Every finding on record at The Pillars of Biloxi

Based on interview, record review, and facility policy review, the facility failed to ensure residents received care and services in accordance with physician orders and professional standards of nursing practice for two (2) of three (3) residents reviewed, as evidenced by the facility did not discontinue narcotic medication as ordered and continued administration for four (4) days after discontinuation for Resident #2 and did not timely implement a newly ordered antibiotic following hospital return for Resident #1, resulting in a five (5) day delay in treatment for a urinary tract infection (UTI). Findings include: A review of the facility's Physician Order Policy, with a revision date of 1/20/2026 revealed .To ensure that residents' medication and treatments are ordered by a licensed physician or other licensed health care professional as permitted by state law. Procedure: Physician orders are carried out.Physician orders are to be recorded in the medical record for each resident.Each order should have the month, day, year and time of receipt.A review of the facility's Medication Administration - General Guidelines Policy and Procedure revised 10/09/2025, revealed .Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.c. Eight Rights - Right resident, right drug, right dose, right route, right time, right reason, right documentation.Resident #2A record review of the Order Entry, dated 12/17/25, revealed Resident #2 had a new order for Oxycodone-Acetaminophen Oral Tablet 5-325 Milligrams (MG) to give one (1) tablet by mouth every 6 hours and discontinue Norco (Hydrocodone-Acetaminophen) 10/325 MG (milligrams) when Oxycodone-Acetaminophen tablets come available. A record review of the Order Summary Report with active orders as of 12/29/25 revealed Resident #2 had a Physician's Order, dated 5/2/25 for Hydrocodone-Acetaminophen 10-325 mg (1) table four times a day for pain and an order for Oxycodone-Acetaminophen 5-325 mg, dated 12/16/25, (1) tablet every six (6) hours. A record review of the Medication Administration Record (MAR) for December 2025, revealed both medications Oxycodone-Acetaminophen 5-325 mg and Hydrocodone-Acetaminophen 10-325 mg was administered to Resident #2 from 12/26/25 through 12/29/25. In a record review of the Controlled Drug Receipt/Record/Disposition Form revealed, Oxycodone-Acetaminophen Oral Tablet 5-325 Milligrams (MG) to give (1) tablet by mouth every (6) hours were delivered to the facility on [DATE] at 8:00 AM, signed out and administered to Resident #2. On 12/26/25 at 6:00 AM Hydrocodone/APAP (Acetaminophen) was signed and given to Resident #2. On 2/23/26 at 10:00 AM, during an interview with License Practical Nurse (LPN) #2, revealed on 12/17/25 the Medical Provider provide new orders for Resident #2 to receive Oxycodone-Acetaminophen Oral Tablet 5-325 (MG) to give (1) tablet by mouth every 6 hours and when the facility received the medication, they were to discontinue the Hydrocodone/APAP (Acetaminophen), upon the facility receiving the medication. On 12/26/25 the facility received the medication, according to the Controlled Drug Receipt/Record/Disposition Form but the staff continue to give both medications from 12/26/25 through 12/29/25. A record review of the admission Record revealed the facility admitted Resident #2 on 6/4/25 with his diagnoses including Intervertebral Disc Degeneration, Lumbar Region without Mention of Lumbar Back Pain or Lower Extremity Pain.A record review of the Quarterly Minimum Data Set (MDS) with and an Assessment Reference Date (ARD) of 2/5/26 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated his cognition was moderately impaired. Resident# 1A record review of a Progress Note, dated 12/24/25 at 1:15 PM, revealed Resident #1 was transferred to a local hospital for pupils non-reactive, left pupil larger than right, and feels hot to touch. A record review of a Progress Note, dated 12/24/26 at 8:30 PM, revealed Resident #1 returned to the facility on medication for UTI. A record review of the local emergency room After Visit Summary, dated 12/24/25, revealed Resident #1 transferred back to the facility for UTI with medications to START taking listed as nitrofurantoin (Macrobid). A record review of the Order Summary Report revealed Resident #1 had a Physician's Order, dated 12/29/25 with a start date of 12/30/29 for Macrobid 100 (MG) per percutaneous endoscopic gastrostomy (PEG) tube two times a day for infection UTI. The order was clarified on 12/30/25 with a start date of 12/30/25 and an end date of 1/9/25 to take the antibiotic medication for (10) days.A record review of the MAR for Resident #1 revealed that Macrobid Oral Capsule was not administered until 12/29/25, which was (5) days after the order was received on 12/24/25. A record review of the admission Record revealed the facility admitted Resident #1 on 10/22/24 and her diagnoses included Anoxic Brain Damage.A record review of the Quarterly (MDS) with an (ARD) of 1/22/26 revealed Resident #1 was comatose and in a persistent vegetative state/no discernible consciousness. On 2/23/26 at 10:40 AM, during an interview with the Director of Nursing (DON), she confirmed that on 12/24/25 Resident #1 was sent to the local hospital for symptoms consistent with a UTI. The resident returned to the facility later that evening with new physician orders to initiate Macrobid twice daily. The DON confirmed the facility failed to implement the new antibiotic order upon the resident's return. She stated the order was missed during the readmission process and the Macrobid was not initiated until 12/29/25. The DON acknowledged this was not in accordance with facility policy or professional standards of practice, which require timely transcription and implementation of all new physician orders upon a resident's return from the hospital. She further confirmed the delay should not have occurred and stated the expectation is that discharge orders are reviewed, reconciled, and initiated immediately upon return to the facility. The DON reported the issue was identified during a subsequent chart review and corrective education was provided to the nursing staff regarding proper hospital return reconciliation procedures. Additionally, during the interview, the DON reviewed record findings related to Resident #2 those new orders dated 12/17/25, Oxycodone-Acetaminophen Oral Tablet 5-325 Milligrams (MG) to give 1 tablet by mouth every 6 hours and discontinue Norco (Hydrocodone-Acetaminophen) 10/325 MG when Oxycodone-Acetaminophen tablets when the Oxycodone-Acetaminophen becomes available. According to Pharmacy the Oxycodone-Acetaminophen did not became available or delivered to the facility until 12/26/25, at that time, the nurse should have discontinue the Hydrocodone-Acetaminophen 10/300 mg. On 12/26/25 the nursing staff did not discontinue the Hydrocodone-Acetaminophen as directed. Resident #2 was receiving both medications on 12/26/25, 12/27/25, 12/28/25, and 12/29/25. She revealed that according to the Controlled Drug Receipt/Record/Disposition Form revealed nursing staff continued to sign out and document administration of Hydrocodone/APAP 10/325 mg four times daily from 12/26/25 through 12/29/25 despite the discontinuation order. The DON acknowledged the medication should not have been administered after the discontinuation date and confirmed this was not consistent with facility policy or accepted standards of medication administration. She confirmed the expectation from her staff is that discontinued medications are immediately removed from active MARs and reconciled with controlled substance records to prevent continued administration.On 2/23/26 at 2:00 PM, during an interview with Registered Nurse (RN) #2, she confirmed that she administered both narcotic medications to Resident #2 because both were active and listed on the Medication Administration Record (MAR). She stated she did not question the duplicate opioid orders at the time of administration and assumed the medications were intended to be given as documented. RN #2 acknowledged that she did not verify whether the Hydrocodone-Acetaminophen had been discontinued upon receipt of the new Oxycodone-Acetaminophen order and confirmed she did not notify the charge nurse, pharmacy, or the DON regarding the duplicate narcotic therapy.

