheet revealed the facility admitted Unsampled Resident L on 05/19/14 with diagnosis, which included [MEDICAL CONDITION]. Unsampled Resident L resided on the Memory Care/Alzheimer's Unit. Review of the quarterly MDS, with an ARD of 10/27/15, revealed Unsampled Resident L scored one (1) of 15 on the BIMS, which indicated severe cognitive impairment. The facility submitted an acceptable Allegation of Compliance (AOC) on 10/30/15 for the Immediate Jeopardy. Review of the facility's AOC revealed the facility took the following action to remove the Immediate Jeopardy. 1. On 10/18/15 at 2:20 PM, facility resident was identified as having left the facility property through the dining room window on the Memory Care Unit without staff knowledge. She was located 0.4 miles from the facility and returned to the facility by staff. 2. At 2:41 PM, on 10/18/15, an LPN performed a Head to Toe evaluation of the resident with no issues or injuries identified and it was documented on the Skin Care Alert form. The Director of Nursing directed the LPN to initiate 1:1 visual supervision of the resident as an immediate plan of care intervention until further orders were received. The primary physician was notified by the LPN at 2:50 PM with no new orders given. The Responsible Party was attempted to be notified by the LPN at 2:50, but was unsuccessful. The LPN was able to reach another family member of the resident at 3:00 PM. The Director of Maintenance was notified of the incident and the LPN placed herself at the breached window until the Director of Maintenance could arrive. The facility Administrator arrived at the facility on 10/18/15 at 3:45 PM and initiated staff interviews and staff training on elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. The Director of Maintenance conducted an Elopement Drill for the day shift on 10/18/15 at 3:55 PM. The Director of Maintenance secured the Memory Care Dining Room windows (3 of 3) and the resident's bedroom windows (2 of 2) at 4:00 PM. The Administrator and the Director of Maintenance reviewed the security of the dining room and resident room window at 5:15 PM. The Administrator had the CNA (who located the resident) take her to the exact site in order to determine distance from the facility and begin establishing a timeline. The resident's plan of care was updated by an LPN with the goal stated of remaining safe within the facility on 10/18/15. On 10/18/15, the Administrator, who holds a Master's Degree in Social Work, conducted an interview to evaluate the psychosocial wellbeing of the resident. During that interview, no mood or anxiety issues were voiced. The results of that interview are documented in the resident's record. 3. On 10/19/15, Risk of Elopement/Wandering Reviews were initiated by facility licensed staff and RN Consultant for 89 of 89 of the facility residents and care plans updated for those residents identified as being at risk for elopement. The Elopement binders, located at both Nursing Stations and the Reception desk were reviewed and updated to reflect current residents at risk for elopement on 10/19/15. All placed security transmitters were checked for placement and function on 10/19/15 by the facility RN Consultant with no negative outcomes detected. All Secure Care system door alarms were checked for proper function on 10/19/15 by the facility RN Consultant and Administrator with no negative issues detected. The Director of Maintenance contacted MS State Department Division of Fire Safety and Construction Architect regarding securing the remainder of (26 of 28) Memory Care Unit resident room windows on 10/19/15 at 10:11 AM and was given approval to secure the remaining 26 of 28 resident room windows on the Memory Care Unit. Training was continued by the Administrator, Director of Nursing, RN Consultant, and the General Manager on elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents for 95 of 108 employees. Off duty staff members were notified that they could not return to work until receiving education on elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. The facility procedures for door alarm and security bracelet testing were reviewed and revised by the General Manager to reflect the manufacturer's recommendations of the Secure Care products. Transmitter testing procedure training was initiated by RN Consultant on 10/19/15 for licensed staff. Physician orders were received for a Psychiatric Evaluation for the resident. A Therapy Screen for therapy needs was conducted on 10/19/15. 4. On 10/20/15, a Physician order was received for cognitive training and it was initiated by the Speech Language Pathologist. On 10/20/15, Risk of Elopement/Wandering Reviews were completed for 88 of 88 of the facility residents and care plans updated for 25 of 88 residents identified as being at risk for elopement by facility licensed staff and the RN Consultant. The Director of Maintenance contacted MS State Department Division of Fire Safety and Construction Architect regarding security of resident room windows on 10/20/15 at 10:00 AM and was given approval to secure the additional 112 windows located in resident rooms, main dining room, activity room and therapy office. The Director of Maintenance completed securing the remainder of the facility windows on 10/20/15 at 3:00 PM. On 10/20/15, the General Manager reviewed the Orientation process to assure it addressed procedures for Elopement/Missing Residents. At 1:10 PM on 10/20/15, an Ad Hoc Quality Assurance Committee Teleconference meeting was held with the Director of Nursing, the Medical Director (per phone), the facility Administrator and General Manager. Discussion topics included; plan of action for all items identified and initiated for the resident affected, audits completed, measures of action completed, staff training conducted, and policies for elopement and procedures for checking function of security bracelets and door alarms were reviewed. Recommendations were made to implement behavior prevention and redirection technique training and to revise the procedure for checking security bracelet function and door alarms according to the manufacturer's recommendations. The Director of Nursing notified State agency of the incident on 10/19/15 at 2:52 PM. 5. On 10/21/15, the Administrator included the training being conducted for elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents for 2 of 2 new employees during their new employee orientation. On 10/21/15, the Physician ordered Psychiatric Evaluation was performed by a Psychiatric Nurse Practitioner with recommendations made to; change [MEDICATION NAME] 20 mg. QHS, discontinue [MEDICATION NAME], change [MEDICATION NAME] to 0.25 mg. TID, continue [MEDICATION NAME] 15 mg. QHS and continue Klonopin 1 mg. BID. On 10/22/15, all facility staff (who had not been scheduled to work) had received training for elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. On 10/23/15 an Elopement drill was conducted by the Director of Maintenance, the Director of nursing, the Administrator, the General Manager, and the RN Consultant to monitor the education provided on 10/18/15, 10/19/15, 10/20/15, 10/21/15, and 10/22/15. The Director of Nursing, the Administrator, the General Manager, and the RN Charge Nurse between the dates of 10/23/15 and 10/29/15 documented 38 staff interviews. This process was used to determine staff knowledge of previous training related to elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. 6. On 10/29/15 at 2:20 PM an Ad Hoc Quality Assurance Committee teleconference was held with the Assistant Director of Nursing, the Administrator, the Activities Director, Activities Assistant #1, Activities Assistant #2, the General Manager, and the Medical Director. Discussion topics included; Education of CNAs assigned to the Memory Care Unit Group Programs and Activities Calendar, Programming for Residents with Cognitive Impairments and Special Needs, Individual Activities and Room Visit Program, and Documentation of Activity Participation, Re-education of both Activities Assistants on the importance of providing scheduled activities and documentation, contacting the Activities Consultant for an additional visit to provide additional education to the Activities Assistants and CNAs, and reviewing Activity Assessments on all the residents identified at risk for elopement and updating their care plans. Recommendations were made to review and revise the upcoming Activity Calendars to assure activity times were staggered to allow weekend duty Activities Assistants to initiate scheduled activities. On 10/29/15 at 2:45 PM, Activity Assessments were reviewed and activity care plans updated for twenty five residents identified as being at risk for elopement by the Director of Social Services and the MDS Coordinator. On 10/29/15, education for 11 of 22 CNAs assigned to the Memory Care Unit was conducted by the Administrator and the Activities Director. Education included Group Programs and Activities Calendar, Programming for Residents with Cognitive Impairments and Special Needs, Individual Activities and Room Visit Program, and Documentation of Activity Participation. On 10/29/15, 2 of 2 Activities Assistants were trained on their responsibilities to provide weekend activit

Based on record review, staff interview and facility policy review, the facility failed to provide adequate supervision to prevent the elopement of Resident #1 for one (1) of five (5) residents reviewed. The facility admitted Resident #1 on 10/12/15. Resident #1 left the faciity on Sunday, 10/18/15 at 1:58 PM by removing the lower pane of a window in the dining/activity room and standing in a dining room chair while facility staff were not supervising the resident. The facility's activity calendar listed a group activity for 10/18/15 at 2:00 PM. Video review revealed the facility held no activity Sunday, 10/18/15 at 2:00 PM on the Memory Care/Alzheimer's Unit. Resident #1 left through the window and walked approximately four tenths (.4) of a mile down a three lane highway. The facility was unaware of Resident #1 missing until a member of the community notified the facility on 10/18/15 at 2:10 PM of an elderly person walking along the highway. The facility discovered Resident #1 was missing and returned the resident to the facility on [DATE] at 2:18 PM. The facility's failure to supervise Resident #1 who resided on the Memory Care/Alzheimer's Unit and exhibited exiting seeking behaviors since admission placed Resident #1 and other residents in need of supervision in a situation that was likely to cause serious harm, impairment, or death. This was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 10/12/15 with Resident #1's admission. The State Agency notified the facility Administrator on 10/28/15 of an Immediate Jeopardy (IJ). An acceptable credible Allegation of Compliance (AOC) was received on 10/30/15 in which the facility alleged removal of the IJ on 10/29/15. The State Agency validated the AOC and determined the IJ was removed prior to exit. The scope and severity for the IJ and SQC at 42 CFR 483.25 (f) Free of Accident Hazards/Supervision (F323) was lowered to an D while the facility develops and implements the Plan of Correction and the facility's Quality Assurance monitors the effectiveness of systemic change to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy entitled Wandering, Unsafe Resident, revised 08/14, revealed, Policy Interpretation and Implementation, 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. Observation of the facility's video recording for 10/18/15, verified by the facility's General Manager, revealed the following in the dining/activity room and hall of the Memory Care/Alzheimer's Unit: 1. From 1:54 PM to 1:57 PM, Resident #1 pulled back the blinds, got a chair and placed it next to the window and removed his/her shoes. Resident #1 stood in the chair by the blinds, then walked across the dining room and exited to the hall, and was not wearing shoes. 