Every finding on record at Ocean Springs Health & Rehabilitation Center

Based on record review, staff interview, and facility policy review, the facility failed to revise Resident #1's comprehensive, person-centered care plan to include individualized interventions for physician-ordered wound care for one (1) of three (3) residents reviewed for care planning, Resident #1.Findings include:A review of the facility's policy Care Plan Revisions Upon Status Change, revised 11/14/2025, revealed, Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change .A record review of the admission Record revealed the facility admitted Resident #1 on 5/20/26 with diagnoses including Amputation. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating his cognition was intact.A record review of the Discharge Instructions revealed, Resident #1 was discharged from a local hospital on 5/20/26 with Orders to .Change dressing daily and as needed with dry gauze and replace ace wrap. A record review of the Order Summary Report for Active, Completed, and Discontinued orders revealed Resident #1 had a Physician's Order, dated 5/29/26, for Wound.RBKA (right below knee amputation) Clean with wound cleanser, apply Xeroform, cover with ABD, wrap with Kerlix every day shift every Mon (Monday), Thu (Thursday). A record review of the Care Plan Report revealed Resident #1 had a focus of I have a surgical wound to the right lower extremity, with a date initiated of 5/29/26. The care plan included interventions to monitor nutritional status, monitor and report changes in skin status, obtain laboratory and diagnostic work as ordered, and complete weekly wound measurements. Resident #1 also had a focus of I have an amputation of the bilateral lower extremities r/t (related to) Diabetes, infection, with a date initiated of 5/29/26. The care plan included interventions related to rehabilitation, pain management, monitoring for bleeding and drainage, monitoring nutritional status to promote wound healing, and monitoring the resident's psychosocial adjustment following the amputation. There were no individualized interventions reflecting the physician-ordered wound treatment initiated on 5/29/26, including cleansing the wound with wound cleanser, applying Xeroform, covering the wound with an ABD, wrapping the wound with Kerlix, or performing dressing changes in accordance with the physician's orders.During an interview with Licensed Practical Nurse (LPN)/MDS #2 on 6/22/26 at 1:14 PM, she revealed there were no care plan interventions or approaches addressing Resident #1's wound care needs. She stated the facility develops an individualized, person-centered care plan for each resident based on the resident's assessed needs and physician orders. LPN #2 confirmed Resident #1's wound care should have been incorporated into the comprehensive care plan and acknowledged this was not completed.During an interview with the Director of Nursing (DON) on 6/22/26 at 3:00 PM, she confirmed Resident #1 was admitted to the facility on [DATE] with physician-ordered wound care following a right below-the-knee amputation. The DON stated the facility's interdisciplinary team is responsible for developing and updating each resident's comprehensive, person-centered care plan to reflect the resident's current conditions, physician orders, and treatment needs. She acknowledged Resident #1's wound care interventions were not incorporated into the comprehensive care plan after the wound care orders were written on 5/29/26. The DON confirmed the residents' wound care needs should have been included in the care plan to provide staff with individualized guidance for monitoring and managing the resident's wound in accordance with facility policy and professional standards of practice.

Based on staff interview, record review, and facility policy review, the facility failed to provide treatment and services in accordance with professional standards of practice by failing to timely transcribe physician-ordered wound care into the resident's medical record and failing to document physician-ordered wound treatments in the clinical record for one (1) of three (3) residents reviewed for wound care (Resident #1).Findings include:A review of the facility's policy Documentation of Wound Treatments revised 11/7/2025 revealed, Policy: The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment.Policy Explanation and Compliance Guidelines.3. Wound treatments are documented at the time of each treatment. A review of the facility's policy Provision of Quality of Care, undated, revealed Policy: Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices.Policy Explanation and Compliance Guidelines.6. Policies and procedures will reflect current professional standards of practice. A. All employees are responsible for following established policies and procedures. A record review of the Discharge Instructions revealed, Resident #1 was discharged from a local hospital on 5/20/26 with Orders to .Change dressing daily and as needed with dry gauze and replace ace wrap. A record review of the Order Summary Report for Active, Completed, and Discontinued orders revealed Resident #1 had a Physician's Order, dated 5/29/26, for Wound.RBKA (right below knee amputation) Clean with wound cleanser, apply Xeroform, cover with ABD, wrap with Kerlix every day shift every Mon (Monday), Thu (Thursday). This was the first order on the medical record, which was nine (9) days after the facility admitted him.A record review of Resident #1's clinical record, including the Treatment Administration Record (TAR), revealed no documentation that physician-ordered wound treatments were performed from the resident's admission on [DATE] through 5/31/26.On 6/22/26 at 11:30 AM, during an interview with Licensed Practical Nurse (LPN) #1, she revealed Resident #1 was admitted to the facility on [DATE] with physician-ordered wound care. LPN #1 acknowledged she provided daily wound care but did not transcribe the physician's wound care orders until 5/29/26, nor did she document the wound care on the TAR or clinical record. She stated physician orders should be transcribed promptly, and wound care should be documented at the time the treatment is provided to ensure continuity of care and an accurate medical record. She acknowledged she did not follow facility policy regarding documentation of wound treatment and dressing changes.On 6/22/26 at 3:00 PM, during an interview with the Director of Nursing (DON), she confirmed Resident #1's physician-ordered incision/wound care orders were received from the hospital upon the resident's admission on [DATE]. The DON explained the facility's admission process requires the admission Nurse to enter all physician orders, including wound care orders, into the facility's computerized medical record upon admission. The DON acknowledged that, in this instance, the admission Nurse did not enter the hospital's wound care orders into the electronic medical record. Instead, the admission Nurse provided the paper copy of the hospital wound care orders to a newly hired Registered Nurse (RN), believing the RN would enter the orders into the computerized charting. The DON stated the newly hired RN was unfamiliar with the facility's admission process and did not know she was responsible for entering the physician's orders into the electronic medical record. The DON further stated the facility's wound nurse (LPN #1) was away from the facility for several days following the resident's admission. Upon her return, she received a verbal report regarding Resident #1's wound care and believed the physician's wound care orders had already been entered into the electronic medical record. Approximately nine days after the resident's admission, the wound nurse discovered the wound care orders had not been transcribed into the computerized chart and immediately entered the physician-ordered wound care into the electronic medical record on 5/29/26. The DON confirmed this was a breakdown in the facility's admission process and acknowledged the physician's wound care orders were not transcribed in accordance with facility policy. The DON stated facility staff performed Resident #1's wound care in accordance with the hospital discharge instructions despite the delay in entering the physician's orders into the electronic medical record. The DON acknowledged the wound treatments were not documented on the TAR or in the clinical record until 6/1/26, which was not consistent with facility policy. A record review of the admission Record revealed the facility admitted Resident #1 on 5/20/26 with diagnoses including Amputation. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating his cognition was intact.

Based on observation, staff interview, and facility policy review, the facility failed to maintain food quality and hygienic practices in accordance with professional standards for food safety related to overly ripened produce, improperly stored food, exposed food, expired food, and unsanitary handling of ready-to-eat food for two (2) of (2) kitchen observations.Findings include:A review of the facility's policy, Sanitation Inspections, Nutrition, and Food Service, with an effective date of 11/30/2014, revealed, .Each item is labeled and dated before refrigeration. Avoid indiscriminate handling of foods with fingers. The proper use of hands, gloves and serving utensils shall be taught to all food handlers .On 09/08/2025 at 10:15 AM, during an observation and interview of the kitchen with the Dietary Manager (DM), Refrigerator #1 was observed to contain two (2) small plates with individual portions of lettuce, tomato, and onions that were not dated, and one (1) cut piece of overly ripe cucumber with dark spots. Refrigerator #2 was observed to contain four (4) bunches of overly ripe celery with withered leaves that were soft and flexible, one (1) opened bag of salad mix with a manufacturer's Best if Used By date of 9/4/25, and five (5) heads of iceberg lettuce with slimy dark leaves and visible white biological growth. The pantry was observed to have a flour bin with the lid left open, exposing the flour, and opened gallon-sized bottles of teriyaki sauce and soy sauce with manufacturer instructions to refrigerate after opening. The DM acknowledged the overly ripe produce, exposed and expired food, and improper storage. He stated he and the cook were responsible for maintaining food quality and that staff were in-serviced monthly on food safety.On 09/09/2025 at 11:19 AM, during a follow-up observation of the kitchen service line and staff interviews with the Baker, she was observed preparing resident trays while picking up bread rolls and pieces of fried fish with her gloved hands, arranging chicken and potatoes on plates with her gloved hands. The [NAME] confirmed she was handling food with her gloved hands and acknowledged the importance of using sanitary practices to prevent cross-contamination. She stated staff received food safety in-services every two (2) weeks. During the same observation, a Dietary Aide (DA) was observed removing a serving spoon from a pan of potatoes, using it to push chicken from one plate to another, then using the same spoon to serve carrots. The DA was further observed placing bread rolls and pieces of fried fish on plates with her gloved hands. In an interview at this time, the DA acknowledged she had handled food with her gloved hands and confirmed she knew food should be handled with proper utensils. She stated staff received in-services on food safety every (2) months. The DM acknowledged the unsanitary handling of food observed during tray service. He stated his expectation was for staff to use utensils for ready-to-eat foods to prevent contamination and foodborne illness. He reported he would conduct additional staff training.On 09/11/2025 at 11:37 AM, during an interview, the Administrator acknowledged he was made aware of the observations of overly ripe produce, exposed food, expired food, and unsanitary food handling practices. He confirmed that it was the responsibility of the DM and [NAME] to maintain food safety standards and stated he would implement daily monitoring to ensure compliance.

Based on record review and interview, the facility failed to accurately report staffing data to the Centers for Medicare and Medicaid Services (CMS) using payroll and other verifiable sources in a uniform format, for one (1) of four (4) quarters reviewed, FY (Fiscal Year) Quarter 3 2025 (April 1-June 20) resulting in the facility triggering for excessively low weekend staffing, no Registered Nurse (RN) hours, and no licensed nursing coverage 24 hours/day.Findings include:A record review of the Payroll Based Journal (PBJ) Staffing Data Report for the third (3rd) quarter (4/1/25 through 6/30/25) revealed the facility triggered for Excessively Low Weekend Staffing, No RN Hours, and Failed to Have Licensed Nursing Coverage 24 Hours/Day. Further review revealed the Infraction Dates for No RN Hours and Failure to Have Licensed Nursing Coverage 24 Hours/Day were 4/1/25 through 4/30/25 and 5/1/25 through 5/31/25.A record review of the Staffing Grid, completed by Human Resources staff member Licensed Practical Nurse (LPN) #4, revealed the facility had RN and nursing coverage on all days in April and May 2025.A record review of the facility's time sheets revealed the facility was not excessively low on staff on the weekends, had licensed nursing coverage 24 hours per day, and had eight (8) hours of Registered Nurse (RN) coverage daily.On 9/11/25 at 1:00 PM, during an interview, LPN #4 stated she was unaware the facility failed to electronically submit PBJ staffing data to CMS accurately for the third quarter of 2025. She confirmed she was responsible for creating the staffing schedule and stated that during April, May, and June 2025, salaried staff helped cover the schedule as needed.On 9/11/25 at 2:00 PM, during an interview, the Human Resources Coordinator stated the corporate office was responsible for submitting the PBJ staffing data for all the corporation's facilities. She stated she was unaware the PBJ staffing information submitted for this facility was inaccurate until she was notified by the State Agency.On 9/11/25 at 3:30 PM, during an interview, the Administrator stated he was not aware the facility failed to electronically submit PBJ staffing data accurately during the third quarter of 2025. He stated the corporate office had been responsible for submitting PBJ staffing data for all the corporation's facilities. The Administrator stated he understood the importance of accurately reporting PBJ information to CMS and acknowledged it was ultimately the facility's responsibility to ensure accuracy. He stated the facility changed ownership to a new company on 6/1/25, and the PBJ data errors occurred under the prior corporate ownership. The Administrator stated he believed a glitch in the prior corporation's system caused the PBJ data inaccuracies and confirmed the infractions occurred only in April and May 2025. He stated no PBJ infractions occurred after the new ownership assumed operations on 6/1/25.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent the recurrence of previously cited deficiencies, specifically, the facility was cited for failing to accurately submit direct care staffing information and failed to ensure the QAPI program was sustained during transitions in leadership to maintain implemented procedures during an annual recertification survey on 4/18/24 and was cited again for the same deficiencies during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for two (2) of (11) deficiencies cited. F851 and F865/867. Findings Include: Review of the facility's policy, Performance Improvement (QAPI), dated 6/1/25, revealed, .The Center and organization have an ongoing Performance Improvement Program with a design and scope that is ongoing and comprehensive.The design and scope of the program is to systematically monitor and evaluate the quality and appropriateness of resident care, pursue opportunities to improve resident care, resolve identified problems and identify opportunities for improvement.Procedure: The Center Executive Director is accountable for the overall implementation.The Center identifies areas for continuous quality monitoring and the monitoring tools to be used.The Performance Improvement (QAPI) Committee reviews and coordinates the proposed activities and identifies the priorities for the coming year.Criteria for selecting aspects of care for improvement are based but not limited to.Regulatory - previous or current regulatory items or identified concerns. Record review of the Provider History Profile revealed the facility received a citation for F851 - Payroll Based Journal and F865-QAPI Program/Plan. Record review of the Centers for Medicare and Medicaid Services (CMS)- 2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date of 4/18/24, revealed the facility received a citation for F851, .Based on staff interview, record review, and facility policy review, the facility failed to accurately submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for Quarter 1 of Fiscal Year (FY) 2023 (October - December 2023) for one(1) of five (5) quarters reviewed and for F865, .Based on staff interview, record review, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAI) Committee failed to ensure the program was sustained during transitions in leadership and failed to maintain implemented procedures and monitor the interventions the committee put into place in April 2022. This was for two (2) recited deficiencies originally cited in April 2022 on an annual recertification survey. The deficiencies were in the area of residents' rights and wounds. The facility's continued failure during two surveys shows a pattern of the facility's inability to sustain an effective QAPI Committee for two (2) of eight (8) deficient practice citations. During the current recertification survey, the facility failed to accurately report staffing data to CMS using payroll and other verifiable sources in a uniform format, for one (1) of four (4) quarters reviewed, resulting in the facility triggering for excessively low weekend staffing, no Registered Nurse (RN) hours, and no licensed nursing coverage 24 hours/day and failed to sustain corrective actions to prevent recurrence of previously cited deficiencies.On 9/11/25 at 5:15 PM, during an interview with the Administrator, he explained that QAPI meetings are conducted quarterly, as well as on an as-needed basis when issues arise. He stated that staff report concerns to him or the Director of Nursing (DON), and he compiles the information for review during the QAPI meetings. He acknowledged that the repeat deficient practice related to Payroll-Based Journal (PBJ) reporting has continued. In his view, the issue is due to a processing glitch, explaining that when information is transmitted to CMS, he believes there may be an error within the Information Technology (IT) department that results in the discrepancies.

Based on staff interview, record review, facility investigation and facility policy review, the facility failed to implement its abuse prevention policy by not reporting and investigating an allegation of misappropriation of resident property in a timely manner for one (1) of 22 sampled residents, Resident #106.Findings Include:A review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation, revised 11/16/2022, revealed, .7. Reporting/Response: Any employee or contracted service provider who.has knowledge of.an allegation of.misappropriation of resident property.is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations . Review of report: Report the results of all investigations to the Executive Director or his or her designated representative and to other officials in accordance with State Law, including to the State Agency, within 5 working days of the incident .A record review of the facility's investigation emailed to the SA on 7/3/25, revealed, .Please accept this email as formal, initial notification of misappropriation of funds that occurred on June 27, 2025 . The investigation detailed that on 6/27/25, Resident #106 reported Certified Nursing Assistant (CNA) #1 was seen handling her change purse and that coins were missing. The record further showed the incident was not reported timely to the State Agency (SA) as required by facility policy. On 9/10/25 at 11:55 AM, during an interview with Licensed Practical Nurse (LPN) #2, she explained that on 6/27/25, while providing wound care to Resident #106, she turned the resident and noticed quarters stuck to her back and a small red change purse tucked inside her gown. LPN #2 stated the resident typically kept the change purse on her overbed table. When she asked the resident about it, the resident reported she had been napping earlier that morning, awoke to a noise, and observed Certified Nursing Assistant (CNA) #1 at her bedside with her change purse open and removing quarters. The resident told LPN #2 she believed money was missing. LPN #2 stated she immediately reported the allegation to the charge nurse on duty, who then reported it to the Director of Nursing (DON). On 9/11/25 at 10:50 AM, during an interview with the DON, she explained that the incident was not reported within required timeframes because leadership initially debated the credibility of the allegation. She confirmed that the allegation should have been reported immediately, in accordance with facility policy, and acknowledged that the delay was a violation of the policy.On 9/11/25 at 11:25 AM, during an interview with the Administrator, he confirmed he did not initially report the allegation because the resident stated she did not want to make a big deal about it. He acknowledged awareness of the facility's policy requiring all allegations of abuse or misappropriation to be reported immediately.A record review of the admission Record revealed the facility admitted Resident #106 to the facility on 7/16/2023 with current diagnoses including Type 2 Diabetes Mellitus.A record review of the Quarterly Minimum Data Set (MDS) with an ARD of 07/08/2025 revealed Resident #106 had a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated she was cognitively intact.

Based on interviews and record review, the facility failed to honor a resident's request for assistance in obtaining personal identification, resulting in a delay of more than one (1) year without follow-up affecting her autonomy and ability to exercise her rights related to personal identification and community access for (1) of (22) sampled residents, Resident #48. Findings include:On [DATE] at 12:31 PM, in an interview, Resident #48 stated she had requested assistance from the facility in completing paperwork and obtaining a state identification (ID) card but that her request had not been fulfilled.On [DATE], at 8:34 AM, during an interview, the Social Services Director stated she had no knowledge of Resident #48's request for assistance with obtaining an ID. She reported the resident frequently brought her insurance mail but had not made the ID request directly to her, acknowledging that the resident may have told the Social Services Assistant instead.On [DATE] at 10:50 AM, during an interview, Social Services Assistant (SSA) #1 recalled Resident #48 previously requested transportation to the Department of Motor Vehicles (DMV) to renew her license and obtain a state ID. SSA #1 stated the resident's out of state driver's license and state ID were expired, and the resident was informed that a birth certificate was required. SSA #1 reported the request had not been resolved due to turnover in the social services department and lack of follow-up from the prior Social Worker. She confirmed the resident had been transported to multiple DMV locations but was unsuccessful each time because she did not have a birth certificate. SSA #1 explained that the resident would need to apply for a birth certificate through another country's embassy before the ID could be obtained.On [DATE] at 4:45 PM, during a follow up interview, the Social Services Director confirmed that the SSA had knowledge of the process to obtain a birth certificate and acknowledged that the matter had not been resolved for Resident #48.On [DATE] at 5:25 PM, during an interview with the Administrator, he revealed his expectations for the Social Services Department are to ensure resident requests are honored.A record review of the admission Record revealed the facility initially admitted Resident #48 on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to prevent the possible spread of infection by not implementing contact isolation precautions timely for (Resident #47) and enhanced barrier precautions (EBP) when providing care for (Resident #4) for two (2) of 22 sampled residents.Findings include:A review of the facility's Policies and Practices - Infection Control, revised October 2018, revealed, This facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections. Policy Interpretation and Implementation.2. The objectives of the infection control policies and procedures are to: a. Prevent, detect, investigate, and control infections in the facility b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public c. Establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions d. Establish guidelines for the availability and accessibility of supplies and equipment necessary for Standard and Transmission-Based Precautions.A review of the facility's policy, Enhanced Barrier Precautions, dated August 2022, revealed, .Enhanced barrier precautions (EBPs) are used to prevent the spread of multidrug-resistant organisms (MDROs) to residents. Policy Interpretation and Implementation.2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions did not otherwise apply. A. Gloves and gowns are applied prior to performing high-contact resident care activity.Resident #47On 9/8/25 at 10:00 AM, during an observation, there was no signage on doors on the 500 Hall indicating residents were on contact isolation precautions. Resident #47, who resides on the 500 Hall, was in her room, lying in bed with his eyes closed. There was no signage on the door indicating contact isolation precautions. On 9/9/25 at 9:08 AM, during an observation, there was signage on Resident #47's door as well as personal protective equipment (PPE) indicating the resident was on contact isolation. Red barrels with biohazard bags were also placed inside the resident's room.On 9/9/25 at 10:15 AM, during an interview, Registered Nurse (RN) #2 stated Resident #47 had tested positive in the hospital for COVID-19 and was admitted to the facility on [DATE]. RN #2 stated she was not working on 9/5/25 and confirmed the facility failed to follow infection control protocol at the time of admission by not placing the resident on isolation precautions. RN #2 stated she normally ensured the contact isolation signage, PPE, and biohazard barrels were placed in the resident's room, and going forward, the admission nurse would assist in ensuring infection control protocols were followed when she was not working. RN #2 confirmed that failing to follow infection control protocol could cause the spread of infection to other residents and staff.A record review of the admission Record revealed the facility admitted Resident #47 on 9/5/25 with diagnoses including COVID-19.A record review of the resident's Entry Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/2/25 revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated she had moderate cognitive impairment.A record review of the Order Summary Report revealed Resident #47 had a Physician's Order, dated 9/8/25, which was three (3) days after admission, for isolation related to a positive Covid-19 test.Resident #4On 9/10/25 at 10:51 AM, during an observation of wound care provided by the Nurse Practitioner (NP), Licensed Practical Nurse (LPN) #2, and Certified Nursing Assistant (CNA) #4, the staff washed their hands and wore gloves, but failed to wear gowns. LPN #2 removed the old bandage on the resident's left hip, and the NP removed staples from the incision. There was no enhanced barrier precautions signage on Resident #4's door.On 9/10/25 at 10:59 AM, during an interview, LPN #2 and CNA #4 confirmed they failed to wear gowns while providing wound care. They stated they typically wore gowns when providing wound care and normally looked for signs on the door stating EBP. They confirmed there was not a sign on the door, and they did not think about wearing a gown at that time.A record review of the admission Record revealed the facility admitted Resident #4 on 8/20/25 with diagnoses including Left Femur Fracture. A record review of the admission MDS, with an ARD of 8/27/25, revealed Resident #4 had a BIMS score of 13, which indicated he was cognitively intact.A record review of the Order Summary Report revealed Resident #4 had a Physician's order, dated 8/21/25 for Enhanced Barrier Precautions related to wounds. On 9/10/25 at 11:17 AM, during an interview, the Director of Nursing (DON) stated staff should wear gowns and gloves when removing staples from an incision or providing wound care. The DON stated EBP required the use of gowns and gloves during wound care, and an EBP sign should have been placed on Resident #4's door. The DON also stated a contact isolation sign and PPE should have been placed on Resident #47's door.On 9/11/25 at 1:10 PM, during an interview, RN #2 stated an EBP sign, and PPE should have been placed on Resident #4's door when the resident was admitted . RN #2 stated the facility failed to place the sign and PPE on the door because she was not working that day. She stated she was unaware that the sign and PPE were missing. RN #2 stated staff could spread infection by not wearing gowns while providing wound care and that it was facility protocol to follow Enhanced Barrier Precautions.On 9/11/25 at 2:20 PM, during an interview, the Administrator stated he expected the facility to follow contact isolation and EBP policies when providing care.