Based on interview, record review, and facility policy review, the facility failed to ensure nursing services were provided by qualified and licensed personnel when a graduate practical nurse (GPN) continued to function in the capacity of a licensed nurse for approximately five and one-half (5 1/2) days after receiving notification of failure of the National Council Licensure Examination (NCLEX) nursing exam for one (1) of three (3) facility nursing staff reviewed.Findings include: A review of the facility's policy Compliance and Ethics - Risk Areas for Fraud and Abuse, revised [DATE], revealed .Resident Quality of Care.2. A. Sufficient staffing - staffing is provided in sufficient numbers and with staff who have appropriate clinical training, licensure and/or expertise to meet the needs of residents. A record review Board of Nursing License Verification for GPN #1 revealed she had a License Type of LPN (License Practical Nurse) Temporary Permit that was issued on [DATE] and expired on [DATE]. A record review of the NCLEX-Practical Nurse (PN) Candidate Report, test date [DATE], results revealed GPN #1 had not passed the exam. A record review of the Board of Nursing website ww.msbn.ms.gov/licensure/applications-and-forms revealed Temporary Permits for New Graduates indicated .if the new graduate fails NCLEX, the temporary permit becomes invalid and the new graduate is no longer able to work off the temporary permit.A record review of the facility's Personnel Action Notice (PAN), dated [DATE], Graduate Practical Nurse (GPN) #1 was terminated on [DATE], due to did not pass state boards.A record review of the facility's Employee Time Cards revealed GPN #1 punched in on [DATE] at 6:50 AM and punched out on 7:16 PM, on [DATE] at 6:55 AM and punched out on 7:17 PM, punched in on [DATE] at 6:53 AM and punched out on 7:21 PM, punched in on [DATE] at 6:50 AM and punched out on 7:22 PM, punched in on [DATE] at 6:55 AM and punched out on 7:13 PM, and punched in on [DATE] at 6:52 AM and punched out on 11:07 AM.A review of GPN #1 staffing schedules and assignment sheets revealed GPN #1 was assigned a full resident assignment during the period [DATE] through [DATE] and functioned in the capacity of a licensed nurse. On [DATE] at 2:00 PM, during an interview with GPN #1, she confirmed that she was notified by the State Board of Nursing and issued a temporary graduate permit on [DATE], with an expiration date of [DATE]. She stated she took the NCLEX-PN on [DATE] and received notification from the State Board of Nursing on [DATE] that she did not pass the examination. GPN#1 confirmed she continued working as a licensed nurse at the facility after [DATE] despite receiving notice of the failed examination. She stated she believed she could continue practicing under the temporary permit until its expiration date of [DATE]. She acknowledged she did not verify with the State Board of Nursing whether the permit remained valid after failing the exam, nor did she notify facility administration of the failed examination results. She confirmed that between [DATE] and [DATE] she continued to function in the role of a licensed nurse, including administering medications, performing treatments, and documenting in the medical recordOn [DATE] at 2:30 PM, during an interview, the Director of Nursing (DON) confirmed she was not aware that GPN #1 failed the NCLEX examination on [DATE]. The DON stated she believed the temporary permit remained valid through [DATE]. She acknowledged the facility did not have a system in place to verify examination results with the State Board of Nursing and relied on the nurse to self-report results. The DON confirmed that had she been aware of the failed examination, GPN #1 would have been immediately removed from the schedule, as practicing without a valid license or permit is not permitted under State law or facility policy. She further confirmed that during the period following the exam failure, GPN #1 continued to administer medications, perform treatments, and document in residents' medical records. The DON stated that upon learning of the failure, she assessed residents assigned to GPN #1 and identified no adverse outcomes.

Based on observation, staff interview, record review and facility policy review, the facility failed to prevent the possible spread of infection, as evidenced by, failure to follow proper hand hygiene for Resident #26 and by placing soiled linen directly onto the floor for two (2) of four (4) days of survey.Findings include:A review of the facility's policy, Handwashing/Hand Hygiene, revised June 2010, revealed . This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water . n. Before and after assisting a resident with toileting . r. after handling soiled or used linens .A review of the facility's policy, Infection Control Program, reviewed 7/16/22, revealed, .Purpose.Decrease the risk of infection for residents and staff.On 8/18/25 at 10:06 AM, during an observation walking in the hallway with the facility's Licensed Social Worker (LSW), Registered Nurse (RN) #2 provided incontinent care for Resident #26. RN #2 cleaned the resident's buttocks, placed soiled linens in a clear plastic bag, applied a clean brief, and assisted the resident with dressing and covering with bed linens, while wearing the same gloves used to clean the resident. On 8/18/25 at 10:09 AM, during an interview, the LSW confirmed RN #2 did not change gloves or perform hand hygiene after cleaning the resident. The LSW stated this was an infection control issue that should be addressed.On 8/18/25 at 10:26 AM, during an interview, RN #2 confirmed she failed to change gloves or wash her hands after cleansing loose stool. She stated she was focused on cleaning the resident and acknowledged that placing clean linens and clothing while wearing soiled gloves could cause the spread of infection.On 8/18/25 at 10:57 AM, during an interview, the Director of Nursing (DON) stated RN #2 should have changed gloves and washed her hands after cleaning stool from Resident #26. The DON confirmed not changing gloves could spread infection. On 8/20/25 at 10:10 AM, during an observation and interview while walking in the hallway, CNA #5 exited room [ROOM NUMBER], and there was soiled linen placed directly on the floor visible from the hallway, CNA #5 explained she did not bring a bag into the room and admitted she should have placed the linen in a soiled linen bag and transported it directly to the soiled linen room. She acknowledged placing soiled linen on the floor could spread infection.On 8/21/25 at 10:50 AM, during an interview, RN #1 stated CNA #5 had told her about placing soiled linen on the floor. RN #1 confirmed staff were in-serviced on infection control procedures, including bagging soiled linen immediately.On 8/21/25 at 4:44 PM, during an interview, the Administrator stated she expected staff to follow the facility's infection control policies at all times.A record review of the admission Record revealed the facility admitted Resident #26 on 8/6/25 with diagnoses including Chronic Obstructive Pulmonary Disease.A record review of the Comprehensive admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/13/25 revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated his cognition was moderately impaired.