2. At 1:57 PM, Resident #1 attempted to follow visitors exiting the secured door of the Unit. 3. At 1:58 PM, Resident #1 walked back to the dining room, stood in a chair in front of the window, pulled back the blinds, removed the entire lower half of the window glass and sat the window on the floor. The resident then knelt on his/her knees on the windowsill and exited the facility window. There were no facility staff members or other residents in the dining room during the entire video. 4. At 2:18 PM, Resident #1 was returned to the building accompanied by facility staff. Interview on 10/27/15 at 2:40 PM with Licensed Practical Nurse (LPN) #2 revealed the Memory Care/Alzheimer's staff was in the library with two (2) Residents on 10/18/15 at the time of the elopement (1:58 PM) of Resident #1. The facility's Receptionist called to inform the staff the facility had received a call from a person in the community that an elderly black female was walking down the highway. LPN #2 stated, We all jumped (up) because the way (Resident #1) was acting prior to that - packing her clothes, banging on doors and windows. We knew who it would be because of the way she had been acting. The staff then began the search for Resident #1 in the building and on the highway. Review of the Activities Calendar for the Memory Care/Alzheimer's Unit revealed on 10/18/15, a supervised scheduled group activities was supposed to have been taking place in the dining/activity room at 2:00 PM. Interview, on 10/27/15 at 3:10 PM with Certified Nurses Assistant (CNA) #4 revealed after the Memory Care/Alzheimer's Unit was searched and Resident #1 was not found, CNA #4 left the building and drove south on the Highway where they found Resident #1 walking down the hill on the side of the highway. CNA #4 stopped the car near Resident #1 and asked where Resident #1 was going. Resident #1 stated she had to get the kids from school. I told her she might get hit and got her in the car. CNA #4 also stated there were staff members in three (3) cars who left the facility to locate Resident #1, and two (2) of the cars blocked traffic while Resident #1 was assisted to the third car. Observation and interview, on 10/27/15 at 4:00 PM, with CNA #2 revealed from the window where Resident #1 exited the building on 10/18/15 at 1:58 PM, the Resident would have walked the entire length of the building, crossed a vacant lot, which was part of the facility, to get to the edge of the property at Highway 11. When this area was walked by angling across the vacant lot and following the drive behind the building, it was 533 steps to the edge of the facility property. The area identified by CNA #2 as where Resident #1 was located was an additional 387 steps from the property line. The Highway had a slight downhill grade, a 55 miles per hour speed limit on 10/18/15 (Sunday) due to no school in session, and there were two (2) lanes going northbound (uphill) and one (1) lane going southbound (downhill). Observation, on 10/29/15 at 10:20 AM, of the window the resident eloped through revealed it was 36.5 inches from the floor to the windowsill, 18 inches from the seat of the chair to the windowsill, and 37 inches from the windowsill to the ground outside of the window. The window where the exit occurred was eight (8) feet wide and four (4) feet 10 inches high, and included three (3) separate windows. Each window was 32.5 inches wide and 58.5 inches wide. The portion of the window which was removes was 30 inches tall. The frame for the window was metal, and each window had two (2) release latches at the bottom of the window, as well as a screen on the lower half of the windows. There was no manufacturer indicated on the windows, there was no known manufacturer's instructions. The windows were originally installed when the building was built. The building was opened in 1981. Although the window could have been raised for the Resident to have exited the facility, Resident #1 removed the lower pane of the window on the right, when facing the three (3) windows. The specific manor in which Resident #1 removed the window is unknown, since the blinds which covered the windows blocked the view of the resident when this occurred. The blinds were 2 inch heavy faux wood blinds. Interview with Resident #1 on 10/28/15 at 2:50 PM revealed Resident #1 believed she worked at the facility and stated her job at the facility was straightening and cleaning. Interview, on 10/27/15 at 3:30 PM, with CNA #1 revealed, when she learned a resident had left the building, she knew immediately it was Resident #1. CNA #1 also stated she entered the dining room and found the blinds over the window that was removed flapping. Interview, on 10/29/15 at 6:08 PM, with the facility Administrator revealed after Resident #1 eloped, the Licensed Social Worker (LSW) was not notified until her return to work on 10/19/15. The Administrator stated she had a Master Social Work degree, but was not a Licensed Social Worker and completed a Psychosocial Evaluation after the elopement. Interview, on 10/30/15 at 1:50 PM, with the Medical Director who was Resident #1's physician, revealed in his opinion Resident #1 was higher functioning. The Medical Director stated the facility notified him right away when the resident eloped, and a Psychiatric Evaluation had been approved after the elopement. The Medical Director also stated the Resident had complained of hip and ankle pain, but there was no pathology identified on the x-rays. Interview, on 10/27/15 at 2:40 PM, with LPN #2 revealed Resident #1 stated she had to get to his/her children and would quit working at the facility if necessary. LPN #2 stated Resident #1 thought she was employed at the facility. Interview, on 12/02/15 at 8:40 AM, with LPN #2 revealed Resident #1 was beating on exit doors and two (2) windows at the nurses' station. LPN #2 added Resident #1 had beat on the same doors and windows 10/17/15, but not to the extent of the behaviors displayed on 10/18/15. LPN #2 stated Resident #1 packed her clothes on 10/17/15 and expressed desire to leave facility. LPN #2 also stated at times Resident #1 is not confused, and at other times is confused. Review of the Accident/Incident Report for Resident #1, dated 10/18/15 at 2:18 PM, and signed by Licensed Practical Nurse (LPN) #2 revealed Resident had been trying to get out of facility, beating on windows and doors saying she was going to get out + (and) wanting to leave. Received call from someone passing by on hwy. (highway) that someone was walking down the hwy. Resident was found. The Accident/Incident Report also stated one-on-one supervision was not implemented until after Resident #1 eloped. Review of the Incident Witness Account Form for Resident #1 and completed by Certified Nursing Assistant (CNA) #1, dated 10/18, revealed 2. When was the last time you saw this resident? In her room packing her bags sayin she ready to go home . 3. What was this resident doing at the last time you saw them? Walk-in and fussing and packin. 4. Did you notice anything unusual that could have contributed to the incident? No every day at the same time 12-4 (12:00 PM to 4:00 PM) she get upset and ready to go home to check on her kids. Interview, on 12/02/15 at 9:15 PM, with CNA #1 revealed after lunch on 10/18/15, Resident #1 became upset and agitated and began screaming and crying and wanted to check on (her) kids (children). CNA #1 stated Resident #1 would pack her clothes in plastic containers, place the container on an overbed table, and take the table near the nurses' station. CNA #1 also stated Resident #1 would get upset and want to go home to check on her children between 12:00 PM and 4:00 PM daily, and that the behavior had been present since admission. Resident #1 would also knock on the glass window at the nurses' station. Review of the Incident Witness Account Form for Resident #1 and completed by CNA #2, dated 10/18, revealed, 2. When was the last time you saw this resident? Walking 400 hall. 3. What was this resident doing at the last time you saw them? Walking 400 hall. 4. Did you notice anything unusual that could have contributed to the incident? Resident has been trying to get out all day. She kept saying she needs to get to her children. Interview, on 10/27/15 at 3:15 PM, with CNA #2 revealed Resident #1 had been pacing the halls and banging on doors or windows the day of the elopement (10/18/15), and added Resident #1 had been like that since admission. CNA #2 also stated the aforementioned behavior usually started between 2:00 PM and 4:00 PM, but on the day Resident #1 eloped, the behaviors started around 12:30 PM. Review of the Incident Witness Account Form for Resident #1 and completed by CNA #3, dated 10/18, revealed, 2. When was the last time you saw this resident? In her room. 3. What was this resident doing at the last time you saw them? She was in room packing clothes and fussing trying to leave. 4. Did you notice anything unusual that could have contributed to the incident? She keep saying she wanted to leave all day. The State surveyor was unable to reach CNA #3 for interview. Review of the Incident Witness Account Form for Resident #1 and completed by CNA #4, dated 10/18, revealed, 2. When was the last time you saw this resident? About 20 minutes prior in hallway fussing, talking about getting a brick and breaking a window out. 3. What was this resident doing at the last time you saw them? Talking about getting out of here to go see about her children. 4. Did you notice anything unusual that could have contributed to the incident? She was real fussy and agitated. Interview, on 12/01/15 at 2:05 PM, with CNA #4 revealed Resident #1 had been asking about a family member and Resident #1 believed she was just visiting the facility. Resident #1 also spoke of her children, and referred to them as babies. CNA #1 stated she witnessed Resident #1 pushing on the main exit door for the Memory Care/Alzheimer's unit. Resident #1 was agitated and fussing and stated she had a brick and would break out the window, adding she could break out any one of the windows. CNA #4 also stated Resident #1 would talk about getting her children off the bus and had been pacing all day on 10/18/15 when the elopement occurred. On 12/07/15 at 11:45 PM after exit from the facility, Resident #1's Responsible Party (RP) returned a call to the state surveyor. The RP revealed prior to admission to the facility, the resident had lived with the RP and had begun to leave the RP's home without the RP's knowledge. The RP stated the resident was sometimes returned to the RP's home by a neighbor. The RP stated Resident #1 was always walking and at times, wanted to walk to the bus station. The RP also added Resident #1 had desired to leave the hospital where she was treated immediately prior to admission to the facility. The RP reported Resident #1 liked to move around. Interview per phone on 11/05/15 at 2:30 PM with the Director of Nursing (DON) revealed she had been aware since Resident #1's admission of the risk for elopement, but had not witnessed nor was she aware of any exit seeking behaviors. Interview per phone on 11/05/15 at 2:40 PM, with the facility's Administrator revealed she had not been aware of any exit seeking behaviors for Resident #1. Review of the resident's Face Sheet revealed the facility admitted Resident #1 on 10/12/15 with diagnoses, which included Dementia and Anxiety. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/19/15, revealed Resident #1 scored seven (07) on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment. The facility submitted an acceptable Allegation of Compliance (AOC) on 10/30/15 for the Immediate Jeopardy. Review of the facility's AOC revealed the facility took the following action to remove the Immediate Jeopardy. 1. On 10/18/15 at 2:20 PM, facility resident was identified as having left the facility property through the dining room window on the Memory Care Unit without staff knowledge. She was located 0.4 miles from the facility and returned to the facility by staff. 