Based on observation, interview, record review, and facility policy review, the facility failed to provide assistance with activities of daily living (ADLs) for residents who are dependent upon staff, related to incontinence care (Resident #109) and shaving (Resident #91) for two (2) of 22 sampled residents.Findings include:A review of the facility's policy, Activities of Daily Living (ADLS) dated 02/01/2022, revealed . To encourage resident choice and participation in activities of daily living (ADL) and provide.assistance as necessary . ADLs includes bathing, dressing, grooming, hygiene, toileting . Procedure.2. CNA (Certified Nurse Aide) will provide needed . assistance to resident.Resident #109On 9/9/25 at 11:05 AM, during an interview, Resident #109 reported she had been left in a soiled brief since 6:00 AM. She stated she pushed the call light several times, but staff turned the light off without returning to provide care. The resident's daughter, present at the time, confirmed she arrived at 9:00 AM, remained until 10:10 AM, returned at 10:30 AM, and no staff had checked on or changed the resident during that time.On 9/9/25 at 11:30 AM, during an interview, Certified Nursing Assistant (CNA) #1 reported she had not checked on or changed Resident #109 during her shift and stated she had been told in report that the resident went to the bathroom independently. She acknowledged she was not familiar with the resident.On 9/9/25 at 11:45 AM, during an observation, CNA #1 checked Resident #109 and confirmed her brief was saturated, and the bed was soiled, requiring a complete bed change.On 9/9/25 at 11:50 AM, during an interview, the facility Ombudsman stated the facility had received numerous complaints from residents being left in soiled briefs for long periods of time.On 09/11/2025 at 2:00 PM, during an interview with the Director of Nursing (DON), she explained all staff are to be aware of residents' needs to provide the appropriate quality of care for each resident and that a resident left in a soiled brief for hours is not acceptable. A record review of the admission Record revealed the facility admitted Resident #109 on 9/8/25 with diagnoses including Aftercare Following Joint Replacement Surgery. Resident #91On 9/8/25 at 11:11 AM, during an observation, Resident #91 was lying in bed watching television. Thick facial hair was noted on the resident's chin and neck. The resident stated she liked to have her facial hair shaved but staff often forgot to do so.On 9/9/25 at 4:15 PM, during an observation, Resident #91 remained with long facial hair. She stated she disliked having facial hair, but that staff forgot to shave her.On 9/9/25 at 4:30 PM, during an interview, CNA #2 explained Resident #91 was a day-shift shower/bath resident and female residents were supposed to be shaved on shower days. She stated whether Resident #91 was shaved was dependent upon the CNA assigned and acknowledged the resident currently had long facial hair. CNA #2 stated Resident #91 was always cooperative and did not refuse care.On 9/10/25 at 9:30 AM, during an interview, Licensed Practical Nurse (LPN) #2 stated she noticed Resident #91 with long facial hair both the previous day and that morning. She explained that CNAs were instructed and in-serviced to provide shaving during bathing or shower care. She confirmed Resident #91 did not refuse care and was cooperative.On 9/10/25 at 2:10 PM, during an interview, the DON stated residents were to be shaved during ADL care, including women. She stated a female resident with long facial hair on her chin was not acceptable and staff were expected to provide the needed care.On 09/11/2025 at 2:30 PM, during an interview with the Administrator, he confirmed that residents left sitting in urine or not receiving timely care was unacceptable and not consistent with facility practices. He stated he expects all residents who are dependent on staff for ADLs to be treated in a dignified manner. He further explained that if staff observe long facial hair, especially on a female resident, it is their responsibility to provide shaving unless the resident refuses, in which case the refusal must be documented in the record. A record review of the admission Record revealed the facility admitted Resident #91 on 11/16/22 with diagnoses including Paraplegia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/14/25 revealed Resident #91 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Section GG revealed Resident #91 was dependent on staff for personal hygiene, toileting, and bathing.

Based on interview and record review, the facility failed to ensure a resident's right to dignity and respect when staff required her to wear a brief against her preference instead of providing a bedpan or assistance to the bathroom for one (1) of (22) sampled residents, Resident #109.Findings include:On 9/9/25 at 11:05 AM, in an interview, Resident #109 reported that the night shift staff told her she would need to wear a brief rather than being assisted to the bathroom or put on a bedpan, despite her reporting that she does not wear briefs.On 09/10/2025 at 4:15 PM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that Resident #109 was already admitted to the facility when she came on shift and she recalled that she thought the resident was wearing a pull-up at that time, and she suggested that a brief might be easier than a pull-up since it would not require pulling up and down. LPN #1 confirmed that the evening shift staff, including herself, used a bedpan for the resident, and she personally assisted the resident onto the bedpan, which she tolerated well. She stated she did not know why the night shift staff chose not to use the bedpan and instead placed the resident in a brief. On 09/11/2025 at 11:00 AM, during a follow-up interview with Resident #109 and her daughter, both explained that when the resident was admitted to the facility, she was not wearing a pull-up or a brief. The daughter stated she dressed the resident at the hospital and confirmed she was wearing panties with an incontinence pad for accidents. The resident reported she continues to wear panties and does not want to feel degraded or disrespected by being asked to wear a brief. She emphasized that she never requested either a brief or a pull-up. The resident explained that when staff attempted to place a brief on her, she objected and only stated that if staff insisted, a pull-up would be preferable to a brief. On 09/11/2025 at 2:00 PM, during an interview with the Director of Nursing (DON), she explained that she does not expect any staff to place a brief or pull-up on a resident who is continent, as this is both a resident rights and dignity issue.A record review of the admission Record revealed the facility admitted Resident #109 on 9/8/25 with diagnoses including Aftercare Following Joint Replacement Surgery.A record review of the BIMS (Brief Interview for Mental Status) document, with an Effective Date of 09/10/2025 revealed Resident #109 was cognitively intact.

Based on record review, interviews, and resident council interview, the facility failed to provide residents or their resident representatives (RRs) with copies of the Resident [NAME] of Rights and admission documents at the time of admission, with the potential to affect all newly admitted residents by depriving them of required information about their rights and responsibilities upon admission for one (1) of 22 sampled residents (Resident #26).Findings include:A review of the facility's admission Agreement revised 5/25, revealed that Section #20 (items a-o) requires residents or their representatives to sign acknowledging receipt of copies received including the Resident [NAME] of Rights, Resident Handbook, and other admissions documents.On 9/8/202 at 2:00 PM, during a resident council meeting, Resident #26 stated she did not recall receiving admission information during the admission process. She stated she was admitted to the facility on [DATE].On 9/10/25, at 4:45 PM, an interview with the admissions Coordinator, who has been employed in the position since January 2025, revealed that she has not provided residents or their representatives with a copy of the Resident [NAME] of Rights or the resident handbook during the admission process. She stated that since the facility's recent acquisition, staff have not been able to order resident handbooks and that resident rights documents were not available to distribute. She acknowledged that although residents and representatives signed the admission agreement acknowledging receipt of the items, she had no materials available to provide.On 9/11/25, at 12:23 PM, during a follow up interview, Resident #26 stated she admitted herself and did not recall receiving a folder with signed admission documents unless her daughter may have taken it.On 9/11/25, at 12:46 PM, the Resident #26's emergency contact and relative stated that no admission paperwork was sent home with her following Resident #26's admission.On 9/11/25, at 2:58 PM, the Admissions Director stated she had completed Resident #26's admission paperwork face-to-face on a Saturday. She recalled verbally explaining the documents but admitted she did not provide physical copies to the resident because she did not have access to a copier in the field. She confirmed that Resident #26 did not receive any admission documents during the admission process.Record Review of the admission Record revealed the facility admitted Resident #26 on 8/30/2025 with diagnoses including Surgical Aftercare following Surgery on the Nervous System.Record review of admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/6/2025, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to personal privacy by posting identifying hospice information on a resident's door for one (1) of 22 sampled residents. Resident #85.Findings include: A review of the facility's policy, Resident Rights dated 11/30/2014, revealed . The Facility will not use or disclose the resident's health information without the Resident's authorization.On 9/8/25 at 10:26 AM, during an observation of Resident #85's room, signage was posted on the resident's door sign labeled (Proper Name of Hospice Provider) with the resident's first initial and last name highlighted in yellow stated Call (Proper Name of Hospice Provider) First. Resident #85 was lying in bed and was unable to verbalize awareness of hospice services or knowledge of the signage posted on her door.On 9/8/25 at 12:40 PM, during a phone interview with Resident #85's resident representative (RR), she reported that she had not requested the hospice sign to be placed on her mother's door. She explained that the sign was placed there by the hospice provider.On 09/10/2025 at 1:20 PM, during an interview and observation with the Hospice Coordinator, she confirmed the sign posted on Resident #85's door regarding hospice services and acknowledged she was aware that signage disclosing resident-specific health information should not be posted. She confirmed the sign was clearly visible to anyone passing by the room. She stated she did not authorize the posting of the signage and had not been informed that it had been placed.On 09/10/2025 at 1:50 PM, during an interview with the Director of Nursing, she stated she was not aware that a hospice sign had been posted on Resident #85's door. She explained that staff are trained and aware that resident privacy must be protected and that personal health information should not be displayed. She was unsure whether hospice staff or another individual placed the sign. She stated it is her expectation that staff would notify her immediately if any signage containing resident-specific health information is posted, and that such signage be removed right away. On 09/11/2025 at 02:40 PM, during an interview with the Administrator, he confirmed he had been informed that Hospice had placed a sign on a resident's door. He explained there should never be any posting of signage containing resident-specific health information, as this violates a resident's right to privacy and dignity.A record review of the admission Record revealed the facility admitted Resident #85 on 10/16/24 with current diagnoses including Dementia. A record review of Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/21/25 revealed Resident #85 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated the resident's cognition was severely impaired. A review of Section O revealed she was receiving hospice care.A record review of the Order Summary Report revealed Resident #85 had a Physician's Order, dated 1/30/25, to admit the resident to hospice services.

Based on observation and staff interview, the facility failed to post daily nurse staffing information in a prominent place readily accessible to residents, staff, and visitors for four (4) of (4) days of survey, which had the potential to affect all 108 residents residing in the facility.Findings include:On 9/8/25 at 10:00 AM, during an initial tour of the facility, there was no daily staffing information posted throughout the building. There was a stop sign on the entranceway door asking staff and family not to allow residents beyond the double doors into the entrance hall.On 9/9/25 at 8:00 AM, during a walkthrough of the facility, the State Agency (SA) did not observe the required daily posting of staffing information.On 9/10/25 at 9:00 AM, during a walkthrough of the facility, the SA did not observe the required daily posting of staffing information.On 9/11/25 at 11:55 AM, during an interview, Licensed Practical Nurse (LPN) #4 stated that the staffing was usually taped on the table in the entrance hallway next to the visitor sign-in book. LPN #4 confirmed she failed to tape the staffing information on the table on 9/8/25, but she did on 9/9/25 through 9/11/25. LPN #4 confirmed residents do not frequent the entrance hallway and acknowledged the sign on the door indicating, Do not allow residents to go beyond this door. LPN #4 stated she had not been posting the daily staffing in a place where all visitors, staff, and residents could see it. She stated she had been told to tape the daily staffing information on the table in the entrance hall daily but was not aware of the regulation requiring staffing to be posted in a prominent area where residents, family, and visitors could see it.On 9/11/25 at 3:30 PM, during an interview, the Administrator and the Director of Nursing (DON) both confirmed the daily staffing postings did not meet the regulatory requirements of being in an area accessible to residents. They confirmed there was a sign asking staff and visitors not to allow residents beyond the double doors into the entrance hall, which prevented residents from seeing the daily posted staffing information. The DON stated the Staff Development Nurse was responsible for posting the daily staffing, including all required information, and ensuring it was posted where everyone could see it. The Administrator and the DON confirmed residents did not frequent the entrance hall and stated they would place the staffing information in a glass case where it would be visible to everyone going forward.

Based on interviews, record review, facility policy review, and facility investigation review, the facility failed to implement care plan interventions for a Resident #1, who was identified as an elopement and wandering risk for one (1) of four (4) residents reviewed. Resident #1 On 2/08/25, at approximately 3:00 PM, Resident #1 exited the facility while unsupervised wearing a wander alarm device that was found to be inoperable. The resident was out of the facility unsupervised and walked approximately 0.7 miles for approximately thirty (30) minutes before being located by facility staff and returned to the facility, crossing a four-lane highway. The facility's failure to implement resident's care plan interventions related to wandering and elopement for Resident #1, put this resident and all other residents at risk for wandering and elopement, at risk for serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ), which began on 2/08/25, when Resident #1 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 2/12/25 at 5:30 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 2/9/25, the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on 2/10/25, prior to the SA's entrance on 2/11/25. Findings include: A review of the facility's policy, Plans of Care, revised 9/25/2017, revealed, .Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and /or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements . Record review of the care plan for Resident #1 revealed Focus: I am an elopement risk/wanderer r/t (related to) History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly .Interventions/Tasks .Ensure wander guard is functioning properly daily . The responsible discipline listed as N (Nurse). A record review of the facility's, Verification of Investigation, revealed it was discovered at approximately 3:00 PM on 2/8/25, that Resident #1 exited the facility. A silver alert was announced and all staff began looking for the resident. A new Certified Nurse Aide (CNA) who had just reported for her 3 PM to 11 PM shift showed a video of an individual she saw walking along the highway. By this time, the resident's girlfriend was in the facility. As soon as they knew where he was, the girlfriend and three (3) CNAs jumped in the car to go to the place where the resident was last seen. Resident #1 was discovered .7 mile from the facility. He was returned to the facility and no injury was noted. On 2/12/25 at 9:55 AM, during an interview Licensed Practical Nurse (LPN) #1 revealed she was working on 2/08/25 and had not checked the wander guard transmitter of Resident #1. She stated that she only checked for placement to ensure the resident was wearing a transmitter. She confirmed that all nurses had access to all resident care plans in computer software. She confirmed that she was aware that Resident #1's care plan included intervention of monitoring the resident's wander guard transmitter for proper functioning daily. On 2/13/25 at 3:55 PM an interview with the Minimum Data Set (MDS) Nurse revealed she stated, care plans were individualized for each resident and that it was very important that care plans be implemented. She described care plans as binding documents that dictates care. She stated that the care plan for Resident #1 included an intervention for monitoring placement and functioning of the resident's wander guard transmitter. She stated that monitoring the functioning of the transmitter was important to provide for his safety and prevent elopement. On 2/13/25 at 5:00 PM, during an interview the Director of Nursing confirmed that implementation of the resident's care plan intervention for monitoring functioning daily was very important for the safety of the resident and prevention of elopement. She said that she expected all nursing staff to follow the care plans for each resident. On 2/13/25 at 5:25 PM, during an interview the Administrator stated that it was very important that residents' care plans be implemented and followed to provide appropriate care and a safe environment for each resident. He confirmed that he expects all nursing staff to follow the residents' care plans and implement interventions including monitoring. He stated that the wander guard transmitters for residents at risk for elopement were not functioning correctly and that proper monitoring could have alerted staff to the problem and that safety protocols/interventions could have been enacted and the elopement prevented. Record review of the Admission Record revealed the facility admitted Resident #1 on 1/28/25 with current diagnoses including Aphasia following Cerebral Infarction, Cognitive Communication Deficit and Legal Blindness. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/04/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 99 and required a staff assessment for his mental status. The staff assessment indicated Resident #1 had a long and short-term memory problem, and his cognitive skills for daily decision making was severely impaired. Further MDS review revealed was assessed as needing partial/moderate assistance for surface-to-surface transfers and walking ten (10) feet. The facility submitted a corrective action plan as follows: 1. On February 8, 2025, at approximately 3:00 pm, CST, Resident #1 exited the center while unsupervised. The unsupervised resident leaving the facility represented an Immediate Jeopardy. The resident was wearing a wander guard device. The Resident was assessed upon return to the facility and had no injuries, the wander guard device was found to be inoperable, and Resident was placed on one-on-one supervision. The facility reviewed the wandering/missing resident policy, educated staff on the wandering/missing resident policy and held a quality assurance meeting. In addition, staff checked all exit doors out of the facility (including the door the Resident exited from). Also, the staff check all wander guards currently being utilized in the building and placed any not working on 1:1 supervision. Finally, staff performed a complete headcount (all residents were found to be in the building with one exception who had properly signed himself out) and the door codes were changed. Based on the steps the facility initiated and completed, the facility contends that the Immediate Jeopardy was removed and represents past noncompliance. This event was reported to the Mississippi State Department of Health via email on Sunday, February 9, 2025, at 2:37 pm. 2. On February 8, 2025, at 3:00 pm, Licensed Practical Nurse (LPN) #1, was notified that Resident #1 could not be accounted for. At 3:02 pm, the Director of Nursing (DON), Executive Director (ED), Social Services Director (SSD), Medical Director (MD) and Regional Director of Clinical Services (RDCS) were notified. At 3:03 pm, Certified Nursing Assistant (CNA) #1 reported to work for her 3-11 shift and upon hearing that a resident was not accounted for, showed the nurse a video she had taken of a man she saw walking next to Hwy 90 on her way to work. The Resident's girlfriend arrived at the facility approximately 3:00 pm and as soon as she saw the video, she and 3 CNAs jumped in the car to go get Resident #1. LPN #2 called the Residents responsible party (Power of Attorney (POA)) and DON. The DON called the ED, MD, and SSD. At 3:30 pm Resident returned to the facility. At 3:36pm the DON was notified the Resident was located .7 of a mile from the facility and safely returned to the facility. 3. On February 8, 2025, at 3:30 pm, Resident returned to facility. Once Resident #1 was back inside center, LPN #2, completed a head-to-toe body audit and no injuries were noted. Registered Nurse (RN) Supervisor #1 completed a head count of all residents, and all were accounted for. On February 8, 2025, at 4:15 pm, the Assistant Maintenance Director performed checks on all exterior doors and windows, along with the wander guard system. His findings determined that all doors were locked and while all alarms were functioning properly, the wander guard bracelet Resident #1 was wearing was not functioning properly. The resident was immediately placed on 1:1 supervision and a 24-hour door monitor put in place at front. The door monitor continued until the wander guard system was verified to function properly and the Quality Assurance monitoring begin (see bullet #8). The door monitor was discontinued on 02/10/2025. The door keypad codes were changed. 4. On February 8, 2025, RN #2/Unit Manager began educating staff on elopement wandering risk policy, missing resident policy, following care plans, abuse and neglect, and resident's rights. The Director of Social Services reassessed Resident #1 Brief Interview for Mental Status (BIMS), which had not changed and was noted to be 99, unable to determine. On February 8-10, 2025, wandering risk evaluation completed on all residents with no newly identified wandering risk. Elopement binders (identifying the 5 residents wearing wander guards) are located at both nurses' stations and up front. At 6:45 pm, an Ad hoc QAPI was held including the ED, DON, and MD to discuss incident and a plan of correction. 5. On Saturday, February 8, 2025, DON conducted interviews to learn of Resident #1's path. It was discovered that Resident #1 most likely exited the front door when a visitor entered the facility. Resident #1 confirmed by a positive head shake that he used the front door and answered yes, that he was trying to go home. 6. On Monday, February 10, 2025, at 2:30 pm, the incident was taken to a quality assurance performance improvement (QAPI) meeting, attended by, Executive Director, Director of Nursing, Infection Preventionist, Medical Director via phone, Director of Dietary Services, Maintenance Director, Minimum Data Set (MDS) LPN #2 and LPN #3. No further action needed. No changes made to policies. 7. On February 8, 2025, in-servicing began on Wandering/Missing Resident, Prevention of Abuse and Neglect, and door alarms policies, and included 3 RNs, 1 LPN and 5 CNAs. On February 9, 2025, in-service continued including 6 LPNs, 2 RNs and 8 CNAs. On February 10, 2025, in servicing continued including 6 LPNs, 11 CNAs, and 3 RNs and 4 ancillary staff. On February 11, 2025, 4 LPN, 9 ancillary staff, 4 RNs. No staff was allowed to work before receiving education. 15 CNAs, 1 RN. Education is on-going until it was 100% complete. Furthermore, the system will be check daily by maintenance staff and the devices will be checked for placement each shift and checked for functionality daily by nursing staff. The daily checks of the door systems and placement of the patient devices, as well as the q shift checks of functionality of the patient devices, will be monitored by DON for completion. (see bullet #8) 8. The following monitoring has been put in place beginning February 10, 2025, and the findings will be evaluated by the Quality Assurance and Improvement Committee. All residents that are assessed and care planned as a potential for elopement will be evaluated for significant change in condition for elopement using the elopement risk evaluation, evaluated quarterly for elopement using the elopement risk evaluation, ensure the care plan reflects elopement risk status and any interventions (i.e., wander guard), wander guard check placement every shift that it is present on the MAR without omissions, order for wander guard check for functionality daily is present on MAR without omissions, elopement books have a current face sheet, resident photograph and risk alert form, binders are in an easily accessible location, staff has been educated on the elopement policy, location of the binders and notification process regarding an possible missing resident, transmitter bands are replaced per manufacturers recommendations if signs of manipulation and/or integrity of the band is compromised, exit doors monitoring system functioning appropriately with supporting documentation, and wand used to test function is easily accessible to check the transmitter function.(once these monitoring task were initiated, we discontinued the door monitor) All the forementioned monitoring task will be conducted by the Director of Nursing enduring 3 times a week for 1 week, then 2 times a week for 2 weeks, then weekly for the next 2 months and then monthly. All results will be presented to the Quality Assurance Committee for evaluation and recommendations as necessary. The Quality Assurance Committee will continue to evaluate all monitoring for 90 days to monitor effectiveness and make changes as necessary. 9. All Corrective Actions were completed on February 9, 2025, and the Immediate Jeopardy was removed on February 10, 2025, prior to the State Agency's entrance on February 11, 2025. Validation: The SA validated on 2/13/25, through interview and record review, that all corrective actions had been implemented as of 2/9/25, and the facility was in compliance as of 2/10/25, prior to the SA's entrance on 2/11/25.