Based on observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADL) care to ensure a resident was kept clean after episodes of incontinence, as evidenced by staff requiring multiple wipes to remove dark residue from the groin area during incontinent care for one (1) of 29 sampled residents, Resident #74.Findings include: On 8/19/25 at 3:35 PM, during an observation and interview, Certified Nurse Aide (CNA) #3, reported that Resident #74 was always incontinent of bowel and bladder and dependent on staff for ADL care, including personal hygiene. During incontinence care with CNAs #2 and #3, Resident #74's groin area required extensive cleaning, with multiple wipes showing brown and black discoloration before the skin was clean. CNA #3 confirmed this was not bowel movement but an accumulation of dirt and residue, commenting the resident had not been adequately cleaned prior to their providing this care. On 8/19/25 at 4:00 PM, during an interview, the Director of Nursing (DON) reported she expected all residents to be properly cleaned after each incontinence episode and not left with soiled or dirty skin. She confirmed care must be provided until the washcloths are clean and no residue remains.On 8/19/25 at 5:00 PM, during a phone interview, CNA #4, who had been assigned to Resident #74 earlier in the day, stated she last changed the resident around 3:00 PM. She reported the resident had not had a bowel movement at that time but had earlier in the day. She explained the resident did not receive a shower that day, as his scheduled showers were on Monday, Wednesday, and Friday.On 8/21/25 at 10:02 AM, during a phone interview with the resident's Resident Representative (RR), she reported she visited every Saturday, and the resident himself had reported the staff did not clean him properly. She noted that his cleanliness varied depending on which aide was assigned.On 8/21/25 at 10:30 AM, during an interview with Resident #74, the resident confirmed his sister visited every weekend. He reported that aides did not always clean him thoroughly, stating some of them go too fast when providing hygiene care.A record review of the admission Record revealed the facility admitted Resident #74 on 4/28/20 with diagnoses including Cerebral Infarction.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/25 revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated his cognition was moderately impaired. A review of Section GG revealed he was dependent on staff for toileting, hygiene care, and showering.

Based on observation, interview, and facility policy review, the facility failed to ensure food items were properly stored, dated, and labeled in the dry goods room, freezer, and cooler for one (1) of two (2) kitchen observations. Findings include:A review of the facility's policy, Food Storage, dated 8/18/2011, revealed . It is the policy of this facility that food storage areas be maintained in a clean, safe, and sanitary manner. Procedure.2. All food not requiring refrigeration shall be stored above the floor . 8. All food stored in refrigerators and freezers that have been opened, will be covered and labeled with the date and name of the food . 11. All condiments that have been opened should be refrigerated and discarded after 30 days .On 8/18/25 at 9:25 AM, during an observation of the kitchen and interview with the Dietary Manager (DM), in the dry goods room, a broken scoop was stored inside the cornmeal, plastic cups were stored directly on the floor, a 16- pound container of cream cheese icing was observed with no opened date and the lid not secured, and an opened bag of Raisin Bran cereal was noted to be repackaged but undated. In Freezer #1, two (2) boxes of frozen cookie dough were opened and left exposed without repackaging or dating. Additional improperly stored items included opened fish patties, Tony's pizza, and corn on the cob, all found exposed without adequate packaging or labeling. In Cooler #2, an opened package of muffins was observed exposed, not repackaged, and undated. The DM acknowledged the findings and confirmed the observed food storage practices were not in accordance with facility policy. He stated facility policy required staff to repackage, and date opened food products, and for frozen foods to be securely closed in their packaging.On 8/21/25 at 3:58 PM, during an interview, the Administrator stated her expectation was that kitchen and dietary staff follow facility policies related to food storage in the refrigerator, freezer, and dry goods room.

Based on record review, interviews, and facility policy review, the facility failed to resolve a grievance in a timely manner for one (1) of (29) sampled residents (Resident #59). Specifically, the facility failed to replace a broken tablet reported on 5/29/25 until nearly three (3) months later, which did not ensure timely grievance resolution in accordance with facility policy.Findings include:A review of the facility's policy, Grievances, Complaints, Recording and Investigating, dated 7/24/23, revealed, .All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance.Policy Interpretation and Implementation.7. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation.within 5 working days of the filing of the grievance or complaint .On 8/18/25 at 11:14 AM, during an interview, Resident #59 stated a staff member knocked her tablet off of a surface and broke it. She stated the facility was to replace the device, but nothing had been done.A record review of the admission Record revealed the facility admitted Resident #59 on 11/15/24 with diagnoses including Chronic Obstructive Pulmonary Disease.A record review of Resident #59's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact.A record review of the Monthly Grievance/Concern Log for May 2025 revealed a grievance was recorded on 5/29/25 for Resident #59 indicating tablet broken accidentally. The Resolution section stated, unable to repair, unable to confirm staff responsibility, and indicated the complainant was notified on 6/2/25.A record review of an Order Summary, dated 8/18/25, revealed the facility ordered a replacement tablet scheduled to arrive on 8/22/25, almost three (3) months after the grievance was filed.On 8/20/25 at 11:51 AM, during an interview, the Licensed Social Worker (LSW) stated Resident #59's smart tablet had been accidentally broken by a staff member. She reported the facility attempted to have it repaired locally but was told it would be too costly and would be easier to replace. She explained she did not interview other staff members because the resident was cognitively intact and had provided the information. On 8/20/25 at 12:06 PM, during an interview, the Administrator stated she was aware of the broken tablet and confirmed it would be cheaper to replace rather than repair. She explained she was waiting for the facility's petty cash card to be loaded before ordering the device. She reported that a new tablet was ordered on 8/18/25 but she had not yet notified the resident. She confirmed the replacement was delayed for nearly three (3) months after the grievance was originally filed.

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 recurrence of previously cited deficiencies, specifically, the facility was cited for failing to ensure residents received proper hygiene care for residents dependent on staff and failed to ensure the proper storage of food during an annual recertification survey on 04/04/2024 and was cited again for the same deficiencies during the current recertification survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for two (2) of eight (8) deficiencies cited. F677 and F812.Findings Include:A review of the facility's policy, Quality Assessment and Performance Improvement (undated), revealed . The facility will implement and maintain a Quality Assessment and Performance Improvement program. Overview: The Quality Assurance and Performance Improvement (QAPI) committee will implement a process that is ongoing, multi-level, and facility wide . The primary purpose of the committee is to identify and analyze actual or potential quality issues, develop and implement appropriate plans to improve performance, to address identified quality issues, and monitor the effectiveness of implemented changes. The committee will make any needed revisions to performance improvement plans .Record review of the Provider History Report revealed the facility received a citation for F677- ADL Care provided for Dependent Residents and F812- Food Procurement, Store/ Prepare/ Service-Sanitary. Record review of the 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 04/04/2024, revealed the facility received a citation for F677, . Based on observation, interviews, record review, and the facility policy review, the facility failed to provide Activities of Daily Living (ADL) care . for residents who require assistance for two (2) of three (3) residents . and for F812, . Based on observation, staff interview, and facility policy review, the facility failed to store food in accordance with professional standards .During the current recertification survey, the facility failed to provide adequate ADL care to ensure a resident was kept clean after episodes of incontinence, as evidenced by staff requiring multiple wipes to remove dark residue from the groin area during incontinent care for one (1) of 29 sampled residents and failed to ensure food items were properly stored, dated, and labeled in the dry goods room, freezer, and cooler for one (1) of two (2) kitchen observations.On 8/21/25 at 4:00 PM, during an interview with the Administrator, she explained that the facility discusses areas of high concern in QAPI meetings and works in good faith to correct problems. She stated that during these meetings, each department head presents issues from their area, and the team determines whether to initiate a Performance Improvement Project (PIP) or provide in-service education to staff. The Administrator acknowledged that staff turnover is ongoing, with new personnel recently hired in activities and social services. She was aware that repeated concerns from the previous survey had resurfaced. Following the last survey, the facility implemented additional in-services on providing ADL care and reinforcing nurses' responsibilities to ensure CNAs completed their tasks and documentation before the end of their shifts. The dietary manager provided in-service education to dietary staff on food storage and handling, while the registered dietitian conducted audits and routine checks on food storage and labeling. She explained that audits related to the plan of correction for prior deficiencies were conducted for three (3) months and reviewed in QAPI meetings; however, once the three (3) months ended, the issues were not revisited because the facility believed they were resolved.