2. At 2:41 PM, on 10/18/15, an LPN performed a Head to Toe evaluation of the resident with no issues or injuries identified and it was documented on the Skin Care Alert form. The Director of Nursing directed the LPN to initiate 1:1 visual supervision of the resident as an immediate plan of care intervention until further orders were received. The primary physician was notified by the LPN at 2:50 PM with no new orders given. The Responsible Party was attempted to be notified by the LPN at 2:50, but was unsuccessful. The LPN was able to reach another family member of the resident at 3:00 PM. The Director of Maintenance was notified of the incident and the LPN placed herself at the breached window until the Director of Maintenance could arrive. The facility Administrator arrived at the facility on 10/18/15 at 3:45 PM and initiated staff interviews and staff training on elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. The Director of Maintenance conducted an Elopement Drill for the day shift on 10/18/15 at 3:55 PM. The Director of Maintenance secured the Memory Care Dining Room windows (3 of 3) and the resident's bedroom windows (2 of 2) at 4:00 PM. The Administrator and the Director of Maintenance reviewed the security of the dining room and resident room window at 5:15 PM. The Administrator had the CNA (who located the resident) take her to the exact site in order to determine distance from the facility and begin establishing a timeline. The resident's plan of care was updated by an LPN with the goal stated of remaining safe within the facility on 10/18/15. On 10/18/15, the Administrator, who holds a Master's Degree in Social Work, conducted an interview to evaluate the psychosocial wellbeing of the resident. During that interview, no mood or anxiety issues were voiced. The results of that interview are documented in the resident's record. 3. On 10/19/15, Risk of Elopement/Wandering Reviews were initiated by facility licensed staff and RN Consultant for 89 of 89 of the facility residents and care plans updated for those residents identified as being at risk for elopement. The Elopement binders, located at both Nursing Stations and the Reception desk were reviewed and updated to reflect current residents at risk for elopement on 10/19/15. All placed security transmitters were checked for placement and function on 10/19/15 by the facility RN Consultant with no negative outcomes detected. All Secure Care system door alarms were checked for proper function on 10/19/15 by the facility RN Consultant and Administrator with no negative issues detected. The Director of Maintenance contacted MS State Department Division of Fire Safety and Construction Architect regarding securing the remainder of (26 of 28) Memory Care Unit resident room windows on 10/19/15 at 10:11 AM and was given approval to secure the remaining 26 of 28 resident room windows on the Memory Care Unit. Training was continued by the Administrator, Director of Nursing, RN Consultant, and the General Manager on elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents for 95 of 108 employees. Off duty staff members were notified that they could not return to work until receiving education on elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. The facility procedures for door alarm and security bracelet testing were reviewed and revised by the General Manager to reflect the manufacturer's recommendations of the Secure Care products. Transmitter testing procedure training was initiated by RN Consultant on 10/19/15 for licensed staff. Physician orders were received for a Psychiatric Evaluation for the resident. A Therapy Screen for therapy needs was conducted on 10/19/15. 4. On 10/20/15, a Physician order was received for cognitive training and it was initiated by the Speech Language Pathologist. On 10/20/15, Risk of Elopement/Wandering Reviews were completed for 88 of 88 of the facility residents and care plans updated for 25 of 88 residents identified as being at risk for elopement by facility licensed staff and the RN Consultant. The Director of Maintenance contacted MS State Department Division of Fire Safety and Construction Architect regarding security of resident room windows on 10/20/15 at 10:00 AM and was given approval to secure the additional 112 windows located in resident rooms, main dining room, activity room and therapy office. The Director of Maintenance completed securing the remainder of the facility windows on 10/20/15 at 3:00 PM. On 10/20/15, the General Manager reviewed the Orientation process to assure it addressed procedures for Elopement/Missing Residents. At 1:10 PM on 10/20/15, an Ad Hoc Quality Assurance Committee Teleconference meeting was held with the Director of Nursing, the Medical Director (per phone), the facility Administrator and General Manager. Discussion topics included; plan of action for all items identified and initiated for the resident affected, audits completed, measures of action completed, staff training conducted, and policies for elopement and procedures for checking function of security bracelets and door alarms were reviewed. Recommendations were made to implement behavior prevention and redirection technique training and to revise the procedure for checking security bracelet function and door alarms according to the manufacturer's recommendations. The Director of Nursing notified State agency of the incident on 10/19/15 at 2:52 PM. 5. On 10/21/15, the Administrator included the training being conducted for elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents for 2 of 2 new employees during their new employee orientation. On 10/21/15, the Physician ordered Psychiatric Evaluation was performed by a Psychiatric Nurse Practitioner with recommendations made to; change Aricept 20 mg. QHS, discontinue Seroquel, change Risperdal to 0.25 mg. TID, continue Remeron 15 mg. QHS and continue Klonopin 1 mg. BID. On 10/22/15, all facility staff (who had not been scheduled to work) had received training for elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. On 10/23/15 an Elopement drill was conducted by the Director of Maintenance, the Director of nursing, the Administrator, the General Manager, and the RN Consultant to monitor the education provided on 10/18/15, 10/19/15, 10/20/15, 10/21/15, and 10/22/15. The Director of Nursing, the Administrator, the General Manager, and the RN Charge Nurse between the dates of 10/23/15 and 10/29/15 documented 38 staff interviews. This process was used to determine staff knowledge of previous training related to elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. 6. On 10/29/15 at 2:20 PM an Ad Hoc Quality Assurance Committee teleconference was held with the Assistant Director of Nursing, the Administrator, the Activities Director, Activities Assistant #1, Activities Assistant #2, the General Manager, and the Medical Director. Discussion topics included; Education of CNAs assigned to the Memory Care Unit Group Programs and Activities Calendar, Programming for Residents with Cognitive Impairments and Special Needs, Individual Activities and Room Visit Program, and Documentation of Activity Participation, Re-education of both Activities Assistants on the importance of providing scheduled activities and documentation, contacting the Activities Consultant for an additional visit to provide additional education to the Activities Assistants and CNAs, and reviewing Activity Assessments on all the residents identified at risk for elopement and updating their care plans. Recommendations were made to review and revise the upcoming Activity Calendars to assure activity times were staggered to allow weekend duty Activities Assistants to initiate scheduled activities. On 10/29/15 at 2:45 PM, Activity Assessments were reviewed and activity care plans updated for twenty five residents identified as being at risk for elopement by the Director of Social Services and the MDS Coordinator. On 10/29/15, education for 11 of 22 CNAs assigned to the Memory Care Unit was conducted by the Administrator and the Activities Director. Education included Group Programs and Activities Calendar, Programming for Residents with Cognitive Impairments and Special Needs, Individual Activities and Room Visit Program, and Documentation of Activity Participation. On 10/29/15, 2 of 2 Activities Assistants were trained on their responsibilities to provide weekend activities and completing documentation by the Administrator and the Activities Director. Both Activities Assistants reviewed and signed a copy of their Job Description on 10/29/15. On 10/29/15, the Administrator contacted the contracted Activities Consultant to provide additional training to both Activities Assistants and the CNAs assigned to the Memory Care Unit during the month of October. 7. Facility alleged removal of the IJ on 10/29/15. On 10/31/15, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. 1. On 10/31/15 the State Agency (SA) surveyor validated by video review Resident #1 left the facility property through the dining room window on the Memory Care Unit without staff knowledge on 10/18/15. 2. On 10/31/15 the State Agency (SA) surveyor validated an LPN #2 performed a Head to Toe evaluation of the resident and documented on the Skin Care Alert form no injuries identified. The Surveyor validated by interview with the LPN #2 that 1:1 visual supervision of the resident was initiated immediately until further orders were received. Documentation review validated the primary physician was notified following the elopement by the LPN #2 with no new orders given, LPN #2 notified a family member of the resident's elopement, and the Director of Maintenance was notified of the incident. Interview with LPN #2 validated the LPN placed herself at the breached window until the Director of Maintenance arrived. The State Agency (SA) surveyor validated by review of the staff sign in sheets and interview that the facility Administrator initiated staff interviews and staff training on elopement, wandering residents, routine resident checks, and safety and supervision of residents. The State Agency (SA) surveyor validated by sign in sheets and interviews that the Director of Maintenance conducted Elopement Drills with the staff across all shifts. The State Agency (SA) surveyor validated by observation and interview with the Maintenance Director that the Director of Maintenance secured the three (3) Memory Care Dining Room windows and the two (2) windows in Resident #1's bedroom. The SA surveyor validated by record review that Resident #1's plan of care was updated on 10/18/15 by LPN #2 with a goal of remaining safe within the facility. The SA surveyor validated by review of documentation that the Administrator conducted an interview on 10/18/15, to evaluate the psychosocial wellbeing of the resident. The SA surveyor validated the Administrator held a Master's Degree in Social Work. 3. On 10/31/15, the SA surveyor validated by record review that Risk of Elopement/Wandering Reviews were initiated on 10/19/15 by facility staff and RN Consultant for 89 of 89 of the facility residents and care plans updated for those residents identified as being at risk for elopement. The SA surveyor validated by binder review and comparison to list of wandering residents that the facility's Elopement binders, located at the Nursing Stations and the Reception desk were updated to reflect current residents at risk for elopement. The SA surveyor validated by review of facility list and documentation that all resident security transmitters were checked for placement and function on 10/19/15, and that all Secure Care system door alarms were checked for proper function on 10/19/15. The SA surveyor validated by phone call and email to SA that the Director of Maintenance contacted MS State Department Division of Fire Safety and Construction Architect regarding securing the remainder of the Memory Care Unit resident room windows on 10/19/15 and was given approval. The SA surveyor validated by review of sign in sheets and interviews that training continued by the Administrator, Director of Nursing, RN Consultant, and the General Manager on elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents for 95 of 108 employees. The SA surveyor validated by review of in-service records that no off duty staff members worked until they had received education on elopement, wandering, routine resident checks, and safety and supervision of residents. The SA surveyor validated by interview and policy review that the facility procedures for door alarm and security bracelet testing were reviewed and revised to reflect the manufacturer's recommendations of the Secure Care products. The SA surveyor validated by record review transmitter testing procedure training was initiated by RN Consultant on 10/19/15 for licensed staff. The SA surveyor validated Physician orders were received for a Psychiatric Evaluation for the resident. The SA surveyor validated a Therapy Screen for therapy needs was conducted on 10/19/15. 