Based on observation, interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision and assessment and monitoring of a wandering alarm device to prevent Resident #1, who was identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. Resident #1 On 2/08/25, at approximately 3:00 PM, Resident #1 exited the facility while unsupervised wearing a wander alarm device that was found to be inoperable. The resident was out of the facility unsupervised and walked approximately 0.7 miles for approximately thirty (30) minutes before being located by facility staff and returned to the facility, crossing a four-lane highway. The facility's failure to adequately assess and monitor the resident's wandering alarm device and provide adequate supervision for Resident #1, who was an elopement risk, put this resident and all other residents at risk for wandering and elopement, at risk for serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 2/08/25, when Resident #1 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 2/12/25 at 5:30 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 2/9/25, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 2/10/25, prior to the SA's entrance on 2/11/25. Findings include: A review of the facility's policy, Elopement/Wandering Risk Guideline revised 08/01/2020 revealed, Overview: To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions . Process .If utilizing a wander monitoring system device check placement of the device every shift and functionality every day . A record review of the facility's, Verification of Investigation, revealed it was discovered at approximately 3:00 PM on 2/8/25, that Resident #1 exited the facility. A silver alert was announced and all staff began looking for the resident. A new Certified Nurse Aide (CNA) who had just reported for her 3 PM to 11 PM shift showed a video of an individual she saw walking long the highway. By this time, the resident's girlfriend was in the facility. As soon as they knew where he was, the girlfriend and three (3) CNAs jumped in the car to go to the place where the resident was last seen. Resident #1 was discovered .7 mile from the facility. He was returned to the facility and no injury was noted. Record review of the weather conditions in Ocean Springs, MS on 2/08/2025 according to www.weatherspark.com revealed at 2:53 PM, the temperature was 75 degrees Fahrenheit, and clear, with 9.21 miles per hour wind. On 2/11/25 at 3:00 PM, during an observation of the facility grounds, the side and back doors of the facility were inside a fence with locked gates. The front door opened to a front porch with a ramp that descended to the well-maintained driveway and front parking lot. It was two hundred (200) feet from the front door to the road in front of the facility. The speed limit for the road was fifteen (15) miles per hour and the SA observed for fifteen (15) vehicles in one minute traveling on the road at 3:00 PM. It was 0.2 miles west from the entrance into the facility driveway to the red light where the road intersected with the six-lane highway. One block west of the intersection the highway changed to four (4) lanes. There were no crosswalks observed across the highway. The local business where Resident #1 was located was 0.7 miles from the entrance into the facility driveway across the highway on the west side of the highway. On 2/11/25 at 3:45 PM, during an interview the Administrator revealed that the facility reported incident identified as Elopement was discovered on 2/08/25 at 3:00 PM when Resident #1's visitor inquired to his whereabouts and the resident could not be located in the facility. The Administrator reported that the facility staff initiated the Missing Resident protocol and Certified Nurses' Aide (CNA) #1, who arrived at the facility at 3:00 PM reported that she had observed the resident walking along the nearby highway. The Administrator reported that the visitor and two CNAs retrieved the resident in the visitor's vehicle and returned him to the facility at 3:30 PM. The Administrator said that staff assessed Resident #1 immediately upon return for injury and dehydration and encouraged fluids by mouth. He stated that staff had conducted a one hundred percent (100%) head count/room check with a resident census and performed a door check on all exit door to ensure they were closed and locked. The Administrator stated Licensed Practical Nurse (LPN) #1 notified the Director of Nurses (DON) who reported to the facility and initiated a thorough investigation and reported the incident to the SA Agency on 2/08/25 at approximately 5:37 PM. He said that LPN #2 notified the Resident Representative (RR) for Resident #1. He confirmed that the resident had been wearing a pair of athletic shorts and a sleeveless T-shirt, two pairs of socks, and one house slipper at the time of elopement. The Administrator explained that all the exit doors were closed and locked with wall-mounted numeric keypads next to each and required a code to be entered to open the door. He said that the front door could also be opened from the outside with the press of a red button. He said that in the absence of any evidence of point of exit, facility investigation concluded that the resident had exited the facility when visitors pressed the red button on the outside and entered the facility. The resident was gone from the facility unsupervised for about half an hour. The Administrator stated that Resident #1 did not suffer any injuries of any kind during or due to the elopement. The Administrator revealed the facility conducted an ad hoc Quality Assurance and Assessment (QAPI) meeting on the evening of 2/08/25 in which the appropriate members were in attendance and policies were discussed with no changes recommended. He said the facility conducted in-service /training related to elopements in which staff would not be able to work until in-serviced. The Administrator said all residents assessed with wandering behaviors and at risk for elopement, including Resident #1, had their wander guard transmitters tested and it was discovered that the transmitters were not operating correctly. He said that a staff member was posted at the front door and residents at risk for elopement were provided with one-on-one supervision until the system components were received on 2/10/25 and testing confirmed the system functioned correctly. On 2/11/25 at 4:30 PM, an observation and interview with Resident #1 revealed the resident was sitting on his bed in his room. He was wearing a wander guard transmitter on his right ankle. He was unable to answer questions or describe out he left the faciity on [DATE]. On 2/11/25 at 5:30 PM, in an interview with CNA #3, she revealed she was working at the time of the elopement of Resident #1 on 2/08/25. She explained that a visitor of Resident #1 arrived and went to the resident's room, and he was not in his room. She said the visitor came out and inquired of staff where he was and the dining room and therapy gym were checked and the resident was not there. After a brief look at common areas LPN #1 called a Code Silver and CNA #1 had just arrived and said she thought she had seen the resident on a nearby highway on her way to the facility. She explained that she and another CNA accompanied the visitor to the area, located the resident and he willingly got into the visitors vehicle and returned to the facility. She said that he did not have any obvious injury. On 2/12/25 at 9:55 AM, during an interview, LPN #1 revealed she was working the 3:00 PM through 11:00 PM shift on 2/08/25 and observed Resident #1 in the lobby minutes before 3:00 (PM). She said she discovered at approximately 3:00 PM that Resident #1 could not be located when a visitor inquired about his whereabouts. She confirmed that the facility policy/procedure for Missing Resident was followed with a Code Silver announced using the overhead public announcement system. She stated that CNA #1 had just arrived and reported that she observed the resident walking along the nearby highway. She confirmed the resident was wearing athletic shorts and a sleeveless T-shirt, two black socks and one house slipper, she confirmed the second slipper had been located in his room upon return to the facility by his visitor and two (2) facility staff at 3:30 PM. She stated that she completed a body audit for Resident #1 immediately upon his return and observed no injuries or signs/symptoms of dehydration and encouraged fluid intake by mouth. She said she notified the resident's primary healthcare provider and received no new orders. She said that all residents at risk for elopement, including Resident #1, had their wander guard transmitter tested and none were functioning correctly. She confirmed that a staff member was posted at the front entrance and all residents at risk for elopement were provided with one-on-one supervision pending system replacement and proper function which was accomplished on 2/10/25. LPN #1 stated that nurses were supposed to test the functionality of the transmitters daily either using a hand-held tester or by taking the resident to the door and observing and documenting the test results in the Medication Administration Record but she had not tested Resident #1's transmitter on 2/08/25. On 2/12/25 at 12:36 PM, during a telephone interview the RR for Resident #1 confirmed that she had been notified shortly after 3:30 PM on 2/08/25 that the resident had left the facility unsupervised and returned to the facility at 3:30 PM with no injuries. On 2/13/25 at 4:50 PM during an interview, the Maintenance Director explained that he tested the functioning of the wander guard system each week and the nurses were supposed to test the transmitters daily. He confirmed that the maintenance department had reported to the facility on [DATE], tested all exit doors and confirmed that all doors were closed and locked correctly but it was determined that the transmitters worn by residents at risk for elopement were not functioning correctly, specifically not preventing the door from opening or sounding alarm if a transmitter was within eight feet of the front door. He confirmed that the maintenance department changed all the numeric codes for wall-mounted keypads (magnetic locks) after 3:30 PM on 2/08/25. The Maintenance Director said that replacement transmitters were ordered on 2/08/25 and arrived at the facility on 2/10/25. He stated that he had tested the system with the newly received transmitters and the system functioned correctly. On 2/13/25 at 5:00 PM, in an observation and interview with the DON, she revealed that the front entrance wander guard system was functioning properly. The DON demonstrated the function of the system was to prevent the door from opening if a wander guard transmitter was within eight (8) feet of the monitor at the door and if the door had been opened and was open and the transmitter was within eight feet an alarm sounded, which also sounded at both nurses stations. She confirmed that at the time of the elopement the system was not functioning properly. The DON confirmed that the police were not notified of the elopement, and the resident was not taken to the hospital and had no injuries or change of condition following the incident. She confirmed that she had attended the QAPI meeting on the evening of 2/08/25. She confirmed that the replacement transmitters for the wander guard system arrived at the facility on 2/10/25 and were replaced and the system was tested and functioned correctly. She confirmed that monitoring for placement every shift and functioning daily was on-going. She confirmed that all staff were provided with in-service with no staff allowed to work without participation in the training. Record review of the Admission Record revealed the facility admitted Resident #1 on 1/28/25 with current diagnoses including Aphasia following Cerebral Infarction, Cognitive Communication Deficit and Legal Blindness. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/04/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 99 and required a staff assessment for his mental status. The staff assessment indicated Resident #1 had a long and short-term memory problem, and his cognitive skills for daily decision making was severely impaired. Further MDS review revealed the resident was assessed as needing partial/moderate assistance for surface-to-surface transfers and walking ten (10) feet. The facility submitted a corrective action plan as follows: 1. On February 8, 2025, at approximately 3:00 pm, CST, Resident #1 exited the center while unsupervised. The unsupervised resident leaving the facility represented an Immediate Jeopardy. The resident was wearing a wander guard device. The Resident was assessed upon return to the facility and had no injuries, the wander guard device was found to be inoperable, and Resident was placed on one-on-one supervision. The facility reviewed the wandering/missing resident policy, educated staff on the wandering/missing resident policy and held a quality assurance meeting. In addition, staff checked all exit doors out of the facility (including the door the Resident exited from). Also, the staff check all wander guards currently being utilized in the building and placed any not working on 1:1 supervision. Finally, staff performed a complete headcount (all residents were found to be in the building with one exception who had properly signed himself out) and the door codes were changed. Based on the steps the facility initiated and completed, the facility contends that the Immediate Jeopardy was removed and represents past noncompliance. This event was reported to the Mississippi State Department of Health via email on Sunday, February 9, 2025, at 2:37 pm. 2. On February 8, 2025, at 3:00 pm, Licensed Practical Nurse (LPN) #1, was notified that Resident #1 could not be accounted for. At 3:02 pm, the Director of Nursing (DON), Executive Director (ED), Social Services Director (SSD), Medical Director (MD) and Regional Director of Clinical Services (RDCS) were notified. At 3:03 pm, Certified Nursing Assistant (CNA) #1 reported to work for her 3-11 shift and upon hearing that a resident was not accounted for, showed the nurse a video she had taken of a man she saw walking next to Hwy 90 on her way to work. The Resident's girlfriend arrived at the facility approximately 3:00 pm and as soon as she saw the video, she and 3 CNAs jumped in the car to go get Resident #1. LPN #2 called the Residents responsible party (Power of Attorney (POA)) and DON. The DON called the ED, MD, and SSD. At 3:30 pm Resident returned to the facility. At 3:36pm the DON was notified the Resident was located .7 of a mile from the facility and safely returned to the facility. 3. On February 8, 2025, at 3:30 pm, Resident returned to facility. Once Resident #1 was back inside center, LPN #2, completed a head-to-toe body audit and no injuries were noted. Registered Nurse (RN) Supervisor #1 completed a head count of all residents, and all were accounted for. On February 8, 2025, at 4:15 pm, the Assistant Maintenance Director performed checks on all exterior doors and windows, along with the wander guard system. His findings determined that all doors were locked and while all alarms were functioning properly, the wander guard bracelet Resident #1 was wearing was not functioning properly. The resident was immediately placed on 1:1 supervision and a 24-hour door monitor put in place at front. The door monitor continued until the wander guard system was verified to function properly and the Quality Assurance monitoring begin (see bullet #8). The door monitor was discontinued on 02/10/2025. The door keypad codes were changed. 4. On February 8, 2025, RN #2/Unit Manager began educating staff on elopement wandering risk policy, missing resident policy, following care plans, abuse and neglect, and resident's rights. The Director of Social Services reassessed Resident #1 Brief Interview for Mental Status (BIMS), which had not changed and was noted to be 99, unable to determine. On February 8-10, 2025, wandering risk evaluation completed on all residents with no newly identified wandering risk. Elopement binders (identifying the 5 residents wearing wander guards) are located at both nurses' stations and up front. At 6:45 pm, an Ad hoc QAPI was held including the ED, DON, and MD to discuss incident and a plan of correction. 5. On Saturday, February 8, 2025, DON conducted interviews to learn of Resident #1's path. It was discovered that Resident #1 most likely exited the front door when a visitor entered the facility. Resident #1 confirmed by a positive head shake that he used the front door and answered yes, that he was trying to go home. 6. On Monday, February 10, 2025, at 2:30 pm, the incident was taken to a quality assurance performance improvement (QAPI) meeting, attended by, Executive Director, Director of Nursing, Infection Preventionist, Medical Director via phone, Director of Dietary Services, Maintenance Director, Minimum Data Set (MDS) LPN #2 and LPN #3. No further action needed. No changes made to policies. 7. On February 8, 2025, in-servicing began on Wandering/Missing Resident, Prevention of Abuse and Neglect, and door alarms policies, and included 3 RNs, 1 LPN and 5 CNAs. On February 9, 2025, in-service continued including 6 LPNs, 2 RNs and 8 CNAs. On February 10, 2025, in servicing continued including 6 LPNs, 11 CNAs, and 3 RNs and 4 ancillary staff. On February 11, 2025, 4 LPN, 9 ancillary staff, 4 RNs. No staff was allowed to work before receiving education. 15 CNAs, 1 RN. Education is on-going until it was 100% complete. Furthermore, the system will be check daily by maintenance staff and the devices will be checked for placement each shift and checked for functionality daily by nursing staff. The daily checks of the door systems and placement of the patient devices, as well as the q shift checks of functionality of the patient devices, will be monitored by DON for completion. (see bullet #8) 8. The following monitoring has been put in place beginning February 10, 2025, and the findings will be evaluated by the Quality Assurance and Improvement Committee. All residents that are assessed and care planned as a potential for elopement will be evaluated for significant change in condition for elopement using the elopement risk evaluation, evaluated quarterly for elopement using the elopement risk evaluation, ensure the care plan reflects elopement risk status and any interventions (i.e., wander guard), wander guard check placement every shift that it is present on the MAR without omissions, order for wander guard check for functionality daily is present on MAR without omissions, elopement books have a current face sheet, resident photograph and risk alert form, binders are in an easily accessible location, staff has been educated on the elopement policy, location of the binders and notification process regarding an possible missing resident, transmitter bands are replaced per manufacturers recommendations if signs of manipulation and/or integrity of the band is compromised, exit doors monitoring system functioning appropriately with supporting documentation, and wand used to test function is easily accessible to check the transmitter function.(once these monitoring task were initiated, we discontinued the door monitor) All the forementioned monitoring task will be conducted by the Director of Nursing enduring 3 times a week for 1 week, then 2 times a week for 2 weeks, then weekly for the next 2 months and then monthly. All results will be presented to the Quality Assurance Committee for evaluation and recommendations as necessary. The Quality Assurance Committee will continue to evaluate all monitoring for 90 days to monitor effectiveness and make changes as necessary. 9. All Corrective Actions were completed on February 9, 2025, and the Immediate Jeopardy was removed on February 10, 2025, prior to the State Agency's entrance on February 11, 2025. Validation: The SA validated on 2/13/25, through interview and record review, that all corrective actions had been implemented as of 2/9/25, and the facility was in compliance as of 2/10/25, prior to the SA's entrance on 2/11/25.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide incontinence care in a timely manner for six (6) of 22 sampled residents and resulted in Resident #57 having skin excoriations and Resident #55 free from wearing two (2) incontinence briefs with a current diagnosis of Urinary Tract Infection (UTI). (Residents #57, #55, #1, #8, #14, and #38) Findings include: Resident #57 On 4/15/24 at 10:00 AM, during an observation, staff were transferring Resident #57 from the bed to an electric wheelchair using a mechanical lift. On 4/15/24 at 4:00 PM, during an observation and interview, Resident #57 was in his electric wheelchair and stated that he had been up in his chair since 10:00 AM and the staff had not changed his brief since then. He explained that he usually wears two (2) incontinence briefs during the day to hold his urine because it takes several staff members to transfer him with the lift and to change him. On 4/15/24 at 4:15 PM, during an observation of incontinence care for Resident #57, Certified Nurse Assistants (CNAs) #3, # 4 and #5 assisted the resident to bed. The CNAs removed two (2) briefs that were saturated with urine and soiled with bowel movement (BM). The resident's perineal area and lower buttocks were red and excoriated. During an interview on 4/15/24 at 4:30 PM, with CNA # 3, CNA #4 and CNA # 5, they explained Resident #57 requested two (2) briefs on dayshift staff did not want to change him and get him back up. The CNAs said they normally assist the resident to bed around 9:00 PM, provide incontinence care, and use a barrier cream on his perineal area and buttocks. An observation on 4/16/24 at 1:00 AM of incontinence care with CNA #7, CNA #12, and CNA #13, revealed Resident #57's brief was saturated with urine. He had redness and excoriations to the perineal area and his lower buttocks had excoriated areas that were bleeding. During an interview on 4/16/24 at 1:30 AM with CNA #7, CNA # 12 and CNA #13 confirmed Resident #57 had excoriated areas and that the nurses had advised them to use a barrier cream. On 4/17/24 at 9:00 AM, during an interview with the Medical Director, he confirmed he had been made aware of the excoriations to Resident #57's perineal and buttock areas. The staff were in the process of transferring him to his wheelchair when he went to the resident's room to observe the areas and he was only able to see the redness and excoriations to the perineal area. He asked the wound care nurse to follow up with the excoriated areas. During an interview on 4/18/24 at 10:33 AM with the Director of Nursing (DON), she stated she was unaware Resident #57 had excoriated areas. A record review of the Admission Record revealed the facility admitted Resident #57 on 8/2/23 and he had current diagnoses including Quadriplegia. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/24 revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Review of section GG revealed Resident #57 required substantial/maximal assistance with toileting hygiene. Resident #55 On 04/16/24 at 1:10 AM, during an observation and interview, Resident #55 was wearing two incontinence briefs. Licensed Practical Nurse (LPN) #2 confirmed he was wearing two briefs. Resident #55 reported sometimes the CNAs will put four (4) or five (5) briefs on him so they will not have to change him during the night. LPN #2 explained residents should not wear two briefs unless there is a specific care plan intervention to do so. She explained that wearing two briefs could cause skin breakdown and moisture associated skin damage. The CNAs should round every two hours to check on the residents, but she did not check behind them to be sure they were completing their rounds. At 1:45 AM on 04/16/24, during an interview with CNA #8, she explained she had not checked on Resident #55 this shift and the 3-11 must have applied two briefs to the resident. She reported she usually started her rounds at 12 AM but had not checked Resident #55 yet. On 04/17/24 at 11:30 AM, during an interview with Registered Nurse #2/Infection Preventionist Nurse, she explained that being left in a soiled brief for long periods of time increased the risk for UTIs and skin breakdown. Record review of the Admission Record revealed the facility admitted Resident #55 on 9/1/22 and had current diagnoses including Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease. Record review of the Quarterly MDS with an ARD of 03/29/24 revealed Resident #55 had a BIMS score of 15, which indicated he was cognitively intact. Section GG revealed he required total dependence for toileting hygiene and Section H revealed he was always incontinent of bowel and bladder. Record review of the Order Summary Report with active orders as of 04/16/24, revealed Resident #55 had a Physician's Order, dated 4/12/24, for Bactrim DS (an oral antibiotic) for UTI until 4/26/24. Further review revealed a Physician's Order, dated 4/4/24, for Macrobid (an oral antibiotic) for acute cystitis (bladder infection) with hematuria (blood in the urine). Resident #1 On 04/15/24 at 12:17 PM, during an observation and interview, Resident #1's call light was lit up and sounding. CNA #2 went into the resident's room, explained that it would be a minute because the staff were passing meals trays, and turned the light off. There were two (2) nurses sitting at the nurse's station and there were no meal trays observed on the hall. CNA #2 explained it was the policy of the facility not to change residents while meal trays were being passed out on the floor. At 12:30 PM on 04/15/24, during an observation and interview, Resident #1 was eating lunch and he stated that he needed to be changed. At 1:15 PM on 04/15/24, during an observation and interview, Resident #1 was sitting in his wheelchair in his room and reported that he had not been changed. On 04/15/24 at 01:25 PM, during an observation and interview, Resident #1 left his room and went down the hallway. CNA #10 explained no one had told her that Resident #1 requested to be changed. A record review of the Admission Record revealed the facility admitted Resident #1 on 12/01/2014 and he had current medical diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction. A record review of the Annual MDS with an ARD of 01/16/24 revealed Resident #1 had a BIMS score of 15, which indicated he was cognitively intact. Section GG revealed he required maximal assistance for toileting hygiene and Section H revealed he was frequently incontinent of bowel and bladder. Resident #8 On 04/16/24 at 1:15 AM, during an observation and interview, Resident #8 was wearing two (2) incontinence briefs that were wet with urine. LPN #2 explained there should be no residents wearing two briefs at any time unless the resident has been care planned to have them. LPN #2 stated that residents wearing two incontinence briefs could cause skin breakdown or infection. On 04/16/24 at 1:45 AM, during an interview with CNA #8, she explained she had not checked on Resident #1 since the beginning of her shift at 11 PM and the double briefs must have come from the 3-11 shift. She stated she usually started her rounds at 12 AM, but she must have forgotten to check on Resident #1. Record review of the Admission Record revealed the facility admitted Resident #8 on 1/15/20 and had current diagnoses including Acute on Chronic Systolic (Congestive) Heart Failure. Record review of the Quarterly MDS with an ARD of 3/6/24 revealed Resident #8 had a BIMS score of 00, which indicated his cognition was severely impaired. Section GG revealed he required maximal assistance with toileting hygiene and Section H revealed he was always incontinent of bowel and bladder. Resident #14 On 04/16/24 at 1:05 AM, during an observation and interview, Resident #14's brief was torn off and there was BM noted on the resident. The incontinence pad underneath the resident had a brown ring. CNA #8 reported it was not unusual for the resident to tear off the brief and explained that she completed rounds on the residents at 12 AM, 2AM, 4 AM, and 6 AM. CNA #8 stated that she did not think she had checked Resident #14's brief earlier because the resident was asleep. She confirmed there was a brown ring noted to the incontinence pad and that Resident #14 had not been changed for a long period of time. On 04/16/24 at 1:23 AM, during an interview with LPN #2, she explained that when there was a brown ring on a resident's incontinent pad, then the resident had not been changed for a long period of time. She said the CNAs should complete rounds on the residents every two (2) hours, but she did not check behind the CNAs. A record review of the Admission Record revealed the facility admitted Resident #14 on 9/3/13 with current medical diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction. A record review of the Quarterly MDS with an ARD of 3/18/24 revealed Resident #14 had a BIMS score of 00, which indicated her cognition was severely impaired. Section GG revealed she required maximal assistance for toileting hygiene and Section H revealed she was always incontinent of bowel and bladder. Resident #38 During an observation on 4/15/24 at 12:17 PM, Resident #38's call light was on and Certified Nurse Aide (CNA) #2 walked into the resident's room, explained to the resident that it would be a minute because she was passing out meal trays, and exited the room. There were no meal trays being served on the hall. During an observation and interview on 4/15/24 at 1:10 PM, Resident #38 was lying in bed and there was a strong odor in the room. Resident #38 explained her brief was soiled before lunch and she had asked the staff to change her. She stated the staff told her that she had to wait because the lunch trays were being passed out. During an observation and interview on 4/15/24 at 1:35 PM, Resident #38 reported to CNA #10 and CNA #1 that she had been sitting in a soiled brief for over an hour. Both reported they were not aware she needed assistance before lunch trays were served. During incontinence care, there was a dark brown ring on the incontinence pad and the resident's brief was heavily soiled. During an interview on 4/15/24 at 2:35 PM, CNA #2 explained she did not tell anyone that Resident #38 had requested to have her brief changed because she had forgotten. On 04/16/24 at 1:20 AM, during an interview and observation, Resident #38 reported that she had not been changed all night. LPN #2 confirmed Resident #38's brief was wet and soiled. A record review of the Admission Record revealed the facility admitted Resident #38 on 1/12/21 with current diagnoses including Spinal Stenosis. A record review of the Quarterly MDS with an ARD of 3/13/24, revealed Resident #38 had a BIMS score of 14, which indicated she was cognitively intact. During an interview with the Director of Nursing (DON), on 04/16/24 at 4:00 PM, she explained she was unaware that staff were applying two incontinence briefs on the residents. She reported that no residents should wear two briefs and she expected the staff to follow the standards of care for all residents. She explained there were enough staff on the units to assist with resident care if the CNAs were busy. She expected staff to keep residents from having to wait for long periods of time to receive assistance with incontinence care. 43283