Based on staff interview, record review, and facility policy review, the facility failed to ensure antipsychotic medications were prescribed for residents with appropriate, clinically documented diagnoses for one (1) of six (6) residents reviewed for unnecessary medications. Resident #157Findings include: A review of the facility's policy, Antipsychotic Medication Use, revised 10/2022, revealed, Policy Interpretation and Implementation 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.A record review of the admission Record revealed the facility admitted Resident #157 on 9/20/24 with diagnoses including Major Depressive Disorder, Single Episode, Unspecified.A record review of the Discharge Summary from an acute care hospital, dated 9/20/24, revealed Resident #157's Problem List/Discharge Diagnosis included Hemorrhagic Cerebrovascular Accident, Disorientation, Pulmonary Embolism, Acute Kidney Injury, and Wheezing.A record review of the Diagnosis Report revealed Resident #157 had a diagnosis of Major Depressive Disorder, Single Episode, Unspecified with an onset date listed as 9/20/24. A record review of the Order Summary Report with an order date range of 9/20/24 through 8/31/25 revealed Resident #157 had Physician's Orders for Olanzapine (an antipsychotic medication), dated 9/20/25 for Mood, for Olanzapine, dated 10/9/24, for Psychosis, Olanzapine, dated 10/22/24 for psychotic disorder, Olanzapine, dated 11/7/24 for Major Depressive Disorder, Single Episode, Unspecified, and Zyprexa (Olanzapine), dated 1/9/25 for Major Depressive Disorder, Single Episode, Unspecified. Further review revealed Physician's Orders for Haloperidol (an antipsychotic medication), dated 1/14/25 for mood and Haloperidol, dated 10/22/24 for Psychosis.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/26/25 revealed Resident #157 had a diagnosis of Depression and there were no other psychiatric/mood disorders indicated.A record review of the Significant Change in Status MDS with ARD of 1/31/25 revealed Resident #157 had a diagnosis of Depression with no other psychiatric/mood disorders indicated.On 8/21/25 at 11:45 AM, in an interview with the pharmacist, he explained that his monthly reviews include evaluating appropriate diagnoses, potential interactions, and duration of therapy. He stated that he does not generally have concerns if the medical record does not contain a specific supporting diagnosis for a medication, because many medications can be prescribed for multiple conditions. On 8/21/25 at 1:32 PM, during an interview with the Director of Nursing (DON), she explained that when a physician provides a new medication order, the physician indicates the diagnosis associated with the medication. The nurse then enters the order into electronic health record, where a prompt appears requiring the associated diagnosis. She stated that orders are reviewed each morning to ensure diagnoses are in place for new medications. She further explained that the Minimum Data Set (MDS) nurse reviews diagnoses for accuracy, and for psychotropic medications, the consultant pharmacist verifies that appropriate diagnoses are present.

Based on observation, interview, record review, and facility policy review, the facility failed to respect a resident's privacy during incontinent care (Resident #26) for one (1) of four (4) days of survey. Findings include:A review of the facility's policy titled, Dignity, revised 7/24/23, revealed, .Each resident shall be cared for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation 1. Residents are treated with dignity and respect at all times.11. Staff promote, maintain, and protect residents' privacy, including bodily privacy during assistance with personal care and treatment procedures.On 8/18/25 at 10:06 AM, during an observation while walking in the hallway with the Licensed Social Worker (LSW), Registered Nurse (RN) #2 was observed providing incontinent care for Resident #26 with the resident's door open. Resident #26's buttocks and genital area were exposed, and privacy was not maintained during the provision of care.On 8/18/25 at 10:09 AM, during an interview, the LSW confirmed she observed RN #2 provide incontinent care with the resident's door open and the resident's buttocks and genital area exposed. The LSW acknowledged that residents, staff, families, and visitors frequently pass by the hallway and confirmed this was a dignity concern that should be addressed.On 8/18/25 at 10:26 AM, during an interview, RN #2 confirmed she failed to close the door while cleaning the resident and admitted the resident's buttocks and genitals were exposed. RN #2 stated she became focused on cleaning the resident and forgot to close the door. On 8/18/25 at 10:57 AM, during an interview, the Director of Nursing (DON) stated the nurse should have closed the door during care and confirmed the resident's body should not have been exposed to anyone who could pass by in the hallway.On 8/21/25 at 4:44 PM, during an interview, the Administrator stated she expected staff to follow the dignity policies.A record review of the admission Record revealed the facility admitted Resident #26 on 8/6/25 with diagnoses including Chronic Obstructive Pulmonary Disease.A record review of the Comprehensive admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/13/25 revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated his cognition was moderately impaired.