4. On 10/31/15 the SA surveyor validated that on 10/20/15, a Physician order was received for cognitive training and it was initiated by the Speech Language Pathologist. The SA surveyor validated by record review that on 10/20/15, Risk of Elopement/Wandering Reviews were completed for 88 of 88 of the facility residents and care plans updated for 25 of 88 residents identified as being at risk for elopement. The SA surveyor validated by email review that the facility's Director of Maintenance contacted MS State Department Division of Fire Safety and Construction Architect regarding security of resident room windows on 10/20/15 at 10:00 AM and was given approval to secure the additional 112 windows located in resident rooms, main dining room, activity room and therapy office. The SA surveyor validated by observation and interview that the Director of Maintenance secured the remainder of the facility windows on 10/20/15 at 3:00 PM. The SA surveyor validated by record review and employee signatures that the facility reviewed the Orientation process to assure it addressed procedures for Elopement/Missing Residents. The SA surveyor validated by record review and sign in sheets that on 10/20/15 at 1:10 PM an Ad Hoc Quality Assurance Committee Teleconference meeting was held with the Director of Nursing, the Medical Director (per phone), the facility Administrator and General Manager and discussed the plan of action and initiated for the resident affected, audits completed, measures of action completed, staff training conducted, and policies for elopement and procedures for checking function of security bracelets and door alarms were reviewed. The SA surveyor validated that recommendations were made to implement behavior prevention and redirection technique training and to revise the procedure for checking security bracelet function and door alarms according to the manufacturer's recommendations. The SA surveyor validated that the Director of Nursing notified State agency of the incident on 10/19/15 at 2:52 PM. 5. The SA surveyor validated that on 10/21/15, the Administrator included the training being conducted for elopement, wandering residents, routine resident checks, and safety and supervision of residents for 2 of 2 new employees during their new employee orientation. The SA surveyor validated on 10/21/15, the Physician ordered a Psychiatric Evaluation be performed by a Psychiatric Nurse Practitioner. The SA surveyor validated that on 10/22/15, all facility staff not scheduled to work had received training for elopement, wandering residents, routine resident checks, and safety and supervision of residents. The SA surveyor validated by record review and sign in sheets that on 10/23/15 an Elopement drill was conducted by the Director of Maintenance, the Director of nursing, the Administrator, the General Manager, and the RN Consultant to monitor the education provided on 10/18/15, 10/19/15, 10/20/15, 10/21/15, and 10/22/15. The SA surveyor validated by interview and record review that the Director of Nursing, the Administrator, the General Manager, and the RN Charge Nurse between the dates of 10/23/15 and 10/29/15 documented 38 staff interviews to determine staff knowledge of previous training related to elopement, wandering residents, routine resident checks, and safety and supervision of residents. 6. The SA surveyor validated by sign sheet review and interview that on 10/29/15 at 2:20 PM a second Ad Hoc Quality Assurance Committee teleconference was held with the Assistant Director of Nursing, the Administrator, the Activities Director, Activities Assistant #1, Activities Assistant #2, the General Manage

Based on review of the Admission Evaluation and Interim Care Plan, resident record review, professional literature review, policy review, and staff interview, the facility failed to develop care plan interventions related to wandering/elopement risk and failed to develop a care plan for activities for Resident #1, for one (1) of five (5) sampled residents reviewed and one (1) of 15 residents residing on the Memory Care/Alzheimer's Unit. The facility admitted Resident #1 on 10/12/15. Upon admission Resident #1's Responsible Party (RP) reported Resident #1 wandered and liked to stay busy. The facility failed to a develop care plan to address activities to socially engage the resident and failed to develop interventions for resident's risk for elopement. After exhibiting exit seeking behaviors such as banging on windows and doors and wanting to check on her children, Resident #1 disassembled a dining room window and left the faciity on Sunday, 10/18/15 at 1:58 PM without supervision. The facility's staff were unaware of any residents missing. Resident #1 walked approximately four tenths (.4) of a mile down a three lane highway. A member of the community notified the facility on 10/18/15 at 2:10 PM of an elderly person walking along the highway. The facility then identified Resident #1 as missing and discovered Resident #1 walking down the highway away from the facility. The facility staff returned Resident #1 to the facility on [DATE] at 2:18 PM. The facility's failure to care plan interventions for exit seeking behaviors and develop an interim care plan for activities upon admission for Resident #1 who resided on the Memory Care/Alzheimer's Unit, placed Resident #1 in a situation that was likely to cause serious harm, impairment, or death. This was determined to be an Immediate Jeopardy (IJ) that began on 10/12/15 with Resident #1's admission. The State Agency notified the facility Administrator on 10/28/15 of an Immediate Jeopardy (IJ). An acceptable credible Allegation of Compliance (AOC) was received on 10/30/15 in which the facility alleged removal of the IJ on 10/29/15. The State Agency validated the AOC and determined the IJ was removed prior to exit. The scope and severity for the IJ at 42 CFR 483.20 (K) Care Plan Development (F279) was lowered to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of systemic change. Findings include: Review of Fundamentals of Nursing Care Concepts, Connections, & Skills by Burton and Ludwig, Second Edition, page 412 read, An initial assessment database includes both objective and subjective data and is completed by interviewing the patient and performing physical assessment of all body systems.You will then compile and analyze the collected data to identify the actual problems the patient has, as well as, potential problems the patient is at risk for developing. These identified problems are used in development of the plan of care. The facility failed to provide an Interim Care Plan policy. Review of the facility policy entitled Wandering, Unsafe Resident, revised 8/14, revealed, Policy Interpretation and Implementation, 3. The Resident's care plan will indicate the resident is at risk for elopement or other safety issues. Review of the facility policy entitled Departmental Supervision, revised 4/06, revealed, Policy Interpretation and Implementation, 4. The Director of Nursing Services and/or the Nurse Supervisor/Charge Nurse, as a minimum, is responsible for: c. Reviewing individual resident care plans for appropriate goals, problems, approaches and revisions based on nursing needs; j. Providing direct resident care as necessary or appropriate. Record review of Resident #1's Admission Evaluation and Interim Care Plan, dated 10/12/15, revealed for Behavioral Factors there was No Obvious Problem. Review of the Risk of Elopement/Wandering Review, dated 10/12/15, revealed, Resident is at risk for elopement/wandering, as evidenced by Resident has a history of elopement. Review of the resident's care plans revealed the facility developed a care plan that read Verbally abusive behavior with agitation and exit seeking on 10/16/15, but failed to include any interventions specific to the resident's exit seeking behaviors. The care plan listed nine (9)interventions related to the resident's aggressive behaviors, but no interventions related to the resident's exit seeking. The resident had a history of [REDACTED]. Review of the resident's plan of care upon admission revealed no care plan for activities. Interview per phone on 11/12/15 at 11:45 AM with the Director of Nursing (DON) revealed each interdisciplinary team member was responsible for updating care plans and adding interventions as needed. The same procedure was used for interim care plans, with each discipline responsible for their care plans. The MDS/Care Plan Licensed Practical Nurse (LPN) was responsible for the review of the care plans for accuracy and completion. The DON also stated any concerns identified in the morning meetings were added by each discipline to the resident's care plan after the meeting. Interview conducted per phone on 11/05/15 at 2:45 PM with the MDS/Care Plan Licensed Practical Nurse (LPN) revealed the standardcomputerized care plans were completed as part of the interim care plans. The MDS/Care Plan LPN also stated Social Services was responsible for the development of the wandering/elopement Care Plan. She also added the reason the facility admitted Resident #1 to the Memory Care/Alzheimer's Unit, which was a locked unit, was due to the resident's risk of elopement. Interview with Resident #1 on 10/28/15 at 2:50 PM revealed Resident #1 believed she worked at the facility. The resident did not recall having exited the window, but then spoke of the ram in the bush which assisted her to leave the facility. On 12/07/15 at 11:45 AM, Resident #1's Responsible Party (RP) returned the surveyor's call and revealed the family talked to the facility regarding elopement from the RP's home and suggested interventions such as worship, music, bible study, and giving Resident #1 tasks such as cleaning her room with a timeline to complete the tasks. Review of the Face Sheet revealed the facility admitted Resident #1 on 10/12/15 with diagnoses, which included Dementia and Anxiety. Review of the admission Minimum Data Set (MDS) , with an Assessment Reference Date (ARD) of 10/19/15, revealed the Brief Interview for Mental Status (BIMS) score was seven (7) which indicated moderate cognitive impairment. The facility submitted an acceptable Allegation of Compliance (AOC) on 10/30/15 for the Immediate Jeopardy. Review of the facility's AOC revealed the facility took the following action to remove the Immediate Jeopardy. 1. On 10/18/15 at 2:20 PM, facility resident was identified as having left the facility property through the dining room window on the Memory Care Unit without staff knowledge. She was located 0.4 miles from the facility and returned to the facility by staff. 