Based on staff interview, record review, and facility policy review, the facility failed to accurately submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for Quarter 1 of Fiscal Year (FY) 2023 (October - December 2023) for one (1) of five (5) quarters reviewed. Findings include: Record review of facility's policy Staffing Requirements, effective 11/30/2014, revealed, .Purpose .To provide a sufficient number of employees . A review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database for FY Quarter 1 (October 1-December 31) revealed the Metric of Excessively Low Weekend Staffing was triggered related to .Submitted Weekend Staffing is excessively low. Record review of the facility PBJ Data entry report for October, November, and December of 2023 revealed PBJ Salaried Employee Hour Adjustments occurred for the Minimum Data Set (MDS) Staff RN and the adjustments did not occur on weekends or for any other facility salaried employees. On 4/16/24 at 2:48 PM, the Human Resource Coordinator explained the corporate office was responsible for submitting PBJ staffing data for all the facilities in the corporation and she was unaware the PBJ staffing information was inaccurate until she had reviewed the audit spreadsheet provided by the corporate office. She stated the PBJ submitted as per the audit spreadsheet did not reflect the salaried employees who had worked hourly on the weekends. She confirmed the data submitted in the first quarter of FY 2024 was not accurate because the facility utilized salary staff on weekends for coverage and this inaccuracy in reporting led to excessively low weekend staffing being triggered. She confirmed that she would not have known this information since she received no feedback of the reported information. During an interview on 4/16/24 at 2:48 PM, with Licensed Practical Nurse (LPN) #4, she stated that she was unaware the facility failed to electronically submit PBJ staffing data to CMS accurately in the first quarter of FY 2024. She confirmed that she was responsible for making the staffing schedules and during October, November, and December of 2023, salaried staff had helped to cover the schedule. The Administrator stated in an interview on 04/18/24 at 1:51 PM, that he was not aware that the facility failed to electronically submit PBJ staffing data to CMS accurately in the first quarter of FY 2024. The Administrator stated that the corporate office was responsible for submitting the PBJ staffing data for all the facilities in the corporation. He confirmed that he was knowledgeable of the importance of accurately reporting PBJ information to CMS and that it was ultimately the responsibility of the facility to ensure accuracy.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right for a dignified dining experience when the staff did not provide incontinence care for a resident which resulted in odors in the resident's room, causing the meal to be unappetizing, for one (1) of 22 sampled residents. Resident #38 Findings include: A review of the facility's policy Resident's Rights and Responsibilities, effective 01/07 revealed .Each nursing facility resident has a right to a dignified existence .A facility must protect and promote the rights of each resident . On 4/15/24 at 12:17 PM, during an observation in the hallway, Resident #38's call light was lit up above the door. Certified Nurse Aide (CNA) #2 walked into the resident's room, explained to the resident that it would be a minute because she was passing out meal trays, and she exited the room. There were no meal trays being served on the hall at that time. On 4/15/24 at 1:10 PM, during an interview and observation, Resident #38 was lying in bed. There was a strong odor in the room. Resident #38 explained her brief was soiled before lunch and she had asked the staff to change her. She stated the staff told her that she had to wait because the lunch trays were being passed out. She said she had to eat her lunch while wearing a soiled brief and she was uncomfortable with the odor. On 4/15/24 at 1:35 PM, in an interview and observation of Resident #38, CNA #10 and CNA #1 came into the resident's room to check on her. The resident reported to both to the CNAs that she had been sitting in a soiled brief for over an hour and had to eat lunch while she was dirty. Both reported they were not aware that the resident needed assistance before lunch trays were served. Resident #38 expressed to both CNAs that she wanted to be changed. During the incontinence care, there was a dark brown ring on the incontinence pad and the resident's brief was heavily soiled. On 4/15/24 at 2:35 PM, during an interview with CNA #2, she explained that she did not tell anyone that Resident #38 had requested and needed to have her brief changed because she had forgotten. On 04/16/24 at 4:00 PM, during an interview with the Director of Nursing (DON), she explained that any staff member, including a CNA or a nurse, could assist with changing a resident and expressed that it was not acceptable for a resident to have to wear a soiled brief while eating lunch or any other time for a long period of time. She explained she expected the staff to assist the residents when they request it and to provide care every two (2) hours and as needed. On 04/18/24 at 3:30 PM, during an interview with the Administrator, he explained he expected all staff to do their job and to treat residents with dignity and respect. He would expect staff to never allow a resident to stay in a soiled brief during lunch. A record review of the Admission Record revealed the facility admitted Resident #38 on 1/12/21 with current diagnoses including Spinal Stenosis. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/13/24, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact.

Based on interviews, record reviews, and facility policy review, the facility failed to develop care plan interventions for a resident with a Urinary Tract Infection (UTI) (Resident #55) and for a resident with Substance Use Disorder (SUD) (Resident #57), and failed to implement a care plan intervention related to a low air loss mattress (Resident #261) for three (3) of 22 resident care plans reviewed. Findings include: A record review of the facility's policy Plans of Care with revision date 09/25/17 revealed . An individual person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative (s) to the extent practicable and updated in accordance with state and federal requirements . Resident #55 On 4/15/24 at 10:55 AM, during an interview, Resident #55 explained he had a UTI and was taking medication for the UTI. Record review of the Admission Record revealed the facility admitted Resident #55 on 9/1/22 and had current diagnoses including Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/29/24 revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Section GG revealed he required total dependence for toileting hygiene and Section H revealed he was always incontinent of bowel and bladder Record review of the Order Summary Report with active orders as of 04/16/24, revealed Resident #55 had a Physician's Order, dated 4/12/24, for Bactrim DS (an oral antibiotic) for UTI until 4/26/24. Further review revealed a Physician's Order, dated 4/4/24, for Macrobid (an oral antibiotic) for acute cystitis (bladder infection) with hematuria (blood in the urine). Record review of Resident #55's Comprehensive Care Plan revealed there was no care plan with interventions developed related to the diagnosis of UTI. At 03:00 PM on 4/17/24, during an interview and review of the comprehensive care plan, the Director of Nursing (DON) confirmed Resident #55 did not have a care plan in place for UTI and that care plans should be updated when new physician orders are received. The care plan should remain in place until the issue is resolved. She stated she expected care plans to be developed to ensure residents are receiving proper care. On 04/17/24 at 3:45 PM, during an interview with Licensed Practical Nurse (LPN) #1, she stated she was responsible for resident care plans. She confirmed there was no care plan developed for Resident #55 related to his UTI and she confirmed he was currently taking antibiotic medication related to UTI. She explained the purpose of the care plan was for staff to know how to take care of the residents and she expected the staff to follow all resident care plans. Resident #57 On 4/16/24 at 9:00 AM, an interview with Resident #57's family member revealed Resident #57 had a history of alcohol abuse since he had an accident which caused him to become paralyzed from the waist down. The family member commented that the resident has been drinking more lately and felt as if he needed some help with substance abuse. The family member stated the facility had not recommended any programs or behavioral health services related to SUD. During an interview on 4/16/24 at 10:00 AM, with License Practical Nurse (LPN) #2 states, she explained that she was the care plan nurse. She confirmed Resident #57 had an alcohol abuse problem and the facility had not developed a care plan or had thought about putting interventions into place to assist the resident with SUD. A record review of the Admission Record revealed the facility admitted Resident #57 on 8/2/23 with current diagnoses including Quadriplegia and Unspecified Injury at C1 Level of Cervical Spinal Cord. A record review of the Annual MDS with an ARD of 3/20/24 revealed Resident #57 had a BIMS score of 15, which indicated he was cognitively Intact. A review of the medical record for Resident #57 revealed there was no comprehensive care plan developed with interventions related to Substance Use Disorder (SUD). Resident #261 Record review of the comprehensive care plan for Resident #261 with an initiation date of 12/08/23, revealed a Focus (Proper Name) has self-care deficits r/t (related to) needs assistance .Intervention/Tasks .THERAPEUTIC MATTRASS (mattress) . On 4/16/24 at 1:00 PM, in an interview with a family member of Resident #261, she explained she attended a care plan meeting with the facility and the Medical Doctor (MD) apologized to her during the meeting because the Resident #261 was moved from the skilled unit to the long term care (LTC) unit in January of 2024 and the facility did not move his air mattress to the new bed. On 4/17/24 at 10:00 AM, in an interview with the Director of Nursing (DON), she confirmed that when Resident #261 moved from the skilled unit to the LTC unit, the low air loss mattress that was ordered for him was not moved to his new bed. Record review of the Admission Record revealed the facility admitted Resident #261 on 9/26/23 with current diagnosis including Injury of Cervical Spinal Cord. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/2/2024 revealed Resident #261 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact.

Based on interviews, record review, and facility policy review, the facility failed to ensure a Pressure Ulcer (PU) intervention related to an air mattress was continued after a room change for one (1) of three (3) residents reviewed for PUs. Resident #261 Findings include: Review of the facility's policy, Skin and Wound revised 1/24/22, revealed, .To provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention and healing of pressure injuries .Process .Pressure Injury Mitigation Strategies .Develop resident centered interventions based on resident risk factors . Record review of the Braden Scale dated 10/17/23, revealed Resident #261 had a score of 17, which indicated he was at risk for PUs. Record review of the Order Summary Report revealed Resident #261 had a Physician's Order, dated 10/26/2023 for a low air loss mattress. During an interview on 4/16/24 at 1:00 PM, with a family member of Resident #261, she explained she attended a care plan meeting with the facility and the Medical Doctor (MD) apologized to her during the meeting because the Resident #261 was moved from the skilled unit to the long term care (LTC) unit in January of 2024 and the facility did not move his air mattress to the new bed. Resident #261 was sent to the hospital emergency room due to abnormal laboratory findings and she had the resident admitted to another facility after the hospital stay. During an interview on 4/17/24 at 9:00 AM with the MD, he confirmed that he had apologized to Resident #261's family member during a care plan meeting because the facility did not ensure the low air loss mattress that was ordered for the resident was moved to his new bed when he was moved from the skilled unit to the LTC unit. During an interview on 4/17/24 at 10:00 AM with the Director of Nursing (DON), she confirmed that when Resident #261 moved from the skilled unit to the LTC unit, the low air loss mattress that was ordered for him was not moved to his new bed. Record review of the Admission Record revealed the facility admitted Resident #261 on 9/26/23 with current diagnosis including Injury of Cervical Spinal Cord. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/2/2024 revealed Resident #261 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact.

Based on interview, record review, and facility policy review the facility failed to implement baseline care plan interventions related to Cardiopulmonary Resuscitation (CPR) for a resident who was found unresponsive for one (1) of four (4) sampled residents. Resident #1 The facility failed to implement the baseline care plan interventions for CPR when Resident #1, who had a Full Code status, was found to be unresponsive and without a pulse or respirations. The nurse incorrectly pulled another resident's chart who had a Do Not Resuscitate (DNR) order and did not initiate CPR or activate emergency services for Resident #1. The facility's failure to implement the baseline care plan resulted in Resident #1 not receiving CPR and emergency services. The resident subsequently expired in the facility. The situation was determined to be an Immediate Jeopardy (IJ) that began on [DATE] when Resident #1 was found by facility staff to be unresponsive and without a pulse or respirations. The facility Administrator was notified of the IJ on [DATE] at 4:30 PM and was provided an IJ Template. Based on the facility's implementation of corrective actions on [DATE], the State Agency (SA) determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed as of [DATE], prior to the SA's first entrance on [DATE]. Findings include: A record review of the facility's policy Plans of Care with a revision date of [DATE] revealed Policy: An individual person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative (s) to the extent practicable and updated in accordance with state and federal regulatory requirements .Procedure: . Develop and implement an Individual Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to .physician orders .and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed . A record review of Resident #1's Care Plan dated [DATE], revealed . Advanced Directives 'Full Code' A record review of the Order Summary Report, with active orders as of [DATE], revealed Resident #1 had a Physician's Order dated [DATE], for Full Code. Record review of the Advance Directives Discussion Document, dated [DATE] revealed, .Please indicate your wishes regarding the following: Cardiopulmonary Resuscitation: PROVIDE . was checked indicating Resident #1 wished to have CPR provided. A record review of Resident #1's Admission Record revealed the facility admitted Resident #1 on [DATE] with diagnoses including Acute Respiratory Failure with Hypoxia, Acute on Chronic systolic (Congestive) Heart Failure, Paroxysmal Atrial Fibrillation, and Atherosclerotic heart disease of native coronary artery without angina pectoris. During an interview with the Director of Nursing (DON) on [DATE] at 09:30 AM, she explained that Resident #1 had a full code status. She confirmed that Resident #1 did not receive CPR or emergency treatment. The DON explained that she expected the nurses to follow the care plan for all residents. On [DATE], at 12:35 PM , during an interview with Licensed Practical Nurse (LPN) #4/Care Plan nurse, she confirmed Resident #1 had a baseline care plan in place for a Full Code status and he did not receive CPR and emergency services. She confirmed the care plan was not followed and that she expected all medical staff to follow the resident's care plan. The facility submitted the following acceptable Corrective Action Plan on [DATE]: Corrective Action Plan Brief Summary of Events: On [DATE], at 9:05 PM, Licensed Practical Nurse (LPN) #1 noted Resident #1 was without pulse and respirations. The facility failed to initiate Cardiopulmonary Resuscitation (CPR) and provide emergency care when Resident #1 was found to be unresponsive and required emergency care. The facility failed to implement a Baseline Care Plan related to the code status of Resident #1. Resident #1 did not receive CPR or emergency care when he was found to be unresponsive and required emergency care. LPN #1 pulled another resident's chart (Resident #2), who had a Do Not Resuscitate (DNR) order, and thought she was reviewing Resident #1's code status and therefore did not perform CPR or provide emergency care. Through root cause analysis, the facility determined LPN #1 failed to accurately identify resident and verify code status. The facility reviewed their CPR and Plan of Care policy and procedures, educated nursing staff on identifying residents, verifying code status, following plan of care and notification of change in resident, and held a quality assurance meeting. The event was reported to Licensure and Certification/Mississippi State Department of Health via email on [DATE], at 10:43 AM, the Mississippi Office of Attorney General on [DATE], at 7:52 PM, State Ombudsmen on [DATE], at 7:30PM, and the Mississippi Board of Nursing on [DATE], at 7:20 PM. On [DATE], at 9:05 PM, LPN #1 requested LPN #2 to confirm Resident #1 was without pulse and respirations. LPN #2 confirmed Resident #1 was without pulse and respirations. LPN #1 requested Registered Nurse (RN) #1 to pronounce Resident #1. At 9:10 PM, on [DATE], LPN #1 notified Director of Nursing (DON), Medical Director, and Responsible Party of Resident #2, of Resident expiration. At 10:05 PM, on [DATE], LPN #1 notified local funeral home and coroner of Resident expiration. On [DATE], at 8:00 AM local funeral home called facility and spoke with RN #2 requesting information on the Resident in their possession. On [DATE], at 8:10 AM, RN #2 contacted Resident #2 Responsible Party. At 8:20 AM on [DATE], RN #2 informed Executive Director (ED) and DON of issue and investigation began. On [DATE], at 11:30 AM, LPN #2 suspended pending investigation, by RN #3. On [DATE], at 12:00 PM, RN #1 suspended pending investigation, by RN #3. At 1:30 PM on [DATE], LPN #1 suspended pending investigation, by RN #3. On [DATE], at 9:30 AM, RN #2 initiated education to nursing staff on accurately identifying resident, verifying code status, following plan of care, abuse, neglect, resident rights and notification of change in resident, to include 50 certified nursing assistants, 26 licensed practical nurses, and 12 registered nurses. No current licensed nurses or newly hired licensed nurses will work without the aforementioned education. On [DATE], at 9:45 AM, ED reviewed all resident photos inside Point Click Care (PCC). No adverse findings. At 10:00 AM on [DATE], LPN #3 audited all resident charts for accurate code status in Point Click Care (PCC), advance directive on chart, and chart tags. Findings of audit were one (1) chart did not have advanced directive election sheet on chart, but it was in PCC, and one (1) chart needed updated advanced directive from hospital return. Advanced Directive election sheet added to chart and advanced directive updated on [DATE], by LPN #3 and RN #3. At 10:00 AM on [DATE], Certified Nursing Assistant (CNA) #1 and CNA #2 checked all door labels for accurate resident names. Findings include one (1) room noted without a name label. Name label was placed on name plate by CNA #1 and CNA #2 on [DATE]. On [DATE], at 12:30 PM, RN #2 and LPN #4 initiated mock code drill for all nursing staff. Mock code drill will be completed on all shifts. On [DATE], at 3:00 PM, ED initiated education to all non-nursing to notify a nurse if resident is observed unresponsive, abuse, neglect, and resident rights, to include 11 dietaries, 7 housekeeping, 4 laundry, 2 maintenance, 3 activity, and 8 administrative. No current non-nursing staff members or newly hired non-nursing staff members will work without the aforementioned education. On [DATE], at 8:00 PM, RN #2 and RN #3 audited care plans for accuracy of code status. No adverse findings. On [DATE], at 12:10 PM, RN #2 initiated education to LPN #1, LPN #2, and RN #1 on accurately identifying residents, verifying code status, following plan of care, abuse, neglect, resident rights and notification on change in resident. At 5:30 PM on [DATE], the Quality Assurance Performance Improvement (QAPI) Committee met to review findings of investigation and conducted a Root Cause Analysis (RCA) and review of Cardiopulmonary Resuscitation (CPR), Plan of Care, and Notification of Change in Resident policy and procedures for changes. Attendees were the Executive Director (ED), Director of Nursing (DON), Director of Rehabilitation (DOR), Unit Manager/RN, Unit Manager/LPN, Infection Control Preventionist, Minimum Data Set (MDS), Assistant Business Office Manager (ABOM), Central Supply Certified Nurse Assistant (CNA), Medical Records, Staffing Development LPN, and Human Resources Director (HRD). The Medical Director (MD) attended by phone. RCA determined additional needs for education to all nurses on accurately identifying residents, verifying code status, following plan of care and notification of change in resident. No changes made to policies. Ongoing monitoring will begin on [DATE], as follows: Code status of all new admissions will be audited within 24 hours of admission by Director of Nursing. All resident Code statuses will be audited weekly times four weeks, then monthly times three months. Mock Code drills will be performed quarterly rotating shifts. Findings will be discussed in Quality Assurance Performance Improvement (QAPI) meeting quarterly. Based on the steps the facility initiated and completed for this event, the facility alleges that corrective actions were completed as of [DATE], and represents past noncompliance since all measures were completed prior to complaint survey entrance. The State Agency (SA) validated the facility's Corrective Action Plan on [DATE]. On [DATE], the SA validated through record reviews and resident and staff interviews the root cause of the Facility Reported Incident on [DATE] was LPN #1 pulled the wrong resident's chart and the chart or resident was not verified by two (2) nurses. On [DATE], the SA validated through record review and resident and staff interviews Resident #1 was found without pulse and respirations. Resident #2's daughter was notified, and the local funeral home and coroner was notified of resident's expiration. On [DATE], the SA validated through record review and staff interviews the facility began investigating on [DATE] and LPN #1, LPN #2, and RN #1 were suspended during the investigation. On [DATE], the SA validated through record reviews of in-service training sign in sheets and staff interviews the in-service was completed on [DATE] to include mock code drill, CPR policy, accurately identifying resident, verifying code status, following plan of care, abuse, neglect, resident rights, and notification of change in resident. All resident photos were reviewed in Point Click Care (PCC), all resident's charts for accurate code status in Point Click Care (PCC), advance directive on chart, and chart tags. All residents' door labels checked for accurate resident names. Sign in sheet for in-service to all non-nursing to notify a nurse if resident is observed unresponsive, abuse, neglect, and resident rights. An audit on all residents' care plans for accuracy of code status was completed on [DATE]. On [DATE] through record review of sign in sheet for in-service for LPN #1, LPN #2, and RN #1 was completed on accurately identifying residents, verifying code status, following plan of care, abuse, neglect, resident rights and notification on change in resident. A record review of the Quality Assurance Performance Improvement (QAPI) Committee met at 5:30 p.m. on [DATE], to review findings of investigation and conducted a Root Cause Analysis (RCA) and review of Cardiopulmonary Resuscitation (CPR), Plan of Care, and Notification of Change in Resident policy and procedures for changes. Attendees were the Executive Director (ED), Director of Nursing (DON), Director of Rehabilitation (DOR), Unit Manager/RN, Unit Manager/LPN, Infection Control Preventionist, Minimum Data Set (MDS), Assistant Business Office Manager (ABOM), Central Supply Certified Nurse Assistant (CNA), Medical Records, Staffing Development LPN, and Human Resources Director (HRD). The Medical Director (MD) attended by phone. RCA determined additional needs for education to all nurses on accurately identifying residents, verifying code status, following plan of care and notification of change in resident. No changes made to policies.