Based on record review, staff interview, and facility policy review, the facility failed to ensure physician orders were followed for obtaining a Hemoglobin (Hbg) A1C (a blood test that measures average blood glucose levels over the past 2-3 months) as ordered for one (1) of six (6) residents reviewed for unnecessary medications. Resident #12.Findings include:A review of the facility's policy Physician's Orders dated 4/13/21 revealed, . Physician's orders are carried out unless the nurse or other licensed personnel believe the order to be inaccurate .A record review of the admission Record revealed the facility admitted Resident #12 on 4/25/18 with diagnoses including Diabetes Mellitus.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/1/25 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) Summary Score of 13, which indicated she was cognitively intact. A record review of the Order Summary Report with active orders as of 8/21/25 revealed Resident #12 had a Physician's Order, dated 10/23/24 for a (Hgb)A1C every six (6) months - April and October.A record review of lab results, dated 10/3/25, revealed HgbA1C results were obtained.A record review of lab results, dated 3/5/25, revealed there was no HgbA1C lab results.On 8/21/25 at 8:00 AM, during an interview with the Director of Nursing (DON), she explained Resident #12 should have had all labs completed per physician orders on 3/5/25 and if the other labs were drawn in March, the HgbA1C test should have been included. She reported that the labs were drawn in March instead of April due to the facility changing laboratory companies.On 8/21/25 at 10:08 AM, during an interview with Registered Nurse (RN) #1, she stated Resident #12's HgbA1C was not obtained in April as ordered. She explained the other labs were drawn in March and all the labs are typically obtained together. She contacted the lab and was told the HbgA1C that was drawn in March could not be processed because the blood was clotted, and the test was never repeated. She further explained that the facility changed laboratory companies in April 2025, and the new lab had better reporting and electronic access.On 8/21/25 at 3:15 PM, during an interview with the DON, she confirmed the HgbA1C was not done as ordered with the other labs and had not been followed up on. She stated RN #1 was responsible for monitoring labs and she expected all labs to be completed as ordered. She reported the physician would be notified and an HgbA1C level would be drawn at this time.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision and ensure environmental safety to prevent Resident #1, a vulnerable resident, from exiting the facility unnoticed and unsupervised for one (1) of three (3) residents reviewed. Resident #1 On 3/23/25, Resident #1, who had a Brief Interview for Mental Status (BIMS) score of eight (8), physically pushed out and removed the window screen in his room and exited the building. Resident #1 exited the facility unnoticed and was last seen inside the facility at 6:00 AM by a Certified Nursing Assistant (CNA) and was found at 6:30 AM by facility staff (Dietary Cook) who was reporting to work. The resident was observed by the [NAME] walking around side of the building and was approximately 130 steps away from the building. Resident #1 was wearing shorts only and no shoes. The facility's failure to provide supervision and ensure environmental safety put Resident #1 and other vulnerable residents 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 3/23/25, when Resident #1 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 4/2/25 at 2:40 PM ad provided an IJ Template. Based on the facility's implementation of corrective actions on 3/23/25, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed as of 3/24/25 prior to the SA's entrance on 4/2/25. Findings include: A review of the facility's policy, Accident and Incidents, dated 2/19/2017, revealed, .It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible and those residents receive supervision and assistance devices to prevent accidents whenever possible . A review of the facility's policy, Emergency Procedure-Missing Resident, dated 3/2023, revealed, .Resident elopement resulting in a missing resident is considered a facility emergency . A record review of the facility's investigation, dated 3/25/25, revealed that on 3/23/25 at 6:30 AM, the Dietary [NAME] was entering the facility and noticed a gentleman walking from the side of the building. The gentleman approached the dietary cook at this time, but he was unable to understand him. The [NAME] asked the man to sit on the curb so that he could get some assistance. A housekeeper was within range of the facility entry door and confirmed that the man was a resident of the facility. The housekeeper notified the nurse on duty that the patient was sitting outside his room on the curb. The resident was escorted back into the facility by the Nurse Supervisor and housekeeper. The resident was unable to explain what he was doing. Through staff interviews and investigation, it was determined that the Nurse on Duty last saw the resident at approximately 4:30 AM when she gave him his medications and treatment. The resident was calm and appeared to have no signs of any type of agitation or anxiousness. Certified Nurse Aide (CNA) #1 observed Resident #1 attempting to enter another resident's room at approximately 6:00 AM on 3/23/25 and re-directed the resident. At some point after the encounter with the Nurse on duty and the CNA, the resident opened a window, removed the screen, and exited the building to get air. The weather was approximately 63 degrees and he was wearing shorts. Upon re-entering the building, the resident was assessed with no signs or symptoms of any injuries and no psychosocial harm found. A record review of the Admission Record revealed the facility admitted Resident #1 on 3/5/25 with diagnoses including Squamous Cell Carcinoma of the Skin and Lip. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated his cognition was moderately impaired. A record review of the Evaluation Bundle dated 3/6/25, signed by Registered Nurse (RN) #2, indicated the resident was not identified as a wander/elopement risk. A record review of a weather report via https://www.timeanddate.com revealed the temperature at the time of the elopement was approximately 63 degrees On 4/2/25 at 6:40 AM, during an interview with the Assistant Director of Nursing (ADON), she confirmed that on 3/23/25 at 6:30 AM the Dietary [NAME] entered the back employee entrance and noticed a man dressed in shorts, no shirt, and no shoes walking from the west side of the facility. She stated the cook was unable to understand the man's speech and asked a housekeeper to confirm his identity. The housekeeper confirmed the individual was Resident #1. The cook stayed with the resident while the housekeeper retrieved the nurse, who assessed the resident for injuries. The resident was then able to walk back to his room independently. The nurse notified her immediate supervisor, who then contacted the Administrator. On 4/2/25 at 7:00 AM, during an interview with RN #1, she explained that Resident #1 did not exhibit elopement behaviors prior to the incident. She stated that around 4:30 AM on 3/23/25, she found the resident in an empty room and redirected him back to his room, completed wound care, and administered pain medication. Later that morning, the housekeeper notified her that Resident #1 had been found outside near the back entrance. She assessed the resident, noted no injuries, and assisted him back to his room. On 4/2/25 at 7:20 AM, during an interview with Housekeeper #1, she confirmed that on 3/23/25 around 6:30 AM, the Dietary [NAME] asked her if the man outside was a resident. She confirmed that he was and immediately ran to get the nurse. On 4/2/25 at 7:30 AM, during an observation of the area from Resident #1's window to the area he was found, the Assistant Director of Nursing (ADON) confirmed the resident had walked approximately 130 feet from his room to the rear entrance of the facility. On 4/2/25 at 8:00 AM, during a phone interview with CNA #1, she reported that at approximately 6:00 AM on 3/23/25, she observed Resident #1 attempting to enter another resident's room. She redirected him back to his room. At 6:30 AM, she was informed by the housekeeper that the resident had been found outside. She and the nurse assisted him back inside. On 4/2/25 at 8:30 AM, during a phone interview, the Dietary [NAME] confirmed that on 3/23/25 at approximately 6:30 AM, he observed a man walking around the back of the facility and was unable to understand him. He asked a housekeeper to confirm if the individual was a resident. Once confirmed, he remained with the resident until staff arrived. On 4/2/25 at 8:45 AM, during a phone interview with CNA #2, she confirmed that on 3/23/25, she saw Resident #1 sitting on the curb with the Dietary [NAME] as she parked her car. The resident's nurse and CNA #1 brought him back inside. On 4/2/25 at 12:00 PM, during an interview with the Administrator, she confirmed CNA #1 had redirected Resident #1 at 6:00 AM, and that he was later found outside at 6:30 AM. She stated the resident had not been previously identified as an elopement risk and he had been at the facility for a little over two weeks. She confirmed the facility performed a full assessment of the resident, accounted for all residents, conducted a Quality Assurance and Performance Improvement (QAPI) meeting the same day, and implemented corrective actions including in-services, reassessments, window safety checks, and elopement drills on all shifts. She confirmed that she reported the incident to the State Agency and the Attorney General's office. On 4/2/25 at 12:30 PM, during an interview with the Director of Nursing (DON), she stated Resident #1 was evaluated on admission and determined to not be at risk for elopement. She confirmed that he had not exhibited wandering or exit-seeking behavior since his admission, which was 18 days prior to the date of the incident. On 4/2/25 at 1:00 PM, during an interview with the Maintenance Director, he confirmed that after being informed of the elopement, he inspected all doors, windows, and