2. At 2:41 PM, on 10/18/15, an LPN performed a Head to Toe evaluation of the resident with no issues or injuries identified and it was documented on the Skin Care Alert form. The Director of Nursing directed the LPN to initiate 1:1 visual supervision of the resident as an immediate plan of care intervention until further orders were received. The primary physician was notified by the LPN at 2:50 PM with no new orders given. The Responsible Party was attempted to be notified by the LPN at 2:50, but was unsuccessful. The LPN was able to reach another family member of the resident at 3:00 PM. The Director of Maintenance was notified of the incident and the LPN placed herself at the breached window until the Director of Maintenance could arrive. The facility Administrator arrived at the facility on 10/18/15 at 3:45 PM and initiated staff interviews and staff training on elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. The Director of Maintenance conducted an Elopement Drill for the day shift on 10/18/15 at 3:55 PM. The Director of Maintenance secured the Memory Care Dining Room windows (3 of 3) and the resident's bedroom windows (2 of 2) at 4:00 PM. The Administrator and the Director of Maintenance reviewed the security of the dining room and resident room window at 5:15 PM. The Administrator had the CNA (who located the resident) take her to the exact site in order to determine distance from the facility and begin establishing a timeline. The resident's plan of care was updated by an LPN with the goal stated of remaining safe within the facility on 10/18/15. On 10/18/15, the Administrator, who holds a Master's Degree in Social Work, conducted an interview to evaluate the psychosocial wellbeing of the resident. During that interview, no mood or anxiety issues were voiced. The results of that interview are documented in the resident's record. 3. On 10/19/15, Risk of Elopement/Wandering Reviews were initiated by facility licensed staff and RN Consultant for 89 of 89 of the facility residents and care plans updated for those residents identified as being at risk for elopement. The Elopement binders, located at both Nursing Stations and the Reception desk were reviewed and updated to reflect current residents at risk for elopement on 10/19/15. All placed security transmitters were checked for placement and function on 10/19/15 by the facility RN Consultant with no negative outcomes detected. All Secure Care system door alarms were checked for proper function on 10/19/15 by the facility RN Consultant and Administrator with no negative issues detected. The Director of Maintenance contacted MS State Department Division of Fire Safety and Construction Architect regarding securing the remainder of (26 of 28) Memory Care Unit resident room windows on 10/19/15 at 10:11 AM and was given approval to secure the remaining 26 of 28 resident room windows on the Memory Care Unit. Training was continued by the Administrator, Director of Nursing, RN Consultant, and the General Manager on elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents for 95 of 108 employees. Off duty staff members were notified that they could not return to work until receiving education on elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. The facility procedures for door alarm and security bracelet testing were reviewed and revised by the General Manager to reflect the manufacturer's recommendations of the Secure Care products. Transmitter testing procedure training was initiated by RN Consultant on 10/19/15 for licensed staff. Physician orders were received for a Psychiatric Evaluation for the resident. A Therapy Screen for therapy needs was conducted on 10/19/15. 4. On 10/20/15, a Physician order was received for cognitive training and it was initiated by the Speech Language Pathologist. On 10/20/15, Risk of Elopement/Wandering Reviews were completed for 88 of 88 of the facility residents and care plans updated for 25 of 88 residents identified as being at risk for elopement by facility licensed staff and the RN Consultant. The Director of Maintenance contacted MS State Department Division of Fire Safety and Construction Architect regarding security of resident room windows on 10/20/15 at 10:00 AM and was given approval to secure the additional 112 windows located in resident rooms, main dining room, activity room and therapy office. The Director of Maintenance completed securing the remainder of the facility windows on 10/20/15 at 3:00 PM. On 10/20/15, the General Manager reviewed the Orientation process to assure it addressed procedures for Elopement/Missing Residents. At 1:10 PM on 10/20/15, an Ad Hoc Quality Assurance Committee Teleconference meeting was held with the Director of Nursing, the Medical Director (per phone), the facility Administrator and General Manager. Discussion topics included; plan of action for all items identified and initiated for the resident affected, audits completed, measures of action completed, staff training conducted, and policies for elopement and procedures for checking function of security bracelets and door alarms were reviewed. Recommendations were made to implement behavior prevention and redirection technique training and to revise the procedure for checking security bracelet function and door alarms according to the manufacturer's recommendations. The Director of Nursing notified State agency of the incident on 10/19/15 at 2:52 PM. 5. On 10/21/15, the Administrator included the training being conducted for elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents for 2 of 2 new employees during their new employee orientation. On 10/21/15, the Physician ordered Psychiatric Evaluation was performed by a Psychiatric Nurse Practitioner with recommendations made to; change [MEDICATION NAME] 20 mg. QHS, discontinue [MEDICATION NAME], change [MEDICATION NAME] to 0.25 mg. TID, continue [MEDICATION NAME] 15 mg. QHS and continue Klonopin 1 mg. BID. On 10/22/15, all facility staff (who had not been scheduled to work) had received training for elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. On 10/23/15 an Elopement drill was conducted by the Director of Maintenance, the Director of nursing, the Administrator, the General Manager, and the RN Consultant to monitor the education provided on 10/18/15, 10/19/15, 10/20/15, 10/21/15, and 10/22/15. The Director of Nursing, the Administrator, the General Manager, and the RN Charge Nurse between the dates of 10/23/15 and 10/29/15 documented 38 staff interviews. This process was used to determine staff knowledge of previous training related to elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. 6. On 10/29/15 at 2:20 PM an Ad Hoc Quality Assurance Committee teleconference was held with the Assistant Director of Nursing, the Administrator, the Activities Director, Activities Assistant #1, Activities Assistant #2, the General Manager, and the Medical Director. Discussion topics included; Education of CNAs assigned to the Memory Care Unit Group Programs and Activities Calendar, Programming for Residents with Cognitive Impairments and Special Needs, Individual Activities and Room Visit Program, and Documentation of Activity Participation, Re-education of both Activities Assistants on the importance of providing scheduled activities and documentation, contacting the Activities Consultant for an additional visit to provide additional education to the Activities Assistants and CNAs, and reviewing Activity Assessments on all the residents identified at risk for elopement and updating their care plans. Recommendations were made to review and revise the upcoming Activity Calendars to assure activity times were staggered to allow weekend duty Activities Assistants to initiate scheduled activities. On 10/29/15 at 2:45 PM, Activity Assessments were reviewed and activity care plans updated for twenty five residents identified as being at risk for elopement by the Director of Social Services and the MDS Coordinator. On 10/29/15, education for 11 of 22 CNAs assigned to the Memory Care Unit was conducted by the Administrator and the Activities Director. Education included Group Programs and Activities Calendar, Programming for Residents with Cognitive Impairments and Special Needs, Individual Activities and Room Visit Program, and Documentation of Activity Participation. On 10/29/15, 2 of 2 Activities Assistants were trained on their responsibilities to provide weekend activities and completing documentation by the Administrator and the Activities Director. Both Activities Assistants reviewed and signed a copy of their Job Description on 10/29/15. On 10/29/15, the Administrator contacted the contracted Activities Consultant to provide additional training to both Activities Assistants and the CNAs assigned to the Memory Care Unit during the month of October. 7. Facility alleged removal of the IJ on 10/29/15. On 10/31/15, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. 1. On 10/31/15 the State Agency (SA) surveyor validated by video review Resident #1 left the facility property through the dining room window on the Memory Care Unit without staff knowledge on 10/18/15. 2. On 10/31/15 the State Agency (SA) surveyor validated an LPN #2 performed a Head to Toe evaluation of the resident and documented on the Skin Care Alert form no injuries identified. The Surveyor validated by interview with the LPN #2 that 1:1 visual supervision of the resident was initiated immediately until further orders were received. Documentation review validated the primary physician was notified following the elopement by the LPN #2 with no new orders given, LPN #2 notified a family member of the resident's elopement, and the Director of Maintenance was notified of the incident. Interview with LPN #2 validated the LPN placed herself at the breached window until the Director of Maintenance arrived. The State Agency (SA) surveyor validated by review of the staff sign in sheets and interview that the facility Administrator initiated staff interviews and staff training on elopement, wandering residents, routine resident checks, and safety and supervision of residents. The State Agency (SA) surveyor validated by sign in sheets and interviews that the Director of Maintenance conducted Elopement Drills with the staff across all shifts. The State Agency (SA) surveyor validated by observation and interview with the Maintenance Director that the Director of Maintenance secured the three (3) Memory Care Dining Room windows and the two (2) windows in Resident #1's bedroom. The SA surveyor validated by record review that Resident #1's plan of care was updated on 10/18/15 by LPN #2 with a goal of remaining safe within the facility. The SA surveyor validated by review of documentation that the Administrator conducted an interview on 10/18/15, to evaluate the psychosocial wellbeing of the resident. The SA surveyor validated the Administrator held a Master's Degree in Social Work. 3. On 10/31/15, the SA surveyor validated by record review that Risk of Elopement/Wandering Reviews were initiated on 10/19/15 by facility staff and RN Consultant for 89 of 89 of the facility residents and care plans updated for those residents identified as being at risk for elopement. The SA surveyor validated by binder review and comparison to list of wandering residents that the facility's Elopement binders, located at the Nursing Stations and the Reception desk were updated to reflect current residents at risk for elopement. The SA surveyor validated by review of facility list and documentation that all resident security transmitters were checked for placement and function on 10/19/15, and that all Secure Care system door alarms were checked for proper function on 10/19/15. The SA surveyor validated by phone call and email to SA that the Director of Maintenance contacted MS State Department Division of Fire Safety and Construction Architect regarding securing the remainder of the Memory Care Unit resident room windows on 10/19/15 and was given approval. The SA surveyor validated by review of sign in sheets and interviews that training continued by the Administrator, Director of Nursing, RN Consultant, and the General Manager on elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents for 95 of 108 employees. The SA surveyor validated by review of in-service records that no off duty staff members worked until they had received education on elopement, wandering, routine resident checks, and safety and supervision of residents. The SA surveyor validated by interview and policy review that the facility procedures for door alarm and security bracelet testing were reviewed and revised to reflect the manufacturer's recommendations of the Secure Care products. The SA surveyor validated by record review transmitter testing procedure training was initiated by RN Consultant on 10/19/15 for licensed staff. The SA surveyor validated Physician orders were received for a Psychiatric Evaluation for the resident. The SA surveyor validated a Therapy Screen for therapy needs was conducted on 10/19/15. 4. On 10/31/15 the SA surveyor validated that on 10/20/15, a Physician order was received for cognitive training and it was initiated by the Speech Language Pathologist. The SA surveyor validated by record review that on 10/20/15, Risk of Elopement/Wandering Reviews were completed for 88 of 88 of the facility residents and care plans updated for 25 of 88 residents identified as being at risk for elopement. The SA surveyor validated by email review that the facility's Director of Maintenance contacted MS State Department Division of Fire Safety and Construction Architect regarding security of resident room windows on 10/20/15 at 10:00 AM and was given approval to secure the additional 112 windows located in resident rooms, main dining room, activity room and therapy office. The SA surveyor validated by observation and interview that the Director of Maintenance secured the remainder of the facility windows on 10/20/15 at 3:00 PM. The SA surveyor validated by record review and employee signatures that the facility reviewed the Orientation process to assure it addressed procedures for Elopement/Missing Residents. The SA surveyor validated by record review and sign in sheets that on 10/20/15 at 1:10 PM an Ad Hoc Quality Assurance Committee Teleconference meeting was held with the Director of Nursing, the Medical Director (per phone), the facility Administrator and General Manager and discussed the plan of action and initiated for the resident affected, audits completed, measures of action completed, staff training conducted, and policies for elopement and procedures for checking function of security bracelets and door alarms were reviewed. The SA surveyor validated that recommendations were made to implement behavior prevention and redirection technique training and to revise the procedure for checking security bracelet function and door alarms according to the manufacturer's recommendations. The SA surveyor validated that the Director of Nursing notified State agency of the incident on 10/19/15 at 2:52 PM. 5. The SA surveyor validated that on 10/21/15, the Administrator included the training being conducted for elopement, wandering residents, routine resident checks, and safety and supervision of residents for 2 of 2 new employees during their new employee orientation. The SA surveyor validated on 10/21/15, the Physician ordered a Psychiatric Evaluation be performed by a Psychiatric Nurse Practitioner. The SA surveyor validated that on 10/22/15, all facility staff not scheduled to work had received training for elopement, wandering residents, routine resident checks, and safety and supervision of residents. The SA surveyor validated by record review and sign in sheets that on 10/23/15 an Elopement drill was conducted by the Director of Maintenance, the Director of nursing, the Administrator, the General Manager, and the RN Consultant to monitor the education provided on 10/18/15, 10/19/15, 10/20/15, 10/21/15, and 10/22/15. The SA surveyor validated by interview and record review that the Director of Nursing, the Administrator, the General Manager, and the RN Charge Nurse between the dates of 10/23/15 and 10/29/15 documented 38 staff interviews to determine staff knowledge of previous training related to elopement, wandering residents, routine resident checks, and safety and supervision of residents. 6. The SA surveyor validated by sign sheet review and interview that on 10/29/15 at 2:20 PM a second Ad Hoc Quality Assurance Committee teleconference was held with the Assistant Director of Nursing, the Administrator, the Activities Director, Activities Assistant #1, Activities Assistant #2, the General Manager, and the Medical Director to discuss Education of CNAs assigned to the Memory Care Unit Group Programs and Activities Calendar, Programming for Residents with Cognitive Impairments and Special Needs, Individual Activities and Room Visit Program, and Documentation of Activity Participation, Re-education of both Activities Assistants on the importance of providing scheduled activities and documentation, contacting the Activities Consultant for an additional visit to provide additional education to the Activities Assistants and CNAs, and reviewing Activity Assessments on all the residents identified at risk for elopement and updating their care plans. The SA surveyor validated by record review that on 10/29/15 at 2:45 PM, Activity Assessments were reviewed and activity care plans were updated for 25 residents identified as being at risk for elopement by the Director of Social Services and the MDS Coordinator. The SA surveyor validated by interview and record review that on 10/29/15, the facility provided education for 11 of 22 CNAs assigned to the Memory Care Unit on Group Programs and Activities Calendar, Programming for Residents with Cognitive Impairments and Special Needs, Individual Activities and Room Visit Program, and Documentation of Activity Participation. The SA surveyor validated by interview and record review that on 10/29/15, 2 of 2 Activities Assistants were trained on their responsibilities to provide weekend activities and completing documentation by the Administrator and the Activities Director. The SA surveyor validated that the Activities Assistants reviewed and signed a copy of their Job Description on 10/29/15. The SA surveyor validated by interview that on 10/29/15, the Administrator contacted the contracted Activities Consultant to provide additional training to both Activities Assistants and the CNAs assigned to the Memory Care Unit during the month of October.

Based on record review, staff interview and facility policy review the facility failed to identify and provide services for the psychosocial needs of Resident #1, a recent admission, who displayed adjustment difficulties related to behavior management for one (1) of five (5) residents reviewed. During the survey, the State Agency determined the facility was not in compliance with the Requirement for Participation in Medicare and Medicaid. MS Complaint # was substantiated with an Immediate Jeopardy (IJ) and Substandard Quality of Care identified on 10/28/15 and determined to exist on 10/12/15. At the time of survey, the facility had a census of 86 and was licensed for 120 beds. On 10/12/15, Resident #1 was admitted to the facility's locked/secured Memory Care/Alzheimer's Unit. Upon admission to the facility's Memory Care/Alzheimer's Unit, the resident's responsible party informed the facility of Resident #1's elopement behaviors prior to admission. Resident #1 had a [DIAGNOSES REDACTED]. Resident #1 was exhibiting exit seeking behaviors by banging on windows and making statements of needing to leave to check on her children. On 10/18/15 at 1:58 PM while unsupervised, Resident #1 stood in a chair, removed her shoes, removed the glass pane from a dining/activity room window, threw her shoes out the window, and left the facility through the window without the knowledge of the facility staff. Resident #1 ambulated approximately four tenths (.4) of a mile from the facility on a three lane highway. A member of the community observed a an elderly person walking along the highway and called to alert the facility on 10/18/15 at 2:10 PM in case it was a resident. Facility staff were unaware Resident #1 was out of the building until the call. The facility staff then located the resident and returned Resident #1 to the facility on [DATE] at 2:18 PM. The facility's failure to meet the psychosocial needs of Resident #1 with wandering risk placed the resident in a situation that was likely to cause serious harm, impairment, or death. This was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 10/12/15 when Resident #1 was admitted . The State Agency notified the facility Administrator on 10/28/15 of an Immediate Jeopardy (IJ). An acceptable credible Allegation of Compliance (AOC) was received on 10/30/15 in which the facility alleged removal of the IJ on 10/29/15. The State Agency validated the AOC and determined the IJ was removed prior to exit. The scope and severity for the IJ and SQC at 42 CFR 483.25 (f) Psychosocial Difficulties (F319) was lowered to an D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance monitors the effectiveness of the systemic change. Findings include: Review of the facility policy entitled Behavioral Assessment, Interventions and Monitoring, dated 03/15, revealed, Policy Statement, 2. Behavioral symptoms will be managed appropriately. Review of the facility policy entitled Management of Behavior for the Memory Care/Alzheimer's Unit, dated 08/28/07, revealed, Fundamental Information Purpose, 3. Family members who have a close relationship with the resident and knowledge of the resident's patterns and routines will be an important resource in developing of interventions . 5. Activities to provide social interaction and support positive utilization of time will be an important aspect of behavior management . Procedure: 1. Upon admissions, various disciplines will gather information from family members and previous care-givers that will give insight into habits, routine, and previously existing behaviors and 3. If a resident exhibits behaviors, assessment will be conducted utilizing input from staff including direct care-givers, and from involved family members. Review of the facility's policy entitled Activity Programing dated 8/28/2007, revealed Programs will encourage communications and social interaction and will utilize past skills and interest. Emphasis will be placed upon maintaining a sense of identity, self-worth, independence, and functional abilities. The policy also stated the purpose was, To consistently implement programming designed to accommodate the psychosocial needs, interest, functional levels and energy levels of the resident population in a manner that provides opportunities each day for a sense of purpose, sense of community, choices, and fun. Resident #1 Review of Resident #1's Patient Progress Notes from the hospital admission immediately prior to admission to the facility revealed an entry, dated 10/01/15 at 1:59 PM, which documented a Psychosocial Assessment and symptoms of increased depression, agitation, forgetting to eat, sleep disturbances and wandering at night and attempting to leave the house. Review of the admission history and physical from the aforementioned hospital stay revealed worsening episodes of confusion and wandering reported. Episodes of agitation and aggression with patient hurling expletives. Review of the facility's Social Services Progress Notes, dated 10/14/15 (two days after admission), revealed Resident #1's niece reported the reason for the resident's admission to the facility's Memory Care/Alzheimer's Unit was due to the resident's wandering. The progress note stated the resident informed the Licensed Social Worker that she needs to leave to go home and check on her babies. There was no documentation of any information which regarded approaches or interventions used by the family members when these behaviors occurred. The note also stated, LSW (Licensed Social Worker) will continue to monitor Resident for any problems or needs. The next entry on the Social Services Progress Notes occurred after Resident #1 eloped on 10/18/15. Resident #1's Responsible Party could not be reached by telephone during the investigation at the facility, but the RP returned the phone call on 12/07/15 at 11:45 AM. The interview with Resident #1's Responsible Party (RP) revealed that the family had verbalized to the facility the interventions that they used at home when the resident became restless and exit seeking. The RP stated that they implemented interventions such as: giving the resident house keeping tasks, using the Bible, gospel music, call her family, and attending church to calm her. The RP stated during the interview that she had told the facility that Resident #1 liked to move around, complete house keeping duties, and stay busy. RP stated that Resident #1 had worked as a janitor and had worked all of her life as a house keeper. The RP stated that she had no knowledge of ever observing any of the residents of the facility's Memory Care/Alzheimer's Unit involved in planned social interactions and/or activities prior to Resident #1's elopement on 10/18/15. The RP stated she usually observed residents seated in the dining room watching television. Review of Resident #1's behavior management plan of care revealed no interventions addressing exit seeking behaviors. Interview per phone, on 11/05/15 at 2:10 PM with the LSW revealed she had been aware of the exit seeking behaviors and the need to have checked on her babies when Resident #1 was first admitted . The LSW also stated interventions included talking to the resident when the resident was agitated. The LSW also stated the Certified Nurses Assistants (CNAs) were instructed to try talking to Resident #1, call the resident's family or redirect the resident. Review of the Behaviors documented by the CNAs for Resident #1 revealed on 10/17/15 documentation for Screaming/Yelling - Nurse Notified. There were no interventions documented. Interview per phone, on 11/05/15 at 2:25 PM with Certified Nurse Assistant (CNA) #1 revealed she attempted to redirect Resident #1 and tried to encourage the resident to go to the enclosed courtyard. CNA #1 stated that she was unable to redirect the resident. CNA #1 stated she also reported the behaviors to the nurse (LPN #2). Review of the Nurse's Notes revealed an entry by Licensed Practical Nurse (LPN) #1, dated 10/14/15 at 3:30 PM for Resident #1 crying. According to the note, when asked, Resident #1 stated, I need to get home to see about my children. The nurse attempted to reorient resident to place and time, but was unsuccessful. Review of the 10/18/15 Nurse's Note for Resident #1 at 2:50 PM by Licensed Practical Nurse (LPN) #2 revealed the resident had eloped from the facility and Resident had been trying to get out of facility for the past three (3) days. She has been packing clothes + (and) beating on doors and windows trying to get out. There were no interventions documented in the Nurse's Note. Interview, on 10/27/15 at 2:40 PM, with LPN #2 revealed the facility staff had been sitting in the library with two (2) residents when a call was received of an elderly female walking by the road. LPN #2 stated most of the residents were in bed. LPN #2 stated Resident #1 was previously employed as a janitor and that Resident #1 thought she was employed at the facility. LPN #2 said Resident #1 also stated she had to get to her kids and would quit her job at the facility in order to get to her children. Interview per phone, on 11/05/15 at 2:20 PM, LPN #2 revealed the day Resident #1 eloped the staff tried redirection when the resident was beating on the doors and windows. The record review of Resident #1's Activities Evaluation, dated 10/12/15, documented that Resident #1 was diagnosed with [REDACTED].#1's Other Psychosocial, Physical, or Environmental Issues that might hinder or reduce activity participation. Resident #1's specific behavior disturbances were not identified. The Evaluation was completed by the Minimum Data Set (MDS)/Care Plan Licensed Practical Nurse (LPN), and signed on 10/15/15. Review of Resident #1's Face Sheet revealed the facility admitted Resident #1 on 10/12/15 with diagnoses, which included Dementia and Anxiety. The Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) score was not completed at the time of elopement. On 11/30/15 at 3:35 PM, an interview with an anonymous family member revealed this family member visited the facility's Memory Care/Alzheimer's Unit on a frequent basis, on weekdays and on weekdays. The family member stated that there was rarely, if ever, any activities and/or planned social interactions observed between the staff and the residents. The family member stated that they did not see interactions that promoted stimulation to the residents on that Memory Care/Alzheimer's Unit. The family member stated that the Residents have planned activity calendars in their rooms for activities, but I very seldom see them doing things. The family member stated, Most of the time when I come, people are lying down in bed. The family member also stated, Some of those ladies, I've never seen them up except to eat. I thought they could take them outside, but mom says they never do that. The facility submitted an acceptable Allegation of Compliance (AOC) on 10/30/15 for the Immediate Jeopardy. Review of the facility's AOC revealed the facility took the following action to remove the Immediate Jeopardy. 1. On 10/18/15 at 2:20 PM, facility resident was identified as having left the facility property through the dining room window on the Memory Care Unit without staff knowledge. She was located 0.4 miles from the facility and returned to the facility by staff. 2. At 2:41 PM, on 10/18/15, an LPN performed a Head to Toe evaluation of the resident with no issues or injuries identified and it was documented on the Skin Care Alert form. The Director of Nursing directed the LPN to initiate 1:1 visual supervision of the resident as an immediate plan of care intervention until further orders were received. The primary physician was notified by the LPN at 2:50 PM with no new orders given. The Responsible Party was attempted to be notified by the LPN at 2:50, but was unsuccessful. The LPN was able to reach another family member of the resident at 3:00 PM. The Director of Maintenance was notified of the incident and the LPN placed herself at the breached window until the Director of Maintenance could arrive. The facility Administrator arrived at the facility on 10/18/15 at 3:45 PM and initiated staff interviews and staff training on elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. The Director of Maintenance conducted an Elopement Drill for the day shift on 10/18/15 at 3:55 PM. The Director of Maintenance secured the Memory Care Dining Room windows (3 of 3) and the resident's bedroom windows (2 of 2) at 4:00 PM. The Administrator and the Director of Maintenance reviewed the security of the dining room and resident room window at 5:15 PM. The Administrator had the CNA (who located the resident) take her to the exact site in order to determine distance from the facility and begin establishing a timeline. The resident's plan of care was updated by an LPN with the goal stated of remaining safe within the facility on 10/18/15. On 10/18/15, the Administrator, who holds a Master's Degree in Social Work, conducted an interview to evaluate the psychosocial wellbeing of the resident. During that interview, no mood or anxiety issues were voiced. The results of that interview are documented in the resident's record. 3. On 10/19/15, Risk of Elopement/Wandering Reviews were initiated by facility licensed staff and RN Consultant for 89 of 89 of the facility residents and care plans updated for those residents identified as being at risk for elopement. The Elopement binders, located at both Nursing Stations and the Reception desk were reviewed and updated to reflect current residents at risk for elopement on 10/19/15. All placed security transmitters were checked for placement and function on 10/19/15 by the facility RN Consultant with no negative outcomes detected. All Secure Care system door alarms were checked for proper function on 10/19/15 by the facility RN Consultant and Administrator with no negative issues detected. The Director of Maintenance contacted MS State Department Division of Fire Safety and Construction Architect regarding securing the remainder of (26 of 28) Memory Care Unit resident room windows on 10/19/15 at 10:11 AM and was given approval to secure the remaining 26 of 28 resident room windows on the Memory Care Unit. Training was continued by the Administrator, Director of Nursing, RN Consultant, and the General Manager on elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents for 95 of 108 employees. Off duty staff members were notified that they could not return to work until receiving education on elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. The facility procedures for door alarm and security bracelet testing were reviewed and revised by the General Manager to reflect the manufacturer's recommendations of the Secure Care products. Transmitter testing procedure training was initiated by RN Consultant on 10/19/15 for licensed staff. Physician orders were received for a Psychiatric Evaluation for the resident. A Therapy Screen for therapy needs was conducted on 10/19/15. 4. On 10/20/15, a Physician order was received for cognitive training and it was initiated by the Speech Language Pathologist. On 10/20/15, Risk of Elopement/Wandering Reviews were completed for 88 of 88 of the facility residents and care plans updated for 25 of 88 residents identified as being at risk for elopement by facility licensed staff and the RN Consultant. The Director of Maintenance contacted MS State Department Division of Fire Safety and Construction Architect regarding security of resident room windows on 10/20/15 at 10:00 AM and was given approval to secure the additional 112 windows located in resident rooms, main dining room, activity room and therapy office. The Director of Maintenance completed securing the remainder of the facility windows on 10/20/15 at 3:00 PM. On 10/20/15, the General Manager reviewed the Orientation process to assure it addressed procedures for Elopement/Missing Residents. At 1:10 PM on 10/20/15, an Ad Hoc Quality Assurance Committee Teleconference meeting was held with the Director of Nursing, the Medical Director (per phone), the facility Administrator and General Manager. Discussion topics included; plan of action for all items identified and initiated for the resident affected, audits completed, measures of action completed, staff training conducted, and policies for elopement and procedures for checking function of security bracelets and door alarms were reviewed. Recommendations were made to implement behavior prevention and redirection technique training and to revise the procedure for checking security bracelet function and door alarms according to the manufacturer's recommendations. The Director of Nursing notified State agency of the incident on 10/19/15 at 2:52 PM. 5. On 10/21/15, the Administrator included the training being conducted for elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents for 2 of 2 new employees during their new employee orientation. On 10/21/15, the Physician ordered Psychiatric Evaluation was performed by a Psychiatric Nurse Practitioner with recommendations made to; change [MEDICATION NAME] 20 mg. QHS, discontinue [MEDICATION NAME], change [MEDICATION NAME] to 0.25 mg. TID, continue [MEDICATION NAME] 15 mg. QHS and continue Klonopin 1 mg. BID. On 10/22/15, all facility staff (who had not been scheduled to work) had received training for elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. On 10/23/15 an Elopement drill was conducted by the Director of Maintenance, the Director of nursing, the Administrator, the General Manager, and the RN Consultant to monitor the education provided on 10/18/15, 10/19/15, 10/20/15, 10/21/15, and 10/22/15. The Director of Nursing, the Administrator, the General Manager, and the RN Charge Nurse between the dates of 10/23/15 and 10/29/15 documented 38 staff interviews. This process was used to determine staff knowledge of previous training related to elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents. 6. On 10/29/15 at 2:20 PM an Ad Hoc Quality Assurance Committee teleconference was held with the Assistant Director of Nursing, the Administrator, the Activities Director, Activities Assistant #1, Activities Assistant #2, the General Manager, and the Medical Director. Discussion topics included; Education of CNAs assigned to the Memory Care Unit Group Programs and Activities Calendar, Programming for Residents with Cognitive Impairments and Special Needs, Individual Activities and Room Visit Program, and Documentation of Activity Participation, Re-education of both Activities Assistants on the importance of providing scheduled activities and documentation, contacting the Activities Consultant for an additional visit to provide additional education to the Activities Assistants and CNAs, and reviewing Activity Assessments on all the residents identified at risk for elopement and updating their care plans. Recommendations were made to review and revise the upcoming Activity Calendars to assure activity times were staggered to allow weekend duty Activities Assistants to initiate scheduled activities. On 10/29/15 at 2:45 PM, Activity Assessments were reviewed and activity care plans updated for twenty five residents identified as being at risk for elopement by the Director of Social Services and the MDS Coordinator. On 10/29/15, education for 11 of 22 CNAs assigned to the Memory Care Unit was conducted by the Administrator and the Activities Director. Education included Group Programs and Activities Calendar, Programming for Residents with Cognitive Impairments and Special Needs, Individual Activities and Room Visit Program, and Documentation of Activity Participation. On 10/29/15, 2 of 2 Activities Assistants were trained on their responsibilities to provide weekend activities and completing documentation by the Administrator and the Activities Director. Both Activities Assistants reviewed and signed a copy of their Job Description on 10/29/15. On 10/29/15, the Administrator contacted the contracted Activities Consultant to provide additional training to both Activities Assistants and the CNAs assigned to the Memory Care Unit during the month of October. 7. Facility alleged removal of the IJ on 10/29/15. On 10/31/15, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. 1. On 10/31/15 the State Agency (SA) surveyor validated by video review Resident #1 left the facility property through the dining room window on the Memory Care Unit without staff knowledge on 10/18/15. 2. On 10/31/15 the State Agency (SA) surveyor validated an LPN #2 performed a Head to Toe evaluation of the resident and documented on the Skin Care Alert form no injuries identified. The Surveyor validated by interview with the LPN #2 that 1:1 visual supervision of the resident was initiated immediately until further orders were received. Documentation review validated the primary physician was notified following the elopement by the LPN #2 with no new orders given, LPN #2 notified a family member of the resident's elopement, and the Director of Maintenance was notified of the incident. Interview with LPN #2 validated the LPN placed herself at the breached window until the Director of Maintenance arrived. The State Agency (SA) surveyor validated by review of the staff sign in sheets and interview that the facility Administrator initiated staff interviews and staff training on elopement, wandering residents, routine resident checks, and safety and supervision of residents. The State Agency (SA) surveyor validated by sign in sheets and interviews that the Director of Maintenance conducted Elopement Drills with the staff across all shifts. The State Agency (SA) surveyor validated by observation and interview with the Maintenance Director that the Director of Maintenance secured the three (3) Memory Care Dining Room windows and the two (2) windows in Resident #1's bedroom. The SA surveyor validated by record review that Resident #1's plan of care was updated on 10/18/15 by LPN #2 with a goal of remaining safe within the facility. The SA surveyor validated by review of documentation that the Administrator conducted an interview on 10/18/15, to evaluate the psychosocial wellbeing of the resident. The SA surveyor validated the Administrator held a Master's Degree in Social Work. 3. On 10/31/15, the SA surveyor validated by record review that Risk of Elopement/Wandering Reviews were initiated on 10/19/15 by facility staff and RN Consultant for 89 of 89 of the facility residents and care plans updated for those residents identified as being at risk for elopement. The SA surveyor validated by binder review and comparison to list of wandering residents that the facility's Elopement binders, located at the Nursing Stations and the Reception desk were updated to reflect current residents at risk for elopement. The SA surveyor validated by review of facility list and documentation that all resident security transmitters were checked for placement and function on 10/19/15, and that all Secure Care system door alarms were checked for proper function on 10/19/15. The SA surveyor validated by phone call and email to SA that the Director of Maintenance contacted MS State Department Division of Fire Safety and Construction Architect regarding securing the remainder of the Memory Care Unit resident room windows on 10/19/15 and was given approval. The SA surveyor validated by review of sign in sheets and interviews that training continued by the Administrator, Director of Nursing, RN Consultant, and the General Manager on elopement, wandering/unsafe residents, routine resident checks, and safety and supervision of residents for 95 of 108 employees. The SA surveyor validated by review of in-service records that no off duty staff members worked until they had received education on elopement, wandering, routine resident checks, and safety and supervision of residents. The SA surveyor validated by interview and policy review that the facility procedures for door alarm and security bracelet testing were reviewed and revised to reflect the manufacturer's recommendations of the Secure Care products. The SA surveyor validated by record review transmitter testing procedure training was initiated by RN Consultant on 10/19/15 for licensed staff. The SA surveyor validated Physician orders were received for a Psychiatric Evaluation for the resident. The SA surveyor validated a Therapy Screen for therapy needs was conducted on 10/19/15. 4. On 10/31/15 the SA surveyor validated that on 10/20/15, a Physician order was received for cognitive training and it was initiated by the Speech Language Pathologist. The SA surveyor validated by record review that on 10/20/15, Risk of Elopement/Wandering Reviews were completed for 88 of 88 of the facility residents and care plans updated for 25 of 88 residents identified as being at risk for elopement. The SA surveyor validated by email review that the facility's Director of Maintenance contacted MS State Department Division of Fire Safety and Construction Architect regarding security of resident room windows on 10/20/15 at 10:00 AM and was given approval to secure the additional 112 windows located in resident rooms, main dining room, activity room and therapy office. The SA surveyor validated by observation and interview that the Director of Maintenance secured the remainder of the facility windows on 10/20/15 at 3:00 PM. The SA surveyor validated by record review and employee signatures that the facility reviewed the Orientation process to assure it addressed procedures for Elopement/Missing Residents. The SA surveyor validated by record review and sign in sheets that on 10/20/15 at 1:10 PM an Ad Hoc Quality Assurance Committee Teleconference meeting was held with the Director of Nursing, the Medical Director (per phone), the facility Administrator and General Manager and discussed the plan of action and initiated for the resident affected, audits completed, measures of action completed, staff training conducted, and policies for elopement and procedures for checking function of security bracelets and door alarms were reviewed. The SA surveyor validated that recommendations were made to implement behavior prevention and redirection technique training and to revise the procedure for checking security bracelet function and door alarms according to the manufacturer's recommendations. The SA surveyor validated that the Director of Nursing notified State agency of the incident on 10/19/15 at 2:52 PM. 5. The SA surveyor validated that on 10/21/15, the Administrator included the training being conducted for elopement, wandering residents, routine resident checks, and safety and supervision of residents for 2 of 2 new employees during their new employee orientation. The SA surveyor validated on 10/21/15, the Physician ordered a Psychiatric Evaluation be performed by a Psychiatric Nurse Practitioner. The SA surveyor validated that on 10/22/15, all facility staff not scheduled to work had received training for elopement, wandering residents, routine resident checks, and safety and supervision of residents. The SA surveyor validated by record review and sign in sheets that on 10/23/15 an Elopement drill was conducted by the Director of Maintenance, the Director of nursing, the Administrator, the General Manager, and the RN Consultant to monitor the education provided on 10/18/15, 10/19/15, 10/20/15, 10/21/15, and 10/22/15. The SA surveyor validated by interview and record review that the Director of Nursing, the Administrator, the General Manager, and the RN Charge Nurse between the dates of 10/23/15 and 10/29/15 documented 38 staff interviews to determine staff knowledge of previous training related to elopement, wandering residents, routine resident checks, and safety and supervision of residents. 6. The SA surveyor validated by sign sheet review and interview that on 10/29/15 at 2:20 PM a second Ad Hoc Quality Assurance Committee teleconference was held with the Assistant Director of Nursing, the Administrator, the Activities Director, Activities Assistant #1, Activities Assistant #2, the General Manager, and the Medical Director to discuss Education of CNAs assigned to the Memory Care Unit Group Programs and Activities Calendar, Programming for Residents with Cognitive Impairments and Special Needs, Individual Activities and Room Visit Program, and Documentation of Activity Participation, Re-education of both Activities Assistants on the importance of providing scheduled activities and documentation, contacting the Activities Consultant for an additional visit to provide additional education to the Activities Assistants and CNAs, and reviewing Activity Assessments on all the residents identified at risk for elopement and updating their care plans. The SA surveyor validated by record review that on 10/29/15 at 2:45 PM, Activity Assessments were reviewed and activity care plans were updated for 25 residents identified as being at risk for elopement by the Director of Social Services and the MDS Coordinator. The SA surveyor validated by interview and record review that on 10/29/15, the facility provided education for 11 of 22 CNAs assigned to the Memory Care Unit on Group Programs and Activities Calendar, Programming for Residents with Cognitive Impairments and Special Needs, Individual Activities and Room Visit Program, and Documentation of Activity Participation. The SA surveyor validated by interview and record review that on 10/29/15, 2 of 2 Activities Assistants were trained on their responsibilities to provide weekend activities and completing documentation by the Administrator and the Activities Director. The SA surveyor validated that the Activities Assistants reviewed and signed a copy of their Job Description on 10/29/15. The SA surveyor validated by interview that on 10/29/15, the Administrator contacted the contracted Activities Consultant to provide additional training to both Activities Assistants and the CNAs assigned to the Memory Care Unit during the month of October.