Based on interviews, record review, and facility policy review, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) and provide emergency services to an unresponsive resident for one (1) of four (4) sampled residents. Resident #1. Resident #1, who had a Full Code status, was found to be unresponsive and without a pulse or respirations. The nurse incorrectly pulled another resident's chart who had a Do Not Resuscitate (DNR) order. Therefore, the nurse did not initiate CPR or activate emergency services for Resident #1. The facility's failure to review the correct code status resulted in Resident #1 not receiving CPR and emergency services. The resident subsequently expired in the facility. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when Resident #1 was found by facility staff to be unresponsive and without a pulse or respirations. The facility Administrator was notified of the IJ on [DATE] at 4:30 PM and was provided an IJ Template. Based on the facility's implementation of corrective actions on [DATE], the State Agency (SA) determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed as of [DATE], prior to the SA's first entrance on [DATE]. Findings Include: A record review of the facility's policy Cardiopulmonary Resuscitation (CPR) with a revision dare [DATE] revealed Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a valid Do Not Resuscitate (DNR) order. Procedure: . 2. Two licensed nurses are to verify . Right Identity .Current physician order for code status . 6. Notify the physician and resident representative/legal representative 7. Document in the medical record. At 09:30 PM on [DATE], during an interview with Licensed Practical Nurse (LPN) #2, she explained she was working the evening of [DATE] when Resident #1 expired. She stated that while she was charting at the nurse's station, LPN #1 came to the station and said that she thought her patient was dead. LPN #1 pulled a chart and pointed out to LPN #2 the DNR page on the chart. LPN #2 stated that she only looked at the DNR page and did not notice it was for Resident #2. LPN #2 explained to LPN #1 that since Resident #1 was a DNR, nothing else had to be done. LPN #1 then asked Registered Nurse (RN) #1 to make the death pronouncement. LPN #1 continued to go through the medical chart and called the doctor, the Director of Nursing (DON), and called the resident's family, but asked LPN #2 to talk to the family on the phone. LPN #2 confirmed that she did not verify the name on the resident's chart or the photo and was not aware that LPN #1 had viewed another resident's chart in error. At 10:00 PM on [DATE], during an interview with RN #1, she explained on the night of [DATE], she was working on the medication cart and was administering medications when she was approached by LPN #1 who asked her to make a death pronouncement for a resident. She stated LPN #1 informed her the resident had a DNR code status and referred to the resident by the name of Resident #2 and not Resident #1. RN #1 confirmed that she did not verify the code status herself and did not know the resident. RN #1 stated that the resident's body was cold and there were no vital signs, so she confirmed that the resident was deceased , and then went back to the hall to complete her medication pass. RN #1 stated that at the end of her shift at approximately 11:00 PM on [DATE], LPN #1 reminded her to document in the medical chart the pronouncement of death for the resident and used the name of Resident #2, and not Resident #1. RN #1 explained that she was not aware of the error until the following morning ([DATE]) when the facility called her and made her aware that the deceased resident was Resident #1 and not Resident #2. She reported that she was at fault in the incident because she did not verify the resident's name or code status. On [DATE] at 09:30 AM, during an interview with the DON, she explained that on the night of [DATE] after 09:00 PM, she received a call from LPN #1 and was told that Resident #2 had passed away. On [DATE] after 8:00 AM, while on her way to the facility, RN #2 called her and told her that she had been informed that the funeral home had called the facility questioning the identity of the body in their possession. The facility immediately began an investigation and discovered the root cause of the incident was that LPN#1 reviewed the wrong chart and the nurses did not verify the identity of the residents when Resident #1 was found to be expired. The DON commented that Resident #1 and Resident #2 did not have similar names, were not in the same room, and had different nurses assigned to them. LPN #1 was assigned to Resident #1 and LPN #2 was assigned to Resident #2. The DON explained that Resident #1 had a full code status and Resident #2 had a DNR status, which resulted in Resident #1 not receiving CPR or emergency treatment. During the facility's investigation on [DATE], the DON stated that while interviewing LPN# 1, she would not acknowledge that she had made a mistake, even when confronted with the paperwork she had completed in the name of Resident #2 and not Resident #1. LPN #1 said she knew it was Resident #1 who had expired, but she could not understand how she made the mistake and insisted that she had reviewed the correct resident's medical chart. The DON said that she expected the nurses to follow the physician orders, code status, and the facility policies for all residents. On [DATE] at 10:00 AM, during an interview with the Administrator, she explained the whole incident was upsetting for the facility and the residents' families involved. She explained it was an accident that should never have happened and that the wrong resident's chart had been pulled, the resident was not correctly identified, and there had been no CPR performed on Resident #1 who had a full code status. She explained she expected the nurses to follow physician orders and facility policies. On [DATE] at 11:00 AM, during an interview RN #2, she explained on the morning of [DATE], she made rounds and noticed that Resident #1 was not in his room. She was told by a Certified Nurse Aide (CNA) that Resident #1 had passed away. She went to review Resident #1's records and did not see any documentation, including a record of death. She stated she called LPN #1 for more information and advised her that Resident #1 had a full code status. At 11:45 AM on [DATE], during an interview with Resident #1's daughter, she explained she was informed by the facility on [DATE] that her father had died . She was told that the nurse had pulled the wrong chart which showed the resident was not a full code. She stated they did nothing to try and resuscitate her father who had a full code status. On [DATE] at 12:00 PM, during a phone interview with LPN #1, she explained she was walking down the hallway around 9:00 PM and went into Resident #1's room and he was not breathing. She stated she went to the nurse's station and reviewed the medical chart and both herself and LPN #2 verified that the resident was a DNR. She said she called the family and asked LPN #2 to talk to the family because she had another resident who was sick. She said she asked two (2) CNAs to clean up the resident and later saw a woman at the facility who was crying. LPN #1 said that she completed the paperwork and called the coroner. She repeated that she had verified with the other nurse that the resident had a DNR code status, and she did not make a mistake. She expressed that she would never not perform CPR on a resident who had a full code status. At 12:30 PM on [DATE], during an interview with Resident #3, who was Resident #1's roommate, he stated that he was on the phone with his mother and made the remark that his roommate was quiet tonight. After some time, a nurse came in to check on the resident and went out of the room and then came back with another nurse. The nurse went out again and another nurse came in with a stethoscope and then left. He reported that he called his mom and said he thought Resident #1 had died . He confirmed that he never saw the staff performing CPR on the resident. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Resident #1 A record review of Resident #1's Admission Record revealed the facility admitted Resident #1 on [DATE] with diagnoses including Acute Respiratory Failure with Hypoxia, Acute on Chronic systolic (Congestive) Heart Failure, Paroxysmal Atrial Fibrillation, Atherosclerotic heart disease of native coronary artery without angina pectoris. A record review of the Order Summary Report, with active orders as of [DATE], revealed Resident #1 had a Physician's Order dated [DATE], for Full Code. Record review of the Advance Directives Discussion Document, dated [DATE] revealed, .Please indicate your wishes regarding the following: Cardiopulmonary Resuscitation: PROVIDE . was checked indicating Resident #1's wished to have CPR provided. Record review of Resident #1's Discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was coded as reason for discharge Death in facility. Discharge Status was coded as deceased . The facility submitted the following acceptable Corrective Action Plan on [DATE]: Corrective Action Plan Brief Summary of Events: On [DATE], at 9:05 PM, Licensed Practical Nurse (LPN) #1 noted Resident #1 was without pulse and respirations. The facility failed to initiate Cardiopulmonary Resuscitation (CPR) and provide emergency care when Resident #1 was found to be unresponsive and required emergency care. The facility failed to implement a Baseline Care Plan related to the code status of Resident #1. Resident #1 did not receive CPR or emergency care when he was found to be unresponsive and required emergency care. LPN #1 pulled another resident's chart (Resident #2), who had a Do Not Resuscitate (DNR) order, and thought she was reviewing Resident #1's code status and therefore did not perform CPR or provide emergency care. Through root cause analysis, the facility determined LPN #1 failed to accurately identify resident and verify code status. The facility reviewed their CPR and Plan of Care policy and procedures, educated nursing staff on identifying residents, verifying code status, following plan of care and notification of change in resident, and held a quality assurance meeting. The event was reported to Licensure and Certification/Mississippi State Department of Health via email on [DATE], at 10:43 AM, the Mississippi Office of Attorney General on [DATE], at 7:52 PM, State Ombudsmen on [DATE], at 7:30PM, and the Mississippi Board of Nursing on [DATE], at 7:20 PM. On [DATE], at 9:05 PM, LPN #1 requested LPN #2 to confirm Resident #1 was without pulse and respirations. LPN #2 confirmed Resident #1 was without pulse and respirations. LPN #1 requested Registered Nurse (RN) #1 to pronounce Resident #1. At 9:10 PM, on [DATE], LPN #1 notified Director of Nursing (DON), Medical Director, and Responsible Party of Resident #2, of Resident expiration. At 10:05 PM, on [DATE], LPN #1 notified local funeral home and coroner of Resident expiration. On [DATE], at 8:00 AM local funeral home called facility and spoke with RN #2 requesting information on the Resident in their possession. On [DATE], at 8:10 AM, RN #2 contacted Resident #2 Responsible Party. At 8:20 AM on [DATE], RN #2 informed Executive Director (ED) and DON of issue and investigation began. On [DATE], at 11:30 AM, LPN #2 suspended pending investigation, by RN #3. On [DATE], at 12:00 PM, RN #1 suspended pending investigation, by RN #3. At 1:30 PM on [DATE], LPN #1 suspended pending investigation, by RN #3. On [DATE], at 9:30 AM, RN #2 initiated education to nursing staff on accurately identifying resident, verifying code status, following plan of care, abuse, neglect, resident rights and notification of change in resident, to include 50 certified nursing assistants, 26 licensed practical nurses, and 12 registered nurses. No current licensed nurses or newly hired licensed nurses will work without the aforementioned education. On [DATE], at 9:45 AM, ED reviewed all resident photos inside Point Click Care (PCC). No adverse findings. At 10:00 AM on [DATE], LPN #3 audited all resident charts for accurate code status in Point Click Care (PCC), advance directive on chart, and chart tags. Findings of audit were one (1) chart did not have advanced directive election sheet on chart, but it was in PCC, and one (1) chart needed updated advanced directive from hospital return. Advanced Directive election sheet added to chart and advanced directive updated on [DATE], by LPN #3 and RN #3. At 10:00 AM on [DATE], Certified Nursing Assistant (CNA) #1 and CNA #2 checked all door labels for accurate resident names. Findings include one (1) room noted without a name label. Name label was placed on name plate by CNA #1 and CNA #2 on [DATE]. On [DATE], at 12:30 PM, RN #2 and LPN #4 initiated mock code drill for all nursing staff. Mock code drill will be completed on all shifts. On [DATE], at 3:00 PM, ED initiated education to all non-nursing to notify a nurse if resident is observed unresponsive, abuse, neglect, and resident rights, to include 11 dietaries, 7 housekeeping, 4 laundry, 2 maintenance, 3 activity, and 8 administrative. No current non-nursing staff members or newly hired non-nursing staff members will work without the aforementioned education. On [DATE], at 8:00 PM, RN #2 and RN #3 audited care plans for accuracy of code status. No adverse findings. On [DATE], at 12:10 PM, RN #2 initiated education to LPN #1, LPN #2, and RN #1 on accurately identifying residents, verifying code status, following plan of care, abuse, neglect, resident rights and notification on change in resident. At 5:30 PM on [DATE], the Quality Assurance Performance Improvement (QAPI) Committee met to review findings of investigation and conducted a Root Cause Analysis (RCA) and review of Cardiopulmonary Resuscitation (CPR), Plan of Care, and Notification of Change in Resident policy and procedures for changes. Attendees were the Executive Director (ED), Director of Nursing (DON), Director of Rehabilitation (DOR), Unit Manager/RN, Unit Manager/LPN, Infection Control Preventionist, Minimum Data Set (MDS), Assistant Business Office Manager (ABOM), Central Supply Certified Nurse Assistant (CNA), Medical Records, Staffing Development LPN, and Human Resources Director (HRD). The Medical Director (MD) attended by phone. RCA determined additional needs for education to all nurses on accurately identifying residents, verifying code status, following plan of care and notification of change in resident. No changes made to policies. Ongoing monitoring will begin on [DATE], as follows: Code status of all new admissions will be audited within 24 hours of admission by Director of Nursing. All resident Code statuses will be audited weekly times four weeks, then monthly times three months. Mock Code drills will be performed quarterly rotating shifts. Findings will be discussed in Quality Assurance Performance Improvement (QAPI) meeting quarterly. Based on the steps the facility initiated and completed for this event, the facility alleges that corrective actions were completed as of [DATE], and represents past noncompliance since all measures were completed prior to complaint survey entrance. The State Agency (SA) validated the facility's Corrective Action Plan on [DATE]. On [DATE], the SA validated through record reviews and resident and staff interviews the root cause of the Facility Reported Incident on [DATE] was LPN #1 pulled the wrong resident's chart and the chart or resident was not verified by two (2) nurses. On [DATE], the SA validated through record review and resident and staff interviews Resident #1 was found without pulse and respirations. Resident #2's daughter was notified, and the local funeral home and coroner was notified of resident's expiration. On [DATE], the SA validated through record review and staff interviews the facility began investigating on [DATE] and LPN #1, LPN #2, and RN #1 were suspended during the investigation. On [DATE], the SA validated through record reviews of in-service training sign in sheets and staff interviews the in-service was completed on [DATE] to include mock code drill, CPR policy, accurately identifying resident, verifying code status, following plan of care, abuse, neglect, resident rights, and notification of change in resident. All resident photos were reviewed in Point Click Care (PCC), all resident's charts for accurate code status in Point Click Care (PCC), advance directive on chart, and chart tags. All residents' door labels checked for accurate resident names. Sign in sheet for in-service to all non-nursing to notify a nurse if resident is observed unresponsive, abuse, neglect, and resident rights. An audit on all residents' care plans for accuracy of code status was completed on [DATE]. On [DATE] through record review of sign in sheet for in-service for LPN #1, LPN #2, and RN #1 was completed on accurately identifying residents, verifying code status, following plan of care, abuse, neglect, resident rights and notification on change in resident. A record review of the Quality Assurance Performance Improvement (QAPI) Committee met at 5:30 p.m. on [DATE], to review findings of investigation and conducted a Root Cause Analysis (RCA) and review of Cardiopulmonary Resuscitation (CPR), Plan of Care, and Notification of Change in Resident policy and procedures for changes. Attendees were the Executive Director (ED), Director of Nursing (DON), Director of Rehabilitation (DOR), Unit Manager/RN, Unit Manager/LPN, Infection Control Preventionist, Minimum Data Set (MDS), Assistant Business Office Manager (ABOM), Central Supply Certified Nurse Assistant (CNA), Medical Records, Staffing Development LPN, and Human Resources Director (HRD). The Medical Director (MD) attended by phone. RCA determined additional needs for education to all nurses on accurately identifying residents, verifying code status, following plan of care and notification of change in resident. No changes made to policies.

The State Agency (SA) conducted the complaint investigation (CI MS # ) from 6/7/21 through 6/10/21 and substantiated CI MS # related to elopement, when the facility failed to provide adequate staff supervision to prevent Resident #3's elopement from the facility on 5/22/21. Resident #3 was last seen at 8:00 PM and found at 10:06 PM. Resident #3 was missing unsupervised and away from the facility for approximately ninety-two minutes. The facility was not aware of Resident #3's absence until they made rounds and the resident was not in the building. Certified Nurse Assistant (CNA) #1 and CNA #2 went to look for Resident #3 and found her in a parked car. Resident was trying to crank car. Resident #3 was found one street over behind the facility. Resident #3 was found to have a small, reddened area on her back. Resident #3 was returned to the facility by CNA #1 and CNA #2 Resident #3 was assessed by LPN #2 for any signs and symptoms of injury and pain. The facility's immediate investigation revealed Resident #3 exited through the exit door on the 600 Hall when the door opened after being pressed down on 10 seconds. Resident #3 was immediately placed on one on one (1:1) supervision after she was returned to the facility at 10:06 PM. During the survey, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 6/8/21 which occurred on 5/22/21 and existed at: CFR(s): 483.25 (d)(1)(2)- Free of Accident Hazards/Supervision/Devices (F689) Scope and Severity - J. The facility's failure to provide adequate supervision to prevent an elopement for Resident #3 who was an elopement and wander risk, allowed the resident to leave the facility, unnoticed and unsupervised until CNA #1 and CNA #2 found the resident sitting in a parked vehicle in a nearby neighborhood, trying to start the vehicle. This situation caused the likelihood for serious injury, harm impairment or death for Resident #3 and other residents with wandering behaviors and at risk of elopement. The SA notified the facility's Administrator of the PNC IJ and SQC on 6/8/21 at 4:45PM. Based on the facility's implementation of corrective actions on 5/22/21, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed as of 5/24/21, prior to the SA's first entrance on 6/7/21. Based on staff interviews, record review, facility investigation review and facility policy review, the facility failed to provide adequate staff supervision to prevent Resident #3's elopement from the facility on 5/22/21 after 8:30 PM. The facility staff did not know Resident #3 was off the facility grounds until they could not locate her in the facility at 8:30 PM. CNA #1 and CNA #2 found Resident #3 in a parked car on a nearby street. This concern was identified for one (1) of eight (8) residents reviewed for wandering behavior and risk for elopement. Findings include: The facility's policy, Wandering/Missing Residents, dated 11/2019, revealed it is the policy of this Center to ensure the safety and well-being of each resident within the environment of the Center while meeting their needs and sustaining a quality of life they can enjoy. On 6/8/21 at 11:35 AM, in an interview with Registered Nurse (RN) #2/ Risk Management stated, we have two (2) residents that wander, Resident #3 and Resident #6. CNA #1 heard the exit door on the 600-Hall alarm go off at 8:00 PM. CNA #1 saw Resident #6 at the door. CNA #1 redirected Resident #6 away from the door. CNA #1 noticed 30 minutes later that Resident #3 was not in the building. Resident #3 was found one street behind the facility in a driveway. Resident #3 was missing for over one hour. Staff left in cars looking for Resident #3. CNA #1 and CNA #2 found Resident #3 in a vehicle in a driveway trying to start the vehicle. The police were called. On 6/8/21 at 1:08 PM, in an interview with the Administrator, stated we had 2 wandering residents that would go to exit doors. Residents #3 and #6 were together often. CNA #1 heard the alarm go off. CNA #1 went to the exit door on the 600 Hall and found Resident #6 at the exit door. CNA #1 redirected Resident #6 back to her room and 20 minutes later she noticed that Resident #3 was missing. Resident #3 was found one street over in a vehicle. Resident #3 was brought back to the facility by CNA #1 and CNA #2. Licensed Practical Nurse (LPN) #2 did a full body audit. Resident #3 was not in distress. She stated it was reported to the SA within two (2) hours. A review of the facility's investigation report revealed they immediately completed a count of all residents to ensure that all residents were accounted for. The staff checked all doors. The facility investigation revealed Resident #3 exited through the exit door on hall 600, when the alarm went off. The facility does not utilize wander guard. The facility staff began to search for Resident #3 inside and outside the facility at 9:00 PM. At 9:15 PM LPN #2 notified the Director of Nursing (DON) and search continued of the facility grounds. At 10:02 PM, CNA #1 and CNA #2 were searching the neighborhood one street over and directly behind the center when they saw the headlights of a vehicle flashing and heard the car alarm sound. The CNAs immediately went to the vehicle and found Resident #3 trying to crank the car. Resident #3 stated she was trying to go to her appointment. The Resident was directed out of the vehicle and back to the facility. One on one was initiated with Resident #3. At 10:30 PM all exterior doors were checked, and codes were changed. The north courtyard gate was secured. At 11:00 PM in-services were done on elopement. wandering screening was done, care plan was updated, and staff interviewed. On 5/23/21 at 9:00 AM, wandering risk assessments were completed and wandering pictures and list updated and placed at each nursing station and ancillary department. At 10:00 AM, stop alarms were added to two (2) exterior doors and new locks placed on courtyard gates. During an interview with the RN #2/Risk Manager on 6/9/2021 at 11:35 AM, she stated when a resident is identified as a risk for wandering/elopement, the staff follows the interventions on the person-centered Comprehensive Care Plan. She stated the Comprehensive Care Plan is changed and updated as needed. RN#2/ Risk Manager clarified the door alarm sounding was the keypad alarm located to the right of the 600 Hall door. RN #2 stated that Resident #3 did not have any dirt, grass, or mud on her clothing. RN #2 stated that there was no evidence that Resident #3 had fallen. RN #2 stated that the reddened area on Resident #3 back disappeared within eight (8) hours. On 6/9/2021 at 11:44 AM, in an interview and observation, the Director of Operations (DOO) demonstrated the use and function of the stop sign alarms placed on the exterior doors and demonstrated the doors will not open when the push bar across the center of the door is pushed. The Director of Operations stated prior to the elopement, the doors would open after 10 seconds whenever the push bar of the door was leaned on or pushed on. The SA observed the stop sign alarm located near the top of the doors on both exterior doors of Hall 600. The DOO opened the door on Hall 600 leading to the interior courtyard and activated the alarm which makes a loud noise. The SA noted staff responding to the alarm during the demonstration. On 6/9/2021 at 11:45 AM, the State Agency (SA), Director of Operations, Administrator, Director of Nursing, and Risk Manager left the facility from the 600 Hall exit door into the fenced exterior yard. SA observed three gates in this area which are secured with a screw-type latch. Gate #1 exits into a wet grassy area with no exterior lighting. The Administrator states this area is always wet due to drainage from the washing machine. SA noted puddled water and wet grass from the facility to the exterior fence in this area. Gate #2 is located between Gates #1 and #3 and does not have a sidewalk access. Gate #2 also exits into a grassy, wooded area where there is no direct exterior lighting. The wooded area is dense with tall underbrush and fences from residential homes located on the back of the property which would prevent the resident from entering the neighborhood from this area. Gate #3 has a sidewalk access with a security light directly above the gate. The gate opens onto a paved street (not a through-street) that turns into a parking lot for surrounding medical offices. The paved area continues by a fenced and gated children's park with playground equipment. The gates to the park are pull latch gates and exits onto a residential street which is near where the resident was located. This street can also be accessed by continuing straight through the hospital parking lot and onto a residential street that loops back toward the houses behind the facility where the resident was located. The SA observed two vehicles traveling on the roadway during the tour. The ground is even, except for sidewalk curbs which have small inclines. The lighting is adequate with streetlights and motion sensor lights attached to medical/office buildings and the hospital. The resident was located 720 feet from the exit door of the facility inside a vehicle at a residential home. A record review of the weather on 5/22/2021 between 8:00 PM. and 10:00 PM. revealed the temperature was 73 degrees, 0% precipitation, and winds at 7-8 mph. On 6/9/2021 at 2:15 PM, the SA conducted a telephone interview with LPN #2. LPN #2 stated she was not sure of the exact time she last saw Resident #3 because she was not assigned to her, but she believed it was approximately 8:15 p.m. LPN #2 stated she heard a door alarm sounding earlier in the shift around 6:00 PM and noted Resident #6 standing at the exit door on 600 Hall that exits to the interior courtyard. LPN #2 stated she looked outside and turned the door alarm off. The LPN stated she did not hear the door alarm go off later in the evening. LPN #2 stated when she was alerted that Resident #3 was missing, she helped search for her. LPN #2 stated she attended an in-service the night of the elopement 5/22/21 on the elopement process and what to do if a resident is missing. LPN stated she saw Resident #3 when she came back to the facilities and did not notice any scratches or injuries. LPN #2 stated resident was placed on one-on-one monitoring. In the telephone interview with CNA #1 on 6/9/21 at 5:00 PM, she stated Resident #3 was assigned to her on the night of the elopement CNA #1 stated the last time she saw Resident #3 was before her final rounds before 9:00 PM. CNA stated she heard an alarm sounding at approximately 8:50 PM and saw Resident #6 at the door trying to get out. The CNA stated she was attempting to redirect Resident #6 and did not look outside the door. CNA #1 stated she started doing her rounds and when she got to Resident #3's room, she noted the resident was not in her room and she started looking for her. CNA #1 stated she notified the nurse and they started doing the protocol. The CNA stated she kept looking for Resident #3 and went outside to try to find her. CNA #1 stated she and another staff member walked down the street into the neighborhood behind the facility and noticed a car alarm going off and noted Resident #3 sitting in the car. The CNA stated Resident #3 was wearing gripper socks that were not wet and slightly dirty. The CNA stated Resident #3 did not have any scratches or bruises. CNA stated she received an in-service that night on elopement and wandering and attending an emergency elopement drill a couple of days after the elopement. CNA stated that residents with wandering behaviors are tagged on the charts and if a resident is identified as a wanderer, she tries to lay eyes on them at least every 30 minutes. In the telephone interview with CNA #2 on 6/9/21 at 4:40 PM, stated she was working on the 500 Hall the night of the elopement. CNA stated she did not hear an alarm sounding, but she saw a staff member through a window walking around outside. CNA #2 went outside and was informed that a resident was missing. CNA stated she assisted with searching for the resident inside and outside of the facility. CNA stated she was walking through a neighborhood behind the facility and did not see resident. CNA stated she walked the neighborhood behind the facility next to the hospital and saw some flashing lights that looked like hazard lights from a vehicle. CNA stated she found Resident #3 sitting in a vehicle about a block away from the facility. CNA stated the resident was not wearing shoes and her socks were dirty but were not wet and she did not see any cuts or bruises on Resident #3. CNA stated they had in services on abuse, neglect, and wandering residents before and after the elopement occurred and Code Silver is paged overhead. CNA also stated that pictures of residents identified as wanders are posted behind the nurse's station, in the office, and by all the doors. On 6/9/21 at 5:40 PM, in an interview with CNA #3 stated she was in-serviced on wandering residents a couple of weeks ago. CNA directed SA to area behind the nurses' station and in the chart room where pictures of wandering residents are displayed. SA observed laminated posters with 9 photos of residents with pictures, names, and room numbers. On 6/9/21 at 5:45 PM, SA observed Resident #3 sitting in a bedside chair in her room. Resident was noted to be dressed in pants and a shirt and well groomed. Resident #3's meal tray was in front of her on an overbed table. Resident #3 noted to be smiling and friendly and invited SA to sit and visit. The resident was able to recall her name but could not give the date or time as she stated her meal tray was her breakfast. The SA attempted to interview the resident; however, she was unable to recall or give any details related to the elopement. A record of the Resident #3 Face Sheet revealed resident was admitted [DATE] with a diagnosis of Alzheimer's Disease. A record review of Resident #3 Wandering Risk Observation dated 2/22/21 revealed resident was admitted as a wanderer on admission. A record review of Resident #3's Admission Minimum Data Set (MDS) with an Assessment Record Date (ARD of 3/06/21, Section C revealed a Brief Interview for Mental Status (BIMS) score of six (06), indicating severely impaired cognitive status and section I revealed a diagnosis of Alzheimer's. A record review of the Comprehensive Care Plan dated 2/21/21, revealed Resident #3 is at risk for attempting to leave the facility without supervision related to periods of confusion due to Dementia. A record review of the nurse's progress notes dated 3/17/21, revealed Resident #3 was wandering throughout the night in other residents' rooms. Nurses Progress Note dated 4/7/21 at 6:09 PM revealed resident was walking the length of the 100, 200, and 600 halls. Nurse Progress Notes dated 4/16/21 at 7:45 PM, revealed Resident #3 was walking down the 100 and 600 halls and required constant redirection by staff. A record review of nurses' progress notes dated 4/23/21 at 6:57PM revealed Resident #3 was wandering the halls. Record review revealed an Elopement Drill was held on 6/8/21 at 5:47 PM. The facility implemented the following Immediate Jeopardy (IJ) Removal Plan/ Corrective Actions, prior to the SA entrance on 6/7/21. In response to the Past Non-compliance IJ and SQC cited at 4:45 PM on 6/7/21, the facility submitted a summary of the event, including an IJ Removal Plan and Correction Actions, taken by the facility to remove the IJ. Brief Summary of Events: On 6/8/21 at 4:45 PM, SA notified facility Administrator of Immediate Jeopardy (IJ) existed at Past Noncompliance and Substandard Quality of Care. On 5/22/21 Resident #3 was missing and could not be located on the facility grounds. Staff immediately began to look for Resident #3. Resident #3 was found in a nearby neighborhood in a park vehicle trying to start it. CNA #1 and CNA #2 found resident and returned the resident to the facility. Corrective Action Plan/Removal Plan 1. On May 22, 2021, at approximately 8:30 p.m. , Resident #3 exited the center while unsupervised. The unsupervised Resident leaving the facility represented an Immediate Jeopardy. The Resident was assessed and had no injuries and was placed on one-on-one supervision upon returning to the center. Through root cause analysis, the facility determined how the Resident was able to leave unsupervised. The facility reviewed their wandering/missing resident policy, educated staff on the wandering/missing resident policy, and held a quality assurance meeting. In addition to the existing wandering/missing resident policy, the facility also removed the delayed egress from three exit doors, including the door the Resident #3 exited through. (Please note that every exit door unlocks in the event that the fire monitoring system alarms.) Based on the steps the facility initiated and completed, the facility contends that the Immediate Jeopardy was removed and represents past noncompliance. This event was reported to Licensure and Certification/Mississippi State Department of Health via phone on May 22, 2021, at 11:11 p.m. 2. On May 22, 2021, at 9:15 p.m., Registered Nurse (RN) #2, was notified that Resident #3 could not be accounted for. At 9:25 p.m., on May 22, 2021, Administrator, Director of Operations, and Nurse Consultant were notified. At 9:27 p.m., on May 22, 2021, Local Police were notified and in route to center. At 9:30 p.m, on May 22, 2021, Medical Director notified that Resident #3 had exited center and police were in route. At 9:32 p.m., on May 22, 2021, Responsible Party notified. At 10:02p.m., on May 22, 2021, Resident was located 720 feet from the center and safely returned to the center. 3. On May 22, 2021, at 10:02 p.m. Resident #3 was located and returned to center. Once Resident #3 was back inside center, Licensed Practical Nurse #3, completed head to toe body audit, noting small red area to lower back which was attributed to a recent fall and not a result of the elopement. Licensed Practical Nurse #4, completed head count of all Residents and all were accounted for. On May 22, 2021, at 10:15 p.m., Maintenance Director performed checks on all exterior doors and windows. His findings determined all doors were locked and alarms were functioning properly. Windows were all shut, and door keypad codes were changed. At 10:30 p.m., on May 22, 2021, one-on-one observation began with Resident #3. 4. At 11:00 p.m., on May 22, 2021, wander risk observation was completed, care plan updated, and laboratory tests [urinalysis (UA), complete blood count (CBC), and complete metabolic panel (CMP)] ordered and completed. On May 23, 2021, at 9:00a.m., wandering risk observations completed on all Residents, with no newly identified resident wandering risk. Resident wandering risk list located at nurse's stations and each ancillary department were updated. 5. On May 24, 2021, at 9:00 a.m., several foot rounds, around the center, were made to determine Resident's path. At 10:00 a.m., on May 24, 2021, Maintenance Director and Regional Maintenance Director completed removal of egress from three (3) exterior doors, exit stopper alarms were added to two (2) exterior doors, and new latches were added to the North courtyard gates. On May 24, 2021, at 11;00 a.m., the incident was taken to a quality assurance performance improvement at an ad hoc meeting, attended by, Administrator, Risk Manager, Infection Preventionist, Medical Director via phone, Director of Nursing, Director of Dietary Services, Social Services, Director of Admissions, Maintenance Director, Assistant Director of Nursing, minimum data set nurses (MDS)Registered Nurse (RN) #3, and minimum data set nurses (MDS) Registered Nurse (RN) #4, Director of Life Enrichment, and Certified Nursing Assistant. No further action needed. No changes made to policy. 6. On May 22, 2021, in-servicing began, on Wandering/Missing Resident, Prevention of Abuse and Neglect, and door alarms policies, and included 11 certified nursing assistants, 5 licensed practical nurses, 1 hospitality aide, 1 dietary, 1 housekeeping, and 1 plant operations manager. On May 23, 2021, in-servicing included, 7 certified nursing assistants, 2 license practical nurses, 2 registered nurses, 7 dietary staff, 3 housekeeping, 2 from laundry, 1 life enrichment, and 1 screener. May 24, 2021, in-services included, 17 certified nursing assistants, 7 license practical nurses, 7 registered nurses, 8 patient care assistants, 5 dietary staff, 5 housekeeping, 2 from laundry, 4 life enrichment, 3 plant operations, 7 administrative, 1 scheduler, and 3 therapists. As of May 24, 2021, no one worked until this in-service had been completed. Based on the steps the facility initiated and completed for this event, the facility alleges that the Immediate Jeopardy was removed as of May 24, 2021 and represents past noncompliance since all measures were completed prior to complaint survey entrance. The facility corrective actions were initiated on 5/22/21. All activities to remove the IJ was initiated on 5/22/21 and completed on 5/24/21. The facility alleges the IJ was removed on 5/24/21. The SA validated on 5/10/21, the facility's investigation of the incident and implementation of the IJ Removal Plan/Corrective Action through observations, facility records review and staff interviews. 1. The SA validated by the facility's investigation and interviews that on 5/22/21 Resident #3 was directed back into the facility by CNA #1 and CNA #2, from a parked vehicle in the nearby neighborhood. Resident #3 was assessed by LPN #2 and was found to have a small, reddened area on her back. Resident #3 was placed on one-on one. The facility removed the egress from the exit doors. The facility initiated an investigation. 2. The SA validated the facility's investigation on 5/22/21 through record review of the investigation report, police report and interview with the DON, Administrator, and Risk Management. 3. The SA validated by staff interviews and record reviews that a body audit for Resident #3, and head count sheets were completed for 5/22/21. Logbooks of the alarm checks and one on one-time logs for Resident #3 were verified. 4. The SA validated by reviewing all residents Wandering Observation Assessments were completed on 5/23/21. Resident #3's labs were drawn on 5/22/21 AT 11:00 PM. 5. The SA validated the facility's investigation through observations of two (2) potential pathways Resident #3 may have used to exit the facility. The SA validated through staff interview and record review the Quality Assurance Performance Improvement (QAPI) was held on 5/24/21 at 11:00 AM. SA reviewed sign in sheets for the QAPI meeting. DON and RN #2/ Risk Management confirmed they attended QAPI meeting. 6. The SA validated on 5/9/21 through 5/10/21 that staff was in-serviced on elopement, by staff interviews, and record reviews. The SA reviewed in-service sign sheets and interviewed LPN #1, LPN #2, LPN #3, CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, CNA #6, Housekeeping #1, and Central Supply Coordinator #1.

Based on observation, staff interview, record review, review of the Mississippi Board of Nursing Administrative Code, and facility policy review, the facility failed to follow standards of practice for cleaning/disinfecting glucometers (blood glucose testing device), per manufacturer's recommendations, for a minimum of 30 seconds wet time, before, and after use, to ensure bloodborne [MEDICAL CONDITION] and bacterial pathogens were killed. The facility also failed to ensure that staff washed their hands before, during, and after performing a blood glucose finger stick, for eight (8) of 13 observations for six (6) residents who received blood glucose finger sticks, Residents #13, #20, #52, #77, #84 and #89. This practice had the potential and likelihood to pose a threat of blood borne cross-contamination between residents who received blood glucose testing. The facility's failure of not following standards of practice for cleaning/disinfecting the glucometers, per manufacturer's recommendations between residents; and to perform hand hygiene between procedures, placed these and other residents who receive blood glucose finger sticks (24 total residents) in a situation which caused a likelihood of serious injury, harm, impairment, or death, related to the spread of blood borne pathogens due to cross-contamination with the multi-resident use of the glucometer. The situation was determined to be an Immediate Jeopardy (IJ), which began on 6/25/19, when the facility failed to follow the manufacturer's guidelines to clean and disinfect the glucometer for the minimum amount of wet time of 30 seconds, prior and after use between residents, to ensure all bacterial/[MEDICAL CONDITION] pathogens were killed; and failed to perform hand hygiene appropriately between residents. The State Agency (SA) notified the Administrator on 6/25/19, of the IJ. An acceptable Removal Plan was received on 6/26/19, in which the facility alleged all corrective actions to remove the IJ were completed on 6/25/19, and the IJ was removed as of 6/26/19. The SA validated the Removal Plan and determined the IJ was removed on 6/26/19, prior to exit. Therefore, the scope and severity for CFR(s): 483 21 (b)(3)(i), F658; Services Provided Meet Professional Standards, was lowered from a K level to an [NAME] level, while the facility develops and implements a plan of correction and monitors the effectiveness of systemic changes to ensure the facility sustains compliance with the regulatory requirements. Findings include: A review of the Mississippi Board of Nursing Position Statement, titled Blood Borne Pathogens, with a revision date of 4/6/2000, revealed the Board recognized the Centers of Disease Control (CDC) and Prevention Guidelines as the accepted standard of nursing practice and required all nurses to practice accordingly. In accordance with the CDC guidelines, in the provision of nursing care, all nurses should adhere to standard precautions, including washing of hands and comply with current guidelines for disinfection and sterilization of re-useable devices. A review of the Centers for Disease Control (CDC) and Prevention guidelines, updated 6/8/17, which regarded shared blood glucose meters, revealed if blood glucose meters were shared, the device should be cleaned and disinfected after every use, per manufacturer instructions, to prevent carry-over of blood and infectious agents. A Review of facility policy titled, Infection Control Monitoring, dated (MONTH) (YEAR), revealed: It is the policy of the Center to investigate the cause of infections (nosocomial and community and hospital acquired) and the manner of spread. The objective of the Infection Control Policies: preventing, identifying, reporting, investigating, and controlling infections and other communicable diseases; designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A Review of facility policy titled, Obtaining a Finger stick Glucose Level, dated (MONTH) (YEAR), revealed staff were to maintain a clean barrier, maintain clean technique, follow instructions provided by the manufacturer of the glucose monitoring system to obtain a blood glucose reading, and to wash hands after removing gloves. The policy also stated to clean the glucose monitor with approved disinfectant before and after each resident use. A review of the booklet titled, EvenCare G2 blood glucose monitoring system users guide (glucose monitor used by the facility), revised (MONTH) (YEAR), revealed: Wipe all external areas of the meter or lancing device, including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use. The booklet documented Micro-Kill bleach germicidal wipes were validated as an effective agent to use on the glucometer. A review of the label of the Micro-kill Bleach wipes, revealed: Contact time: Allow surface(s) to remain wet for 30 seconds to kill all of the bacteria [MEDICAL CONDITION] **on the label**(virucidal-including but not limited to [MEDICAL CONDITION]/B/C, Human immunodeficiency virus type I, influenzas, norovirus, and Rotavirus) of the wipes except a one (1) minute contact time is required to kill [MEDICAL CONDITION][MEDICATION NAME] and [MEDICATION NAME] mentagrophytes and a three (3) minute contact time is required to kill [MEDICAL CONDITION] spores. Reapply as necessary to ensure that the surface remains wet for the entire contact time. A review of the EvenCare G2 booklet titled, Healthcare Professional Operators Manual, revised 3/2011, revealed a self-test question which asked, What is the procedure for disinfecting the EvenCare G2 Meter? with an answer of: Clean the meter with a disinfecting wipe. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Allow the surface of the meter to remain wet at room temperature for the contact time/kill time listed on the canister. Then, wipe the meter dry or allow to air dry. The Operator's manual also revealed: Cleaning and disinfecting the meter and lancing device is very important in the prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter and lancing device surface, so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease-causing agents are destroyed on the meter and lancing device surface. Resident #20 A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Resident #47 also received Insulin per sliding scale twice daily. During an observation, on 06/24/19 at 3:35 PM, LPN #3 placed two (2) plastic cups on top of the medication cart with each containing a glucometer. LPN #3 stated, I'm using the plastic cups as barriers, is that alright? LPN #3 was instructed to go by the facility's policies and procedures. LPN #3 stated that he was new, he had been in Florida, and he didn't know if the rules were different. LPN #3 did not clean either glucometer and never voiced that he cleaned the glucometers prior to the testing procedure. LPN #3 entered Resident #20's room, gloved, and performed the finger stick. LPN #3 removed his gloves, exited the room, and placed the glucometer on the medication cart. LPN #3 retrieved Micro-kill bleach wipes out of a container, shrugged his shoulders and asked, How long are you supposed to clean the glucometer? I know in Florida it's different. We had to keep it wrapped for several minutes. I'm not sure of the rule here. LPN #3 was instructed again to go by the facility's policy and procedure of cleaning the glucometer. LPN #3 read the label on the back of the Micro-kill Bleach wipe container, and aloud stated that the contact time was 30 seconds to kill all of the bacteria [MEDICAL CONDITION] listed on the label for the virucidal blood borne pathogens, except one (1) and three (3) minute contact time for other pathogens such as [MEDICAL CONDITION][MEDICATION NAME] and [MEDICATION NAME] mentagrophytes and [MEDICAL CONDITION]. LPN #3 cleaned the contaminated glucometer for approximately 10 seconds (timed by watch), then placed the glucometer back into the same dirty cup. LPN #3 retrieved the [MEDICATION NAME] from the cart, placed it in his un-gloved hands, and entered Resident #20's room. LPN #3 gloved, administered the insulin to Resident #20, removed his gloves and exited the room, all without washing or sanitizing his hands. LPN #3 laid the insulin pen on the cart, without a barrier, opened the cart, and placed the insulin pen inside, without sanitizing the pen. LPN #3, without hand hygiene, proceeded to the next resident. Resident #84 A review of the (MONTH) 2019 MAR indicated [REDACTED]. During an observation on 06/24/19 at 3:45 PM, LPN #3 removed the glucometer from a second cup. He did not clean the glucometer, nor did he voice that he had cleaned it prior to the procedure. LPN #3 went to Resident #84's room door, donned a gown due to isolation set up, then proceeded down the hall to find out why the resident was on isolation. LPN #3 carried the cup/glucometer, not covered, down the hall with him. LPN #3 returned to the Resident's room, still holding the cup/glucometer, entered and crossed over to the B bed, and found the resident wasn't there. LPN #3 stated,Resident #84 is not on isolation, however her roommate is on contact isolation. LPN #3 placed the glucometer/cup back on the medication cart, without cleaning the glucometer or removing the testing strip. LPN #3 did not perform hand hygiene at any time prior, during, or after the procedures. He proceeded to the next resident. Resident #13 A review of the (MONTH) 2019 MAR indicated [REDACTED]. During an observation on 6/24/19, at 3:55 PM, LPN #3 entered Resident #13's room with the glucometer that was previously taken to Resident #84's isolation room. LPN #3 gloved and obtained the resident's blood sugar (BS). LPN #3 exited the room, placed the cup/glucometer on the medication cart, removed his gloves, obtained the Micro-kill Bleach wipes, and wiped the glucometer for approximately nine (9) seconds, and then placed the glucometer back into the same contaminated plastic cup. LPN #3 opened the medication cart and obtained Resident #13's [MEDICATION NAME], entered the resident's room, gloved, and administered the insulin. He removed his gloves, exited the room, opened the medication cart, and placed the insulin pen inside the medication cart, without wiping and/or sanitizing the [MEDICATION NAME]. LPN #3 did not perform hand hygiene prior, during, or after the procedure. He proceeded to another resident and gave oral medications. LPN #3 still had not washed or sanitized his hands between all four (4) of these rooms. LPN #3 Interview: During an interview on 06/24/19 at 4:45 PM, LPN #3 stated, When I come out of a room, I wash the glucometer for 30 seconds. But, I did not know to clean it 30 seconds until you told me to read the Micro-kill bleach wipes and then I saw it. I'm from Florida and we kept the glucometer covered for two (2) minutes. When asked about washing his hands, LPN #3 stated, I didn't wash my hands except me handling the bleach wipes when I cleaned the glucometer. You're right, I don't think I washed my hands in all of the rooms I went into, now that I think about it. When I came back to the cart I didn't wash or sanitize my hands. When asked about the insulin pens, LPN #3 stated he did recall laying the pens on the cart and putting them back in the medication cart without cleaning them. He stated that he was extremely nervous. He stated taking the plastic cup with the glucometer into more than one room, without cleaning it, is an infection control issue. He stated that he should have cleaned the glucometer for the 30 seconds. He stated, But again, I didn't know that until you told me to read the Micro-kill Bleach wipe container. He stated that he had received training on infection control and cleaning the glucometer after he was hired. Review of a facility document, Day Five New Hire Orientation, dated 6/5/19, revealed LPN #3 had received training on infection control bloodborne pathogens and use of Glucose Monitors. Resident #84 During an observation on 06/25/19 at 3:40 PM, LPN #1 placed two (2) plastic cups on a tray on top of the medication cart, with each cup containing a glucometer. LPN #1 gloved and retrieved a Micro-kill Bleach wipe from the cart's bottom drawer. She obtained the glucometer (glucometer #1) and cleaned the glucometer for approximately five (5) seconds (timed by watch). She then placed the glucometer back into the plastic cup. LPN #1 then took glucometer #2 out of the other cup and cleaned it with a Micro-kill wipe for approximately four (4) seconds, then placed the glucometer back into the cup. LPN #1 removed her gloves and took the cup containing glucometer #1 to Resident #84's room. LPN #1 gloved, performed the finger stick, removed her gloves, and exited the room. LPN #1 gloved and retrieved a Micro-kill Bleach wipe from the medication cart and wiped the glucometer approximately seven (7) seconds (timed with watch) and then placed it into a clean cup on the medication cart. LPN #1 did not perform hand hygiene at any time prior, during, or after the procedure. She proceeded to the next resident. Resident #13 (second observation for resident) During an observation on 06/25/19 at 3:49 PM, LPN #1 retrieved glucometer #2, entered Resident #13's room, gloved, and performed the finger stick. LPN #1 placed the glucometer back into the plastic cup, removed her gloves, and exited the room. LPN #1 gloved, obtained a Micro-kill Bleach wipe and cleaned the glucometer for approximately eight (8) seconds (timed by watch). LPN #1 placed the clean glucometer into a clean plastic cup. LPN #1 removed her gloves and obtained the resident's [MEDICATION NAME]. LPN #1 administered the insulin to Resident #13, then placed the insulin [MEDICATION NAME] back into the medication cart drawer, without cleaning/sanitizing the pen. LPN #1 did not perform hand hygiene prior, during, or after the procedure. She proceeded to the next resident. Resident #89 (procedure not performed) A review of the (MONTH) 2019 MAR indicated [REDACTED]. During an observation on 06/25/19 at 3:55 PM, LPN #1 obtained the plastic cup containing glucometer #1, (previously used on Resident #84) entered Resident #89's room, but the resident was not in the room. LPN #1 placed the cup/glucometer on top of the medication cart and covered it with a Kleenex, stating she would leave it there until Resident #89 returned to her room. LPN #1 went to the medication room and returned. She opened the medication box, and obtained a paper cut to her left finger. LPN #1's finger was bleeding and she wiped it with an alcohol wipe. She then placed a band-aid on her finger. LPN #1 still had not performed any type of hand hygiene. Resident #20 (second observation for resident) During an observation on 06/25/19 at 4:05 PM, LPN #1 obtained the glucometer, covered with the Kleenex, and entered Resident #20's room. LPN #3 gloved, performed the finger stick, removed her gloves, and exited the room. LPN #1 took Micro-kill Bleach wipes and cleaned glucometer #1 for approximately 15 seconds (timed with watch), then placed it into a clean plastic cup to dry. LPN #1 stated, I rotate the glucometers to allow one (1) to dry while I use the other one. I've never really timed how long I let it dry, all I know is that it's dry by the time I get ready to use it. LPN #1 failed to perform hand hygiene prior, during, and after the procedure, then continued to the next resident. Resident #89 During an observation on 06/25/19 at 4:20 PM, LPN #1 obtained the cup/glucometer #2, entered Resident #89's room, gloved, and performed the finger stick. LPN #1 removed her gloves, and exited the room. LPN #1 gloved, retrieved a Micro-kill Bleach wipe, and cleaned glucometer #2 for approximately seven (7) seconds (timed with watch), placed glucometer #2 into a clean plastic cup, and removed her gloves. LPN #1 retrieved Resident #89's [MEDICATION NAME] from the medication cart, entered Resident #89's room, performed the injection, removed her gloves, and exited the room. LPN #1 did not perform hand hygiene prior, during, or after the procedures. LPN #1 interview: During an interview, with RN #4 present, on 06/25/19 at 4:35 PM, LPN #1 stated that she washed her hands prior to beginning work on the medication cart. She stated she used a glucometer that had been cleaned with the Micro-kill wipes and air dried. LPN #1 stated, I wipe the glucometer I guess two (2) minutes, but that seems like a long time to me. I don't time it, I just clean it. I can say I thoroughly clean it and set it up-right to dry. She stated she had two (2) glucometers that she used, both cleaned with Micro-kill wipes. She stated she used one glucometer, cleaned it, and returned it to the cart. She stated she donned gloves, used Micro-kill wipes, and cleaned the glucometer for an estimated two (2) minutes, put it up-right in a clean plastic cup. She stated she moved on to the next resident and used the second glucometer for the next resident. She stated she rotated the glucometers, letting them dry. LPN #1 stated that she cleaned each glucometer approximately two (2) minutes between residents, with the Micro-kill Bleach wipes. She stated that she had been in-serviced yearly on infection control and more often for cleaning of the glucometer. When asked if she felt that she cleaned the glucometer for two (2) minutes like she previously stated, LPN #1 stated, No I don't feel like I cleaned it for 1-2 minutes; time passes. When asked if she washed her hands at any time while obtaining the finger stick glucose tests, LPN #1 stated she had forgotten to wash her hands, she usually did, but she was nervous. LPN #1 stated she thought she was doing the correct wiping time, but she didn't time the cleaning of the glucometer. When asked if she thought not cleaning the glucometer per the manufacturer recommendation was an infection control issue, she stated, I do think it was an infection control issue. You have to make sure stuff gets killed. LPN #1 was not observed to use the hand sanitizer at any time during the observations, nor did she voice that she had used the sanitizer. LPN #1 was observed by the surveyor continuously throughout the process of performing the finger sticks of the four (4) residents, Resident #13, #20, #84, and #89, and did not observe any type of hand hygiene prior, during, or after the procedures between residents. A review of a facility document titled, Competency Check List, dated 5/20/19, revealed LPN #1 signed that she was checked off on handwashing and cleaning the glucometer according to manufacturer's guidelines. A facility document titled, Glucometer Cleaning Skills Checklist, dated 5/20/19, revealed LPN #1 was checked off to disinfect the glucometer, by cleaning the meter surface with Medline Micro-kill Bleach Germicidal wipes by the following instructions: Wipe all external areas of the meter, including front and back surfaces, until visibly clean. Avoid wetting the meter strip port. Allow the surface of the meter to remain wet at least 30 seconds at room temperature. Resident #52 Review of the (MONTH) 2019 MAR, revealed Resident #52 received finger stick glucose checks daily, scheduled at 4:30 PM. During an observation on 6/25/19 at 3:40 PM, LPN #2 completed the narcotic medication count and prepared to perform a finger stick procedure. LPN #2 cleaned the glucometer with a Micro Kill germicidal wipe for approximately 10 seconds, then placed it on a tray on the medication cart. She obtained the glucometer, entered Resident #52's room, applied clean gloves, and performed the finger stick. LPN #2 returned to the medication cart and cleaned the glucometer with a Micro Kill germicidal wipe for approximately 10 seconds and allowed it to air dry. LPN #2 did not wash her hands or use any Alcohol Based Hand Gel (ABHG) after counting the narcotic medications, prior to entering the resident's room, before the procedure, during the procedure, after the procedure, or after leaving the resident's room. LPN #2 proceeded to the next resident. Resident #77 Review of the (MONTH) 2019 MAR indicated [REDACTED]. During an observation on 6/25/19 at 3:50 PM, LPN #2 entered Resident #77's room, retrieved some paper towels, and placed the silver tray with the glucometer on the resident's nightstand, on the paper towels. LPN #2 applied clean gloves, cleaned the resident's left middle finger, and performed the glucose testing. She then returned to the medication cart, cleaned the glucometer with a Micro Kill germicidal wipe for approximately eight (8) seconds, and placed it in the medication cart. LPN #2 did not wash her hands or use hand sanitizer prior to entering the resident's room, before the procedure, during the procedure, or after the procedure. During an interview on 6/25/19 at 3:55 PM, LPN #2 stated, related to the procedures she'd performed for Resident #52 and Resident #77, that she had gotten all of her supplies out and wiped everything down. She stated she brought her items into the room, put a barrier down, and wiped the resident's finger with alcohol. She stated she did the fingersticks, wiped the resident's finger again, and wiped everything before she put it in the cart. She stated she cleaned the glucometer with the germicidal wipe for one (1) minute she guessed. She stated she would have to use a timer to know for sure. She stated, I don't know what to tell you anymore. She stated she should wash her hands between residents and/or when her hands were soiled. She stated she didn't understand why she had to wash her hands, since she had used gloves to perform the fingersticks. During an interview on 06/25/19 at 6:09 PM, RN #2/Infection Control Nurse/Risk Management Nurse, stated, If there is a pathogen in the blood, by not cleaning the glucometer, you could pass it on. If there is something that could be considered an infectious process, then you could pass it on. RN #2 stated that nurses are taught to clean the glucometer for 30 seconds, with a five (5) minute dry time. She stated there were two (2) glucometers on the cart so one can be cleaned and let dry, while the other is used. She stated she wasn't going to say there couldn't be a problem by not cleaning the glucometer between residents, because it could very well be. She stated she had provided an in-service recently about infection control, but the nurse's weren't there. She stated that she touched on infection control every six (6) months at a minimum, but if there was an issue, she did the in-service more often. She stated that staff were taught to wash their hands when gloves are removed, because there could be pin-holes in the gloves. During an interview on 06/26/19 at 3:25 PM-3:30 PM, RN #3/ Staff Development Nurse stated, Not cleaning the glucometer could cause an infection to go from person to person. If one (1) person has something, then by not cleaning the glucometer, it could spread. Yes, I see it as an infection control issue. I see it as an opportunity for education because we know better. She stated that hand-washing was an issue for the same reasons and that handwashing was always the best practice. During an interview on 06/25/19 at 6:20 PM, the Director of Nursing (DON) stated that not cleaning the glucometer is an infection control issue, because of the potential for transmitting infections or germs. She stated that it could cause cross-contamination. She stated the recommended time of cleaning the glucometer is 30 seconds, with a dry time of three (3)-five (5) minutes. The DON stated education was provided many times about cleaning the glucometer per manufacturer recommendations, as well as handwashing. She stated if staff were not cleaning the glucometers for the allotted time, to make sure there is no blood or body fluids, cross-contamination could occur. She stated hands should be washed before going into a room, when having contact with a resident, afterwards, and sometimes in-between, depending on the procedure. During an interview, on 06/25/19 at 7:05 PM, the Administrator stated, What is the difference in cleaning the glucometer for 10-11 seconds and 30 seconds? She stated that the glucometer was cleaned, just not the 30 seconds. During an interview on 06/26/19 at 9:08 AM, the Medical Director stated that the glucometer itself should not actually touch any blood; the lancet and the glucometer strip touches the blood. He stated that it was his understanding that they are supposed to wipe the glucometer before and after use. He stated that the Center for Disease Control (CDC) recommended handwashing for 20 seconds, so if the glucometer doesn't touch blood, then 20 seconds cleaning the glucometer should be adequate. He stated, If I walk in a room and my hands are in my pocket and I never take them out of my pocket, then they are not dirty. However, if I do physical activity in that room, then I should wash my hands to prevent the spread of germs. The facility submitted an acceptable Removal Plan on 6/26/19, for the Immediate Jeopardy. Review of the facility's Removal Plan revealed the facility took the following actions to remove the Immediate Jeopardy: Brief Summary: On 6/25/19 at 7:00 PM, CST, the State Agency informed the Administrator and the Director of Nursing of an immediate jeopardy with infection control due to a glucometer not being cleaned for a full 30 seconds, according to the manufacturer's guidelines by LPN #1, LPN #2 and LPN #3 prior/after performing a finger stick blood glucose check, which is a standard of practice. Corrective Actions: 1. On 6/25/19 at 7:30 PM, the Administrator called a mandatory meeting with the nursing staff to notify Immediate Jeopardy had been called. Nurses on duty, including a total of four (4) Licensed Practical Nurses (LPN) and two (2) Registered Nurses (RN) were instructed to clean all eight (8) glucometers (by disinfecting for a full 30 seconds) and perform proper handwashing. LPNs that were currently on the medication cart completed proper handwashing and cleaning of the glucometers. Education was then initiated by the DON to follow current policies on glucometer use and infection control with handwashing. This was completed on 6/25/19, by 10:00 PM. 2. On 6/25/19 at 8:00 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) initiated an in-service, including a skills check-off list, in regards to glucometer infection control protocol, handwashing, and safety by following the manufacturer guidelines for cleaning the glucometers. This included four (4) LPNs and two (2) RNs. 3. On 6/25/19 at 9:15 PM, an Emergency Quality Assurance (QA) meeting was held with the Medical Director, Administrator, DON, ADON, Infection control Officer, Business Office Manager, Housekeeping Supervisor, Laundry Supervisor, Life Enrichment Director, Minimum Data Set (MDS) Nurse Coordinators, Restorative Nurse, Maintenance Director, Admissions/Marketing Nurse, and Food Service Director, to discuss the events after Residents #13, #20, #52, #77, #84, and #89 were exposed to the surface of the glucometer and the importance of following the policy for infection control protocol, handwashing, and safety in regards to the cleaning manufacturer guidelines for the glucometers. The QA committee also reviewed policies on infection control, care planning, manufacturer guidelines for the blood glucose monitoring system/disinfecting bleach wipes, and infection control protocol safety in relation to glucose monitoring systems and proper handwashing with no changes to any of the current policies. 4. On 6/25/19 at 9:00 PM, the Care Plan Coordinator revised all diabetic Care Plans to include the proper cleaning of the glucometer machines for all residents that require blood glucose monitoring. There are currently 24 residents receiving blood glucose monitoring. 5. On 6/25/19 at 8:00 PM, the Infection control Officer initiated an all nursing staff that were currently on duty (total of four (4) LPNs and two (2) RNs) on infection control, care planning, manufacturer guidelines for the blood glucose monitoring system/disinfecting bleach wipes, and infection control/handwashing protocol safety in relation to glucose monitoring systems, which is a nursing Standard of Practice. We currently have 40 Licensed Nursing staff members. 6. On 6/25/19 at 8:15 PM, the Administrator completed a one-on-one (1:1) education with LPN #1, LPN #2, and LPN #3 on cleaning/disinfecting glucometers with emphasis on the 30 second time frame for cleaning/disinfecting as well as handwashing protocols. 7. On 6/25/19 at 8:55 PM, all 24 residents who receive blood glucose finger sticks were assessed for exposure complications by the DON and the ADON, with no complications noted. In addition, the assessments completed of the 24 residents, there were no signs and/or symptoms of any acute infection from blood borne pathogens noted. There are currently no residents receiving blood glucose monitoring with a [DIAGNOSES REDACTED]. 8. No nursing staff will be allowed to work until they have completed this in-service and competency return demonstration, in regards, to proper handwashing and glucometer cleaning/disinfecting by professional standards. The facility alleges that all corrective actions to remove the immediate jeopardy were completed on 6/25/19, and the immediate jeopardy removed as of 6/26/19. The State Agency (SA) validated through observation, interview, and record review, that the facility completed the following actions to remove the IJ: Corrective Actions: 1. The SA validated through interview, that on 6/25/19, the Administrator called a mandatory meeting with the nursing staff and notified them of the Immediate Jeopardy. Nurses on duty, including a total of four (4) Licensed Practical Nurses (LPNs) and two (2) Registered Nurses (RNs) were instructed to clean all eight (8) glucometers (by disinfecting for a full 30 seconds) and perform proper handwashing. LPNs that were currently on the medication cart completed proper handwashing and cleaning of the glucometers. Review of sign-in sheets and staff interview validated that education was initiated by the DON to follow current policies on glucometer use and infection control with handwashing. This was completed on 6/25/19, by 10:00 PM. 2. The SA validated through staff interview, review of skills check offs and sign-in sheets, that on 6/25/19, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) initiated an in-service, including a skills check-off list, in regards to glucometer infection control protocol, handwashing, and safety, by following the manufacturer guidelines for cleaning the glucometers. This included four (4) LPNs and two (2) RNs. 3. The SA validated by review of the sign-in sheet and staff interview, that on 6/25/19, an Emergency Quality Assurance (QA) meeting was held with the Medical Director, Administrator, DON, ADON, Infection control Officer, Business Office Manager, Housekeeping Supervisor, Laundry Supervisor, Life Enrichment Director, Minimum Data Set (MDS) Nurse Coordinators, Restorative Nurse, Maintenance Director, Admissions/Marketing Nurse, and Food Service Director, to discuss the events after Residents #13, #20, #52, #77, #84, and #89 were exposed to the surface of the glucometer, and the importance of following the policy for infection control protocol, handwashing, and safety, in regards to the manufacturer cleaning guidelines for the glucometers. The QA committee also reviewed policies on infection control, care planning, manufacturer guidelines for the blood glucose monitoring system/disinfecting bleach wipes, and infection con (TRUNCATED)

Based on observation, staff interview, record review, review of the Mississippi Board of Nursing Administrative Code, and facility policy review, the facility failed to follow standard precautions of infection control, during the performance of routine finger-stick testing of blood sugars. The facility failed to to clean/disinfect the glucometer, per manufacturer's recommendation of a minimum of 30 seconds wet time, before, and after use, to ensure bloodborne [MEDICAL CONDITION] and bacterial pathogens were killed; and failed to ensure that staff washed their hands before and after performing a blood glucose finger stick, for eight (8) of 13 observations, for six (6) residents who received blood glucose finger sticks, Residents #13, #20, #52, #77, #84 and #89. This practice had the potential and/or likelihood to pose a threat of blood borne cross-contamination between residents who received blood glucose testing. The facility's failure of not following standard precautions for infection control, by not providing handwashing and not disinfecting the glucometer per manufacturer's recommendations between residents, placed these and other residents who receive blood glucose finger sticks (24 total residents) in a situation which caused a likelihood of serious injury, harm, impairment, or death, related to the spread of blood borne pathogens due to cross-contamination with the multi-resident use of the glucometer. The situation was determined to be an Immediate Jeopardy (IJ), which began on 6/25/19, when the facility failed to clean and disinfect the glucometer for the minimum amount of wet time of 30 seconds, prior and after use between residents, per manufacturer's recommendations, to ensure all bacterial/[MEDICAL CONDITION] pathogens were killed. The State Agency (SA) notified the Administrator on 6/25/19, of the IJ. An acceptable Removal Plan was received on 6/26/19, in which the facility alleged all corrective actions were completed on 6/25/19, and the IJ was removed as of 6/26/19. The SA validated the Removal Plan and determined the IJ was removed on 6/26/19, prior to exit. Therefore, the scope and severity for CFR(s): 483.80(a)(1)(2)(4)(e)(f), F880; Infection Prevention and Control, was lowered from a K level to an [NAME] level, while the facility develops and implements a plan of correction and monitors the effectiveness of systemic changes to ensure the facility sustains compliance with the regulatory requirements. The facility also had an infection control issue that did not rise to the IJ level, related to a urinary catheter drainage bag laying on the floor for one (1) of (6) six residents with urinary catheters observed, Resident #57. Findings include: A review of the Mississippi Board of Nursing Position Statement, titled Blood Borne Pathogens, with a revision date of 4/6/2000, revealed the Board had regulations in place to recognize the Centers of Disease Control (CDC) and Prevention Guidelines as the accepted standard of nursing practice, and to require all nurses to practice accordingly. In accordance with the CDC guidelines in the provision of nursing care, all nurses should adhere to standard precautions, including washing of hands, and comply with current guidelines for disinfection and sterilization of re-useable devices. A review of the Centers for Disease Control (CDC) and Prevention guidelines, last updated 6/8/17, regarding shared blood glucose meters, revealed if blood glucose meters were shared, the device should be cleaned and disinfected after every use, per manufacturer instructions, to prevent carry-over of blood and infectious agents. Review of facility policy titled, Infection Control Monitoring, dated (MONTH) (YEAR), revealed: It is the policy of the Center to investigate the cause of infections (nosocomial and community and hospital acquired) and the manner of spread. The objective of our Infection Control Policies are: preventing, identifying, reporting, investigating, and controlling infections and other communicable diseases. It is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of a facility policy titled, Obtaining a Finger stick Glucose Level, dated (MONTH) (YEAR), revealed staff were to maintain a clean barrier, maintain clean technique, follow instructions provided by the manufacturer of the glucose monitoring system to obtain a blood glucose reading, and to wash hands after removing gloves. The policy also stated to clean the glucose monitor with approved disinfectant before and after each resident use. A review of the booklet titled EvenCare G2 blood glucose monitoring system users guide (glucose monitor used by the facility), revised (MONTH) (YEAR), revealed: Wipe all external areas of the meter or lancing device, including both front and back surfaces, until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use. The booklet documented Micro-Kill bleach germicidal wipes were validated as an effective agent to use on the glucometer. A review of the label of the Micro-kill Bleach wipes, revealed: Contact time: Allow surface(s) to remain wet for 30 seconds to kill all of the bacteria [MEDICAL CONDITION] **on the label**(virucidal-including but not limited to [MEDICAL CONDITION]/B/C, Human immunodeficiency virus type I, influenzas, norovirus, and Rotavirus) of the wipes except a one (1) minute contact time is required to kill [MEDICAL CONDITION][MEDICATION NAME] and [MEDICATION NAME] mentagrophytes and a three (3) minute contact time is required to kill [MEDICAL CONDITION] spores. Reapply as necessary to ensure that the surface remains wet for the entire contact time. A review of the EvenCare G2 booklet titled, Healthcare Professional Operators Manual, revised 3/2011, revealed a self-test question which asked, What is the procedure for disinfecting the EvenCare G2 Meter? with an answer of: Clean the meter with a disinfecting wipe. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Allow the surface of the meter to remain wet at room temperature for the contact time/kill time listed on the canister. Then, wipe the meter dry or allow to air dry. The Operator's manual also revealed: Cleaning and disinfecting the meter and lancing device is very important in the prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter and lancing device surface, so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease-causing agents are destroyed on the meter and lancing device surface. Record review of a facility document titled, Order Listing Report, dated 6/25/19, revealed that a total of 24 residents received finger stick blood glucose testing at the facility. Resident #20 A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Resident #47 also received Insulin via [MEDICATION NAME], per sliding scale, twice daily. An observation on 06/24/19 at 3:35 PM, revealed LPN #3 placed two (2) plastic cups on top of the medication cart with each containing a glucometer. LPN #3 turned and stated, I'm using the plastic cups as barriers, is that alright? The LPN was instructed to go by his facility's policies and procedures. LPN #3 stated I'm new here and I came from Florida and the rules are different there. I don't know the rules here yet. LPN #3 did not clean either glucometer and LPN #3 never voiced that he had cleaned the glucometers before starting the testing procedure. LPN #3 entered Resident #20's room, without performing hand hygiene. LPN #3 gloved and set the plastic cup containing the glucometer on the over-bed table. LPN #3 obtained Resident #20's Blood Sugar (BS). LPN #3 put the glucometer back into the same plastic cup. LPN #3 removed his gloves and exited the room, without washing or sanitizing his hands. LPN #3 placed the cup/glucometer back on the medication cart. LPN #3 took Micro-kill bleach wipes out of a container, shrugged his shoulders and asked, How long are you supposed to clean the glucometer? I know in Florida it's different. We had to keep it wrapped for several minutes. I'm not sure of the rule here. LPN #3 was encouraged to go by facility's policy and procedure of cleaning the glucometer and also to look on the back of the Microkill wipes for contact time. LPN #3 read out loud the label on back of the Micro-kill Bleach wipe container, as he pointed with his forefinger, that the contact time was 30 seconds to kill all of the bacteria [MEDICAL CONDITION] listed on the label for the virucidal blood borne pathogens, except one (1) and three (3) minute contact time for other pathogens such as [MEDICAL CONDITION][MEDICATION NAME] and [MEDICATION NAME] mentagrophytes and [MEDICAL CONDITION]. LPN #3 then placed the Micro-kill Bleach wipes back on the medication cart and took the contaminated glucometer out of the cup and cleaned it for approximately 10 seconds (timed by watch). After wiping the glucometer, LPN #3 then placed the glucometer back into the same dirty cup. Without performing hand hygiene, LPN #3 opened the medication cart, pulled out the [MEDICATION NAME][MEDICATION NAME], and laid it on the medication cart, without a barrier. LPN #3 obtained a needle from the cart drawer and applied the needle to the pen. LPN #3 put the insulin pen in his un-gloved hands and entered Resident #20's room. LPN #3 laid the insulin pen on the over-bed table, without a barrier. LPN #3 gloved, administered the insulin to Resident #20, removed his gloves, and exited the room; all without washing or sanitizing his hands. LPN #3 went back to medication cart, laid the insulin pen on the cart, without a barrier, opened the cart, and placed the insulin pen inside, without sanitizing the pen. LPN #3, without hand hygiene, proceeded to the next resident. Resident #84 A review of the (MONTH) 2019 MAR, revealed Resident #84 received finger stick glucose monitoring twice a day, related to [DIAGNOSES REDACTED]. An observation on 06/24/19 at 3:45 PM, revealed LPN #3 removed the glucometer from the second cup. LPN #3 did not clean the glucometer, nor did he voice that he had cleaned it prior to the procedure. LPN #3 placed the glucometer strip into the glucometer, approached Resident #84's room door, and donned a gown due to isolation set up. LPN #3 proceeded down the hall to find out why the resident was on isolation. LPN #3 carried the cup/glucometer with the strip inserted into the glucometer, which were not covered, down the hall with him. LPN #3 returned to the Resident's door, still holding the cup/glucometer, and stated that Resident #84 is not on isolation, however her roommate is on contact isolation. LPN #3 entered the room, crossed over to the B bed area, and found that Resident #84 was not there. LPN #3 placed the glucometer/cup back on the medication cart. LPN #3 did not destroy the strip or clean the glucometer. LPN #3 left the plastic cup/glucometer sitting on the cart and did not wash his hands or perform hand hygiene at any time prior, during, or after the procedures. He proceeded to the next resident. Resident #13 A review of the (MONTH) 2019 MAR indicated [REDACTED]. An observation on 6/24/19, at 3:55 PM, revealed LPN #3 entered Resident #13's room with the glucometer that was previously taken to Resident #84's isolation room. He did not perform hand hygiene, nor clean the glucometer. The glucometer still had the unused strip in the slot. LPN #3 entered Resident #13's room, sat the plastic cup holding the glucometer on the over-bed table, gloved, and obtained the resident's blood sugar (BS). LPN #3 put the contaminated glucometer back into the same plastic cup. LPN #3 picked up the plastic cup, still having his gloves on, walked out into the hall, and placed the cup/glucometer on the medication cart. LPN #3 removed his gloves, obtained the Micro-kill Bleach wipes, and wiped the glucometer for approximately nine (9) seconds, and then placed the glucometer back into the same contaminated plastic cup. LPN #3 opened the medication cart and obtained Resident #13's [MEDICATION NAME][MEDICATION NAME], laid it on top of the cart without a barrier, obtained and applied a needle from the cart, and laid the pen on a sheet of paper (census sheet) that was lying on the cart. LPN #3 picked up the insulin pen and entered the resident's room, laid the insulin pen on the over-bed table without a barrier, and gloved. LPN #3 did not wash or sanitize his hands. LPN #3 administered the insulin, then laid the [MEDICATION NAME] on the over-bed table, without a barrier, and removed his gloves. LPN #3 exited the room, laid the insulin pen on the medication cart without a barrier, opened the medication cart, and placed the insulin pen inside the medication cart, without wiping and/or sanitizing the [MEDICATION NAME]. LPN #3 did not perform hand hygiene prior, during, or after the procedure. He proceeded to administer oral medications to Resident #192, on 06/24/19, at 4:05 PM. During this medication administration, LPN #3 used a spoon to help get the [MEDICATION NAME] pill out of a medication cup and placed it on the pill splitter. LPN #3 then used his un-gloved hands to help balance the pill into the splitter. He administered the medication to the resident. LPN #3 still had not washed or sanitized his hands between all four (4) of these rooms. LPN #3 Interview: During an interview on 06/24/19 at 4:45 PM, LPN #3 revealed his process during the blood glucose testing for Resident's #13, #20, and #84. He stated that he put the glucometer in a cup that was used as a barrier. Then, he checked the blood sugars. LPN #3 stated that when he came out of a room, he put the glucometer back into the same cup, then after he cleaned the glucometer, he again placed it in the same dirty cup. He stated he had always used the same cups over and over. He stated, When I come out of a room, I wash the glucometer for 30 seconds. But, I did not know to clean it 30 seconds until you told me to read the Micro-kill bleach wipes and then I saw it. I'm from Florida and we kept the glucometer covered for two (2) minutes. Now that I think about it, I probably should have put the cup in the garbage can after I used it, but I sat it back on the medication cart and I should have just thrown it away. He stated that he took the same plastic cup into two (2) different rooms. When asked about washing his hands, LPN #3 stated, I didn't wash my hands except me handling the bleach wipes when I cleaned the glucometer. You're right, I don't think I washed my hands in all of the rooms I went into, now that I think about it. When I came back to the cart I didn't wash or sanitize my hands. When asked about touching the pill with his bare hands, LPN #3 stated I didn't realize I touched the pill with my hands. I was using a spoon and maybe I inadvertently touched the pill with my hand and didn't realize it. I was so nervous. You're right. At that point I still had not washed my hands. When asked about the insulin pens, LPN #3 stated he did recall laying the pens on the cart without a barrier and without cleaning them. He stated that he was extremely nervous. He stated, It all was stupid of me. Yes, I do see for sure that not washing my hands and taking the plastic cup with the glucometer into more than one room, without cleaning it, is an infection control issue. I also know that placing the cleaned glucometer into the dirty cup is an infection control issue. I should have cleaned the glucometer for the 30 seconds, but again, I didn't know that until you told me to read the Micro-kill Bleach wipe container. Thank you for explaining it all to me. I could have done better, and I should have done better. I did receive training when I was hired on infection control and cleaning the glucometer. A review of facility document titled Day Five New Hire Orientation, dated 6/5/19, revealed LPN #3 signed that he had received training on infection control bloodborne pathogens and use of Glucose Monitors. Resident #84 An observation on 06/25/19 at 3:40 PM, revealed LPN #1 placed two (2) plastic cups on a tray, that was on top of the medication cart, with each cup containing a glucometer. LPN #1 took one (1) of the glucometers and laid it on a Kleenex on the medication cart. LPN #1 gloved and retrieved a Micro-kill Bleach wipe from bottom drawer on medication cart. LPN #1 picked up the glucometer (glucometer #1) and cleaned the glucometer for approximately five (5) seconds (timed by watch), and then placed it back into the plastic cup. LPN #1 then took glucometer #2 out of the other cup and cleaned it with a Micro-kill wipe for approximately four (4) seconds and placed the glucometer back into the cup. LPN #1 removed her gloves and took the cup containing glucometer #1 to Resident #84's room. LPN #1 gloved, performed the finger stick for Resident #84, and placed the glucometer back into the cup. She removed gloves, and exited the room, all without washing or sanitizing her hands. LPN #1 gloved and retrieved a Micro-kill Bleach wipe from the medication cart and wiped the glucometer approximately seven (7) seconds (timed with watch) and then placed it into a clean cup on the medication cart. LPN #1 removed her gloves and proceeded to the next resident. LPN #1 did not perform hand hygiene at any time prior, during, or after the procedure. Resident #13 (second observation for resident) Observation on 06/25/19 at 3:49 PM, revealed LPN #1 took the plastic cup containing glucometer #2, entered Resident #13's room, gloved, and performed the finger stick. LPN #1 placed the glucometer back into the plastic cup, removed gloves, and exited the room. LPN #1 laid the tray with the cup/glucometer on the medication cart and then gloved. LPN #1 reached into the bottom drawer of the cart and obtained a Micro-kill Bleach wipe and cleaned the glucometer for approximately eight (8) seconds (timed by watch). LPN #1 placed the clean glucometer into a clean plastic cup. LPN #1 removed her gloves, placed the cup/glucometer #2 behind cup/glucometer #1, and obtained the [MEDICATION NAME] Insulin. LPN #1 administered the insulin to Resident #13, then placed the insulin [MEDICATION NAME] back into the medication cart drawer, without cleaning/sanitizing the pen. LPN #1 did not perform hand hygiene prior, during, or after the procedure. She proceeded to the next resident. Resident #89 (first attempt-procedure not performed) A review of the (MONTH) 2019 MAR, revealed Resident #89 received finger stick glucose testing, with sliding scale [MEDICATION NAME] Solution injector twice daily. Observation on 06/25/19 at 3:55 PM, revealed LPN #1 obtained the plastic cup containing glucometer #1, (previously used on Resident #84) to perform the finger stick blood glucose test, but Resident #89 was not in the room. LPN #1 placed the cup/glucometer on top of the medication cart and covered with a Kleenex, stating she would leave it there until Resident #89 returned to her room. LPN #1 went to the medication room for another medication. LPN #1 returned and opened the medication box, and obtained a paper cut to her left finger. LPN #1's finger was bleeding and she wiped it with an alcohol wipe. She then placed a band-aid on her finger. LPN #1 still had not performed hand hygiene. Resident #20 (second observation for resident) Observation on 06/25/19 at 4:05 PM, revealed LPN #1 picked up the tray, which contained the cup/glucometer covered with a Kleenex, and entered Resident #20's room. LPN #3 gloved, performed the finger stick, removed her gloves, and exited the room without washing or sanitizing her hands. LPN #1 took Micro-kill Bleach wipes and cleaned glucometer #1 for approximately 15 seconds (timed with watch) then placed it into a clean plastic cup to dry. LPN #1 sat the cup/glucometer behind the plastic cup containing glucometer #2. LPN #1 stated that she forgot the reading of the resident's BS, so she picked up glucometer #1 with a Kleenex, reviewed the BS, then placed the glucometer back into the same cup. LPN #1 stated, I rotate the glucometers to allow one (1) to dry while I use the other one. I've never really timed how long I let it dry, all I know is that it's dry by the time I get ready to use it. LPN #1 failed to perform hand hygiene prior, during, and after the procedure, then continued to the next resident. Resident #89 (procedure performed) An observation on 06/25/19 at 4:20 PM, revealed LPN #1 obtained the cup/glucometer #2, entered Resident #89's room, gloved, and performed the finger stick. LPN #1 removed her gloves, and exited the room. LPN #1 went to the medication cart, gloved, and retrieved a Micro-kill Bleach wipe from the bottom drawer of the medication cart. LPN #1 cleaned glucometer #2 with Micro-kill Bleach wipes for approximately seven (7) seconds (timed with watch) and then placed glucometer #2 into a clean plastic cup. LPN #1 removed gloves and placed the cup/glucometer #2 behind glucometer #1. LPN #1 retrieved Resident #89's [MEDICATION NAME] from the medication cart and laid it on top of the cart without a barrier. LPN #1 obtained a needle from the med cart and applied it to the [MEDICATION NAME]. LPN #1 entered Resident #89's room, performed the injection, removed her gloves, and exited the room. LPN #1 did not perform hand hygiene prior, during, or after the procedures. LPN #1 interview: During an interview, in the presence of RN #4, on 06/25/19 at 4:35 PM, LPN #1 stated that she washed her hands prior to working the medication cart. She stated her process was to use a Kleenex or a paper towel for a barrier. She stated she used a glucometer that has been cleaned with the Micro-kill wipes and left to air dry. She stated, I wipe the glucometer I guess two (2) minutes, but that seems like a long time to me. I don't time it, I just clean it. I can say I thoroughly clean it and set it up-right to dry. She stated she had two (2) glucometers that she used, both cleaned with Micro-kill wipes, and she placed one in front of the other in plastic cups on top of the cart. She stated she used one glucometer, cleaned it, and returned it to the cart. She stated she donned gloves, used Micro-kill wipes, and cleaned the glucometer for an estimated two (2) minutes, put it up-right in a clean plastic cup, and then place it behind the second glucometer, which had already been cleaned. She stated she moved on to the next resident and used the second glucometer for the next resident. She stated she rotated the glucometers, letting them dry. LPN #1 stated that she cleaned each glucometer approximately two (2) minutes between residents with the Micro-kill Bleach wipes. She stated that she had been in-serviced yearly on infection control and more often for cleaning of the glucometer. She stated that it had been a while, but yes, she had seen policy and procedure on handwashing and infection control. When asked if she felt that she cleaned the glucometer for two (2) minutes like she previously stated, LPN #1 stated, No I don't feel like I cleaned it for 1-2 minutes; time passes. When asked if she washed her hands at any time while obtaining the finger stick glucose tests, LPN #1 stated, Oh man, I forgot to wash my hands. I do it but I'm just nervous. LPN #1 stated Yes I should do different. I want to do it correctly. I thought I was doing the correct time wiping it. I didn't time the cleaning of the glucometer. It's my issue, not the facility's issue. I'm the one that didn't do it correct. I take whole responsibility of self. When asked if she thought not cleaning the glucometer per the manufacturer recommendation was an infection control issue, she stated I do think it was an infection control issue. You have to make sure stuff gets killed. At this time, RN #4 stated, We learned in school that you could use hand sanitizer in-between residents if your hands aren't soiled. RN #4 stated that LPN #1 used hand sanitizer. LPN #1 reached into her pocket and pulled out Germ-x and said Yea, I used Germ-x during procedures. I keep Germ-x in my pocket. LPN #1 was not observed to use the hand sanitizer at any time during the observations, nor did she voice that she had used the sanitizer. LPN #1 was observed by the surveyor continuously throughout the process of performing the finger sticks of the four (4) residents, Resident #13, #20, #84, and #89, and did not observe any type of hand hygiene prior, during, or after the procedures between residents. A review of a facility document titled, Competency Check List, dated 5/20/19, revealed LPN #1 signed that she was checked off on handwashing and cleaning the glucometer according to manufacturer's guidelines. A facility document titled Glucometer Cleaning Skills Checklist dated 5/20/19, revealed LPN #1 was checked off to disinfect the glucometer by cleaning the meter surface with Medline Micro-kill Bleach Germicidal wipes by the following instructions: Wipe all external areas of the meter including front and back surfaces until visibly clean. Avoid wetting the meter strip port. Allow the surface of the meter to remain wet at least 30 seconds at room temperature. A review of a facility document titled, Day Four New Hire Orientation, dated 6/19/18, revealed LPN #1 was in-serviced on Handwashing, Bloodborne Pathogens, use of [MEDICATION NAME], infection control, and use of Glucose Monitors. Review of a facility document titled, In-Service Training Record, dated 2/13/19, revealed LPN #1 was in-serviced on Cleaning Blood Glucose (CBG's) cleaning the machine storage and other usage. Resident #52 Review of the (MONTH) 2019 MAR, revealed Resident #52 received finger stick glucose checks daily, scheduled at 4:30 PM. On 6/25/19 at 3:40 PM, after LPN #2 had completed the narcotic medication count, she prepared to perform a finger stick procedure. LPN #2 cleaned a silver tray with a Micro Kill germicidal bleach wipe and cleaned the glucometer with a Micro Kill germicidal wipe for approximately 10 seconds. After cleaning the glucometer, she placed the glucometer on the silver tray and allowed it to air dry. She entered Resident #52's room, applied clean gloves, cleaned the resident's left index finger with an alcohol prep pad and pricked the resident's finger with the lancet. She cleaned the resident's left index finger again with an alcohol prep pad. She placed the soiled lancet in a plastic cup and the alcohol prep pad in another plastic cup. LPN #2 returned to the medication cart, where she discarded the lancet and alcohol prep pad. She cleaned the glucometer with a Micro Kill germicidal wipe for approximately 10 seconds and allowed it to air dry. LPN #2 sat the glucometer on the silver tray. LPN #2 did not wash her hands or use any Alcohol Based Hand Gel (ABHG) after counting the narcotic medications, prior to entering the resident's room, before the procedure, during the procedure, after the procedure, nor after leaving the resident's room. She proceeded to the next resident. Resident #77 Resident #77's (MONTH) 2019 MAR indicated [REDACTED]. On 6/25/19 at 3:50 PM, observation revealed LPN #2 entered Resident #77's room, retrieved some paper towels, and placed the silver tray with the glucometer on the resident's nightstand on the towels. She applied clean gloves, cleaned the resident's left middle finger with an alcohol prep pad, pricked his left middle finger with the lancet, and performed the glucose testing. She placed the soiled lancet in a plastic cup, and the soiled alcohol prep pad in a plastic cup. She walked back to the medication cart and disposed of the soiled items. She then cleaned the glucometer with a Micro Kill germicidal wipe for approximately eight (8) seconds, and placed it in the medication cart's uppermost top right drawer in an empty alcohol prep pad box. She cleaned the silver tray with the Micro Kill germicidal wipe. LPN #2 did not wash her hands or use hand sanitizer prior to entering the resident's room, before the procedure, during the procedure, nor after the procedure. On 6/25/19 at 3:55 PM, interview with LPN #2 revealed her overview of the steps she had taken while performing the fingersticks on both Resident #52 and Resident #77. She stated she had gotten all of her supplies out and wiped everything down. She stated she brought her items into the room, put a barrier down, and wiped the resident's finger with alcohol. She stated she did the fingerstick, wiped the resident's finger again, and wiped everything before she put it in the cart. She stated she should clean the glucometer with the germicidal wipe for one (1) minute she guessed. She stated she would have to take a timer out and physically set it to know. She stated I don't know what to tell you anymore. She stated she knows about hand washing, but she had worn gloves. She stated she should wash her hands between residents and/or when her hands are soiled. She stated, Wash your hands before care, well, I mean if you wear gloves to do an accucheck, I don't understand, I really don't. An interview on 06/25/19 at 6:09 PM, with RN #2, Infection Control Nurse/Risk Management Nurse, revealed, If there is a pathogen in the blood, by not cleaning the glucometer, you could pass it on. If there is something that could be considered an infectious process, then you could pass it on. RN #2 stated that nurses are taught to clean the glucometer for 30 seconds, with a five (5) minute dry time. She stated there were two (2) glucometers on the cart so one can be cleaned and let dry, while the other is used. She stated, I'm not going to say that it couldn't be a problem not cleaning the glucometer between residents, because it could very well be. I'd be crazy to say it wouldn't. She stated that there had just been an in-service on hand-washing, with the Certified Nursing Assistants (CNA's), but not the nurses; they would be next. She stated that she touched on infection control every six (6) months at a minimum, but if there was an issue, she did the in-service more often. She stated, As a matter of fact, I just did an in-service the other day on infection control. She stated that staff was taught to wash their hands when gloves are removed, because there could be pin-holes in the gloves. She stated that having Germ-x in a pocket is an infection control issue. She stated, You don't put anything in your pockets. An interview on 06/26/19 at 3:25 PM-3:30 PM, with RN #3, Staff Development Nurse, revealed, Not cleaning the glucometer could cause an infection to go from person to person. If one (1) person has something, then by not cleaning the glucometer, it could spread. Yes, I see it as an infection control issue. I see it as an opportunity for education because we know better. She stated that hand-washing was an issue for the same reasons. She stated, Spreading germs from one to another is an issue. Safe hand washing is best practice. During an interview on 06/25/19 at 6:20 PM, the Director of Nursing (DON) stated, Yes ma'am, not cleaning the glucometer is an infection control issue. There is the potential for transmitting infections or germs. It could cause cross contamination. She stated the recommended time of cleaning the glucometer is 30 seconds, with a dry time of three (3)-five (5) minutes. The DON stated that was taught in in-services many, many times. She stated, It is an infection control issue for a nurse not to wash her hands between caring for residents, because it could spread infection. She stated if staff are not cleaning the glucometer for the allotted time, to make sure there is no blood or body fluids, that could cause cross contamination. The DON stated, I can tell you, if you have anything in your pocket and you take it out, then yes, it could be a potential infection control issue, because your pocket is considered dirty. She stated that staff are taught to wash their hands when going into a room to perform a procedure, prior to gloving, and after you finish the procedure you remove your gloves and wash your hands. She stated, You wash your hands before

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure Resident #10 was free of accidents. This was for one (1) of 21 residents reviewed out of a sample of 21, which resulted in Resident #10 sustaining 2nd degree burns to her thigh from hot coffee served from the Snack Shack (Resident #10). Findings include: Resident #10 Review of the facility's "EXCEPTION REPORT" dated 8/20/13 at 1915 (7:15 p.m.) revealed, "Description of the event: Resident spilled coffee on her right leg." "Location of the event: (this was left blank)." "Affected Individual's comments: I was trying to get coffee and spilled it." Review of a written statement signed by Certified Nursing Assistant (CNA) #1, signed 8/20/13, revealed "(Resident #10) asked me if I could make her a cup of coffee. I went into the snack room & put her sugar in the cup. There was not coffee in the pot. (Resident #10) asked me if I could make a new pot of coffee I told her I did not know how to make a new pot & for her to step out & I would go get someone who knew how. I closed the door behind me. About 5-10 minutes later I hear someone yelling & that is when I found (Resident #10) in the snack room with Hot coffee all over her." Interview with CNA #1 on 9/27/13 at 3:55 p.m. revealed, "She (Resident #10) wanted coffee so I went in there (Snack Shack) and there wasn't any. So I exited (Snack Shack) and closed the door behind me, to get someone to help me make some (coffee). I heard a holler and she (Resident #10) was in the room (Snack Shack) in her wheelchair and had spilled hot water on herself from trying to make the coffee herself. I don't know how she got in the door." Interview with Resident #10 on 9/25/13 at 12:10 p.m., revealed "I was showing them how to make it. I still don't understand how it happened. I know I wasn't suppose to be there, but I volunteered to show this little girl how to make coffee. It was just a stupid accident." Resident #10 stated two (2) CNAs were present at the time of the incident. Resident #10 was able to recall the brand of coffee maker that was located in the snack area. Observation on 9/25/13 at 12:10 p.m. with the Wound Care Nurse revealed a wound to Resident #10's right thigh with a reddened area which measured 16.2 centimeters (cm) X 18 cm with an open area 2 cm X 4 cm to inner thigh area. Area was cleaned with normal saline. Hydrogel was applied and wrapped with gauze and ace wrap. Review of Resident #10's medical record, revealed a note signed by the Nurse Practitioner which was dated 8/21/13. This note revealed, "History: Pt (patient) c (with) burn top of R (right) thigh approx (approximate) 6-8" (six to eight inches) X 4-6" (four to six inches) from spilling hot liquid on her. Pt with 2 (two) lg (large) fluid filled blisters now. Assessment/Plan: Burn II (second degree) R thigh." Observation of the "Snack Shack" on 9/25/13 at 3:10 p.m. revealed the (brand) coffee maker on countertop was the same brand that Resident #10 had recalled. A canister of coffee was on the countertop. The temperature of the coffee was tested at 160 degrees Fahrenheit. The door to the "Snack Shack" had a combination lock on the outside. Interview with Nursing Home Administrator during the tour confirmed that all staff are aware of the combination on the door. Review of a statement provided by the Nursing Home Administrator, dated September 25, 2013 revealed, "Ocean Springs Nursing Center does not have a policy on the monitoring of temperatures for hot beverages." Interview with the Nursing Home Administrator (NHA) on 9/26/13 at 4:05 p.m. revealed, "This was a situation in which the resident (Resident #10) was independent. The room (Snack Shack) is off limits because it needs to be. I believe we should be cited because our staff did not make sure the door was closed, evidently." Record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/8/13, revealed a Brief Interview for Mental Status (BIMS) score of 9 (nine), which indicated Resident #10 had moderate impairment in daily decision making skills. On this MDS Resident #10 was coded to require setup assist with eating. Review of Resident #10's care plans revealed, "Observed to have poor judgment at times" with an initiation date of 12/31/10. Interview with the Nurse Practitioner on 9/27/13 at 10:15 a.m. revealed, "I saw the report, went to see her, and I was surprised at the size of it (burn). I spoke with (Physician). It is 2nd degree burns in part of it. They were good size blisters. No sign of infection. It is healing. It looks better every time." Interview on 9/27/13 at 10:20 a.m. with Physician revealed, "I really haven't seen it. The nurse practitioner has been taking care of it. I was notified. If there is a concern, from the nurse practitioner, she calls and talks to me. I understand it is a second degree burn. I understand it is an uncomplicated burn." Review of the facility's policy entitled "Accidents and Incidents" did not address locking the Snack Shack door. The Nursing Home Administrator provided a letter, dated September 25, 2013, which revealed "The facility does not have a policy on the serving of hot beverages."

Based on staff interview, record review and facility policy review, the facility failed to develop care plan interventions to address identified safety awareness problems for one (1) of twenty-one (21) residents reviewed which resulted in Resident #10 sustaining 2nd [MEDICAL CONDITION] the right thigh from hot coffee (Resident #10). Findings include: Resident #10 Review of the facility's policy entitled "Care Plan-Comprehensive", dated [DATE], revealed "A comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident." Review of Resident #10's care plans revealed, "POTENTIAL FOR MEMORY IMPAIRMENT R/T HX (HISTORY) OF INCREASED CONFUSION, DIFFICULTY WORD FINDING, DECREASED SAFETY AWARENESS R/T DX (DIAGNOSIS) [MEDICAL CONDITION] R/T HX OF STM (SHORT TERM MEMORY) AEB (AS EVIDENCED BY) UNABLE TO RECALL 3 WORDS AEB: RESIDENT C/O (COMPLAINTS OF) OF RECENT MEMORY LOSS. OBSERVED TO HAVE POOR JUDGEMENT AT TIMES.(date initiated 12/31/10)." There were no interventions to address the identified problems of decreased safety awareness or poor judgment. Record review revealed the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/8/13, had a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #10 had moderate impairment in daily decision making skills. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with the Director of Nurses (DON) on 9/27/13 at 10:10 a.m., revealed "I don't see it here. We really don't have an intervention for decreased safety and awareness. Nothing but observing for it, but we are not doing anything to address it." Interview with Licensed Practical Nurse (LPN) #1 on 9/27/13 at 2:10 p.m. confirmed that there were no interventions to address Resident #10's identified problem of poor judgment or poor safety awareness.