keypads. He installed L-brackets on resident room windows to prevent them from opening more than six inches and conducted elopement drills for all shifts. He also confirmed attending all required in-services. On 4/2/25 at 3:00 PM, during an interview with the Nurse Practitioner (NP), she confirmed that Resident #1 was not identified as an elopement risk and had not exhibited any behavioral issues since his admitted [DATE]. The facility submitted a corrective action plan as follows: On 3/23/2025 at 6:35 AM, the Registered Nurse (RN) escorted the resident into the facility and assessed him with no signs or symptoms of injuries with vitals within normal limits. On 3/23/2025 at 6:50 AM, the Director of Nurse (DON) was notified by the nurse supervisor that the resident was outside on the curb and escorted back into the building. DON instructed the nurse supervisor to transfer Resident #1 to the secured unit for increased observation; as well as using a current daily census to perform a head count on all residents, and all residents were accounted for. On 3/23/2025 at 7:50AM, the Administrator was notified of the incident. On 3/23/2025 at 7:55 AM, the Administrator contacted the Maintenance Supervisor to inspect all windows. On 3/23/2025 at 9:15 AM, the Maintenance Director reported to the facility to inspect the windows, all doors, windows, and keypads were working properly. On 3/23/2025 at 9:28 AM, the Administrator notified the State Agency. On 3/23/2025 at 11:50 AM, Licensed Social Worker interviewed Resident #1; he stated he just wanted to get air, and the Licensed Social Worker found no psychosocial harm. On 3/23/2025 at 12:15 PM, the Maintenance Director placed L brackets on all resident windows, which are metal shaped so that the windows are unable to open greater than six inches. On 3/23/2025 at 12:30 PM, an Emergency Quality Assurance Performance Improvement (QAPI) meeting was held that included the Administrator, Medical Director, DON, Regional Director of Operations, Regional Nurse Consultant, Unit Manager, Infection Preventionist, and Staff Development. The QAPI team discussed the adverse event, reviewed the immediate actions taken, reviewed policy and procedures. No changes were made to the policies and procedures. It was determined through staff and resident interview Resident #1 exited the facility by opening the window and removing the screen and going out for air. It was determined the Maintenance Director placed L brackets on all resident windows, which are metal shaped so that the windows are unable to open greater than six inches. QAPI Minutes Included: On 3/23/2025 an in-service was conducted by the Administrator for all staff prior to their oncoming shift and via telephone on missing residents, elopement risk policies, whom and when to notify if there is a missing resident, elopement books and arm band placement on each resident. On 3/23/2025 all windows were verified to be in proper working order by the maintenance supervisor. All windows were secured with L shape brackets to prevent residents from exiting the facility. Maintenance will perform weekly visual inspections for four weeks and monthly thereafter to ensure that all windows and screens are in proper working order. On 3/23/2025 Elopement drills were completed on all shifts (7A-3PM, 3P-11P, 11P-7A) by the maintenance supervisor and Assistant Administrator. Drills will be continued weekly for four weeks and monthly thereafter and will be brought in for review and recommendations during monthly QAPI. Any findings will be addressed immediately by the Administrator and/or Director of Nursing. On 3/23/2025, all staff will be in-serviced for elopement/wandering. No staff will be allowed to work until they have received the in-service. On 3/23/2025, the Nurse on duty moved Resident #1 to the secure unit, every one hour checks were put into place and fresh air walks were initiated. On 3/23/2025 100% of all residents were assessed by the Licensed Practical Nurse to verify that anyone deemed at risk for wandering or elopement proper interventions were in place. In-house census of 146 residents reviewed at this time and there was a total of 58 residents deemed at risk. On 3/23/2025 100 % audit completed for all care plans to verify that any resident deemed a wandering or elopement risk were identified and updated. On 3/23/2025 the Licensed Social Worker assessed Resident #1 to determine that there were no findings of psychosocial harm. Validation: The SA validated through interview and record review view, that all corrective actions had been implemented as of 3/23/25, and the facility was in compliance as of 3/24/25, prior to the SA's entrance on 4/2/25.

Based on interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent Resident #1, who was identified as a fall risk, from falling and causing the resident to sustain a mildly displaced fracture of the proximal right humerus for one (1) out of three (3) sampled residents, Resident #1. Findings include: A review of the facility's Safety and Supervision of Residents, reviewed 8/2023, revealed: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The record review of the facility investigation revealed Resident #1 had a witnessed fall on 2/13/25 at 6:49 AM. Certified Nurse Assistant (CNA) #1 reported that during the transfer of the resident from her bed to the wheelchair, the resident slipped, and CNA #1 lowered the resident to the floor. The facility sent the resident to the hospital for evaluation and treatment due to bruising and swelling to her right hand. The resident's x-rays showed a mildly displaced, slightly impacted fracture of the proximal right humerus with overlying soft tissue swelling. Following the investigation, CNA #1 was terminated because she did not follow the care plan for transferring the resident, resulting in a fall with injury. Record review of the Progress Notes revealed on 2/13/25 at 6:00 AM, while CNA #1 was attempting to transfer the resident, her foot slipped, and she fell on top of CNA #1. The resident was assessed with no apparent injuries. Vital signs were taken, and the medical provider, Assistant Director of Nurses (ADON), and Resident Representative (RR) were notified. Record review of the Progress Note revealed on 2/13/25 at 5:47 PM, the resident complained of pain to her right arm. The resident's hand was swollen and bruised, and she was sent to the local emergency department. Record review of the Emergency Documentation dated 2/13/25 at 3:23 PM revealed patient is a patient of the nursing facility. Patient is unsure how she fell but has right upper arm pain. She has significant bruising to her right upper arm and was placed in a sling by local ambulance. The assessment was completed with a fracture of the proximal end of the humerus. A sling and pain medication were prescribed, and the resident was transferred back to the facility. Record review of the diagnostic radiology on 2/13/25 revealed Impression: Mildly displaced, slightly impacted fracture of the proximal right humerus with overlying soft tissue swelling. No definitive evidence of additional fracture of the right upper extremity. Record review of the Admission Record revealed the facility admitted the resident on 8/27/2013 with diagnoses including Hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. On 3/17/25 at 11:15 AM, during an interview with the Administrator in Training (AIT), he revealed that Resident #1 had a witnessed fall on 2/13/25. CNA #1 reported that during the transfer from her bed to her wheelchair, the resident slipped, and CNA #1 lowered the resident to the floor. The facility sent the resident to the hospital for evaluation and treatment due to bruising and swelling to her right hand. The resident's x-rays showed a mildly displaced, slightly impacted fracture of the proximal right humerus with overlying soft tissue swelling. Following the investigation, CNA #1 was terminated because she did not follow the care plan for transferring the resident, resulting in a fall with injury. The facility provided in-services to all care staff following the incident on accidents, transfers, care plans, and incident reporting. Additionally, the facility performed an emergency Quality Assurance Performance Improvement (QAPI) on 2/14/25. On 3/21/25 at 10:20 AM, during an interview with the ADON, she confirmed that on 2/13/25, as she was arriving at the facility at approximately 6:30 AM, Registered Nurse (RN) #2 informed her that Resident #1 had a witnessed fall by CNA #1. RN #2 did not witness the fall but observed Resident #1 lying on top of CNA #1. According to CNA #1, Resident #1 was slipping during the transfer, and she caught her and let her land on CNA #1. RN #2 assessed the resident and informed the Nurse Practitioner (NP) and Resident Representative (RR). Later in the day, the resident had noticeable bruising on her right hand. New orders were received, and she was transferred to the local hospital, where she was diagnosed with a mildly displaced, slightly impacted fracture of the proximal right humerus with overlying soft tissue swelling. On 3/21/25 at 10:40 AM, during a phone interview, CNA #1 confirmed that on 2/13/25, during the transfer of Resident #1, the resident's foot slipped, and she fell , landing on CNA #1, who was taught to break her fall. She revealed that the resident never touched the floor and landed on the CNA#1. She stated she did not use the sit-to-stand lift for the transfer because the battery was not charged, and that was the way she transferred the resident that morning. During an interview on 3/21/25 at 12:30 PM, the Director of Nurses (DON), confirmed that she was not in the facility on 2/13/25, but Resident #1 did have an accident, resulting in a mildly displaced, slightly impacted fracture of the proximal right humerus with overlying soft tissue swelling. She confirmed that CNA#1 did not follow the care plan to use the sit-to-stand lift and that the accident may not have occurred if she had used the lift. Validation: The SA validated on 3/21/25, through interview and record review, that all corrective actions had been implemented as of 2/14/25, and the facility was in compliance as of 2/14/25, prior to the SA's entrance on 3/17/25.

Based on interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions for a resident who was identified as a fall risk, resulting in a fall that caused the resident to sustain a mildly displaced fracture of the proximal right humerus, for one (1) out of three (3) sampled residents. Resident #1. Findings include: A review of the facility's Care Plans, Comprehensive Person-Centered, reviewed 10/2022, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas . A record review of the care plan revealed: .Date Initiated: 09/22/2015: Focus: Resident has self-care deficit .Interventions/Tasks: Transfer: Extensive, (X2) times two (2) Assist (w) with/sit to stand lift . Date initiated: 03/21/2023. The record review of the facility investigation revealed Resident #1 had a witnessed fall on 2/13/25 at 6:49 AM. Certified Nurse Assistant (CNA) #1 reported that during the transfer of the resident from her bed to the wheelchair, the resident slipped, and CNA #1 lowered the resident to the floor. The facility sent the resident to the hospital for evaluation and treatment due to bruising and swelling to her right hand. The resident's x-rays showed a mildly displaced, slightly impacted fracture of the proximal right humerus with overlying soft tissue swelling. Following the investigation, CNA #1 was terminated because she did not follow the care plan for transferring the resident, resulting in a fall with injury. Record review of the Progress Notes revealed on 2/13/25 at 6:00 AM, while CNA #1 was attempting to transfer the resident, her foot slipped, and she fell on top of the CNA. The resident was assessed with no apparent injuries. Vital signs were taken, and the medical provider, Assistant Director of Nurses (ADON) and Resident Representative (RR) were notified. Record review of the Progress Note revealed on 2/13/25 at 5:47 PM, the resident complained of pain to her right arm. The resident's hand was swollen and bruised, and she was sent to the local emergency department. Record review of the Emergency Documentation report dated 2/13/25 at 3:23 PM reveled that patient is a patient of the nursing facility. Patient is unsure how she fell but has right upper arm pain. She has significant bruising to her right upper arm and was placed in a sling by local ambulance. The assessment was completed with a fracture of the proximal end of the humerus. The resident was prescribed a sling and pain medication, then transferred back to the facility. Record review of the diagnostic radiology on 2/13/25 revealed Impression: Mildly displaced, slightly impacted fracture of the proximal right humerus with overlying soft tissue swelling. No definitive evidence of additional fracture of the right upper extremity. Record review of the Admission Record revealed the facility admitted the resident on 8/27/2013 with diagnoses including Hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. During a phone interview on 3/21/25 at 10:40 AM, CNA #1 confirmed that on 2/13/25, during the transfer of Resident #1, the resident's foot slipped, and she fell , landing on the CNA #1, who was taught to break her fall. CNA#1 stated she did not use the sit-to-stand lift for her transfer because the battery was not charged, and that was the way she transferred the resident that morning. CNA #1 confirmed that according to the care plan, she should have used the lift, but since the resident requested to get up to go smoke, she felt as if she could have transferred her without problems. On 3/21/25 at 12:00 PM, during an interview with the Minimum Data Set (MDS)/Licensed Practical Nurse (LPN) #1, confirmed that she expects all staff to follow the comprehensive care plan interventions for residents. The care plans are person-centered and address residents' needs and safety. She explained that care plans are accessible to staff through computerized charting and are reviewed periodically. MDS/ LPN #1 reported that in-service training is provided to the staff regarding following care plans but acknowledged that some staff may not consistently follow them and disciplinary action is taken when necessary. On 3/21/25 at 12:30 PM, during an interview with the Director of Nurses (DON), she confirmed that CNA #1 did not follow the care plan for the transfer of Resident #1 by using the sit-to-stand lift. She expected all staff to follow the residents' care plans, which are designed to provide each resident with care based on their individual needs. She confirmed that the resident's care plan includes the use of a sit-to-stand lift for transfers. She agreed that if this intervention had been implemented, the incident may have been prevented. Validation: The SA validated on 3/21/25, through interview and record review, that all corrective actions had been implemented as of 2/14/25, and the facility was in compliance as of 2/14/25, prior to the SA's entrance on 3/17/25.

Based on interviews, record reviews, facility policy reviews, and the facility's investigation, the facility failed to provide adequate supervision 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. The facility's failure to provide supervision resulted in Resident #1 exiting the facility unsupervised and unnoticed by facility staff. Resident #1 was brought to the therapy gym at approximately 9:50 AM on 8/8/24 and left unattended. She was determined to be missing at 9:55 AM and was found at 10:23 AM, about one (1) mile from the facility. During the investigation, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 8/8/24 and existed at 42 CFR: 483.25 (d)(1)(2)- Free of Accidents Hazards/Supervision/Devices (F689) - Scope and Severity J. This situation placed Resident #1 and other residents at risk for wandering and elopement, likely for serious injury, serious harm, serious impairment, or death. The SA notified the facility's Administrator of the IJ and SQC on 8/13/24 at 3:00 PM and provided the Administrator with the IJ template. Based on the facility's implementation of corrective actions on 8/8/24, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 8/9/24, prior to the SA's entrance on 8/12/24. Findings Include: A review of the facility's policy, Accidents and Incidents, dated August 7, 2013, revealed, Policy: It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible and that residents receive supervision and assistance devices to prevent accidents whenever possible . A review of the facility's policy, Emergency Procedure-Missing Resident, reviewed 03/2023, revealed, Policy Statement: Resident elopement resulting in a missing resident is considered a facility emergency. Policy Interpretation and Implementation 1. Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety . A record review of the facility's investigation, Resident Incident Timeline, revealed that on 08/08/24 at 9:55 AM, the staff identified that Resident #1 was not in the therapy gym where she had been escorted to receive therapy services. The staff were notified that the resident was missing; after searching the building and perimeter, it was determined that the resident had left the facility. The facility called a Code W (elopement) within the facility. The missing resident procedures were initiated, and the resident was located at 10:23 AM, approximately 1 mile from the facility, walking in a residential area. Upon returning the resident to the facility, the Nurse Practitioner (NP) performed a thorough assessment, with labs and urinalysis performed. The resident's face was noted to be flushed, and the resident took fluids cooperatively. It was determined through staff and resident interviews that Resident #1 exited the facility through the Rehabilitation door, as visitors and staff frequently enter and exit through these doors. During an interview with the Administrator on 08/12/24 at 10:10 AM, it was confirmed that on 08/08/24 at approximately 10:00 AM, Resident #1 exited the facility through the rehabilitation unit and was located approximately 1 mile from the facility at 10:23 AM. The resident had been assisted to the therapy gym at approximately 9:50 AM by a Certified Nurse Aide (CNA) and she was sitting in her favorite chair looking outside the double doors. The NP and Licensed Practical Nurse (LPN) #2 found Resident #1 with a flushed face and brought her back to the facility. Resident #1 was calm while entering the automobile and spoke about robbing a bank. Upon returning to the facility, she was evaluated by the NP, with labs and urinalysis performed. Resident #1 drank water cooperatively. The weather on 08/08/24 at 10:00 AM was clear skies and a temperature of 92 degrees with no rain. The resident wore a cap, jeans, a short-sleeved shirt, a cardigan, and open-toe slides. Following the incident, all residents were accounted for, checked for any problems, and assessed for elopement risk. The resident had no family and was her own Responsible Representative (RR). The facility immediately notified the State Agency (SA) and Attorney General's Office (AGO). The facility began in-services for all staff on Elopement. The Administrator confirmed they held an emergency Quality Assurance and Performance Improvement (QAPI) meeting and began implementing corrective actions. The Administrator stated the facility began to have additional elopement drills and in-serviced all employees on elopement and supervision of residents. The Administrator provided the SA with copies of the statements received regarding the investigation and the sign-in page of the QAPI meeting that was held on the afternoon of the incident to discuss the incident and steps needed to prevent this from happening again. The facility conducted an investigation and submitted it to the SA and AG office. Following their investigation, they determined there were no signs of abuse or neglect. Through a root cause analysis by the Director of Nursing (DON) and Administrator, it was determined that the resident exited by following another person out the door before the door was able to close completely; the resident was sitting in a chair five feet from the door. The resident had been known to wander on her unit and exhibit exit-seeking behavior. During an interview with the DON on 08/12/24 at 10:20 AM, it was confirmed that Resident #1 was admitted to the facility on [DATE], was very weak, and was not initially identified as an elopement risk. She was admitted to the rehabilitation unit for therapy. During her stay, Resident #1 showed signs of improvement and began entering other residents' rooms, carrying laundry, and making/remaking beds. On 06/28/24, a second wandering evaluation was performed, and she was deemed a wandering risk. On 08/12/24 at 10:30 AM, during an interview and observation drive-through with LPN #2 of the route from the facility to the location where Resident #1 was found, the distance was determined to be 1.1 miles. LPN #2 pointed out where Resident #1 was found at the end of the sidewalk, and stated the resident was dressed in pants, a shirt, and a gray sweater with open-toe shoes. During the observation, there were sidewalks on either side of the road, but not on both sides. There were 3-4 cars on the road at the time of the observation. A large waterway was observed along one side of the route, with two signs indicating Caution Alligators and Snakes May Be Present. It was confirmed that when Resident #1 was found, the NP assessed her and observed no injuries. LPN #2 confirmed that when it was determined that Resident #1 was missing from the facility, a Code W was called throughout the entire facility. All staff began to search for Resident #1, and the NP and LPN #2 started driving in search of her. LPN #2 drove west of the building for approximately one mile and found her at the end of the sidewalk. On 08/12/24 at 10:52 AM, during an interview with Rehabilitation Certified Nurse Assistant #1 (R-CNA #1), she revealed that she learned Resident #1 was missing when walked from Resident #1's unit to the Rehabilitation unit and the Speech Therapist (ST) questioned if she had seen Resident #1, but she had not. After not locating Resident #1 in her unit, she immediately reported to the Administrator, and Code W was called, initiating a search for Resident #1. R-CNA #1 confirmed that Resident #1 always sat in the Rehabilitation Unit facing the double doors. She also confirmed that outpatients, staff, and families frequently used the rehab door. On 08/12/24 at 1:05 PM, during an interview with the Maintenance Director, it was revealed that he checked all doors daily, and all doors closed and locked as required. All doors to enter or exit the building required a code. Since the incident with Resident #1, the facility removed the numeric keypad from outside the door to prevent staff and visitors from entering unless a staff member inside the facility let them in. On 08/13/24 at 1:01 PM, during an interview with the Social Worker (SW), it was confirmed that on 06/28/24, when Resident #1 showed signs of wandering, a second wandering evaluation was performed, and the facility then placed Resident #1 in another unit. On 8/13/24 at 1:59 PM, during an interview with CNA #2, she confirmed she assisted Resident #1 to the therapy gym on 8/8/24 at approximately 9:50 AM. She was aware the resident was an elopement risk, and she advised the therapy staff the resident was sitting in her favorite chair waiting for therapy services. A record review of the weather report from the website https://www.wunderground.com/calendar/us/ms/biloxi/KGPT revealed that it was 92 degrees on 08/08/24 at 10:00 AM. A record review of the Admission Record revealed that the facility admitted Resident #1 on 06/17/24 with current diagnoses including Altered Mental Status. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/23/24 revealed a Brief Interview for Mental Status (BIMS) score was five (5), indicating that the resident was cognitively impaired. A review of Section E, which addressed behavior, showed that the resident wandered on one (1) to three (3) days, but the wandering was not considered to have a significant impact on the resident. A record review of the Progress Notes revealed that on 06/28/24 at 3:48 PM, social services moved Resident #1 to a new unit due to exit-seeking behavior on the Rehabilitation Unit. A record review of the Wander Evaluation dated 06/17/24 revealed the Resident #1 was not at risk for wandering. A record review of the Wander Evaluation dated 06/28/24 revealed Resident #1 was identified as at risk for wandering as she had grown stronger and was able to ambulate independently on the unit. She expressed a desire to go home which formerly was Tent city for homeless. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 8/12/24: On 8/13/2024 at 3:00 PM, the State Agency presented an IJ template which notified the Administrator that the facility failed to provide supervision necessary to prevent an elopement for Resident #1, a vulnerable resident, who left the facility unnoticed and unsupervised and failed to implement care plan interventions related to wandering/elopement risks. On 8/8/2024 at 9:55 AM, the staff identified that the resident was not in the therapy gym where she was escorted to receive therapy services. The staff were notified that the resident was missing, after searching the building and perimeter it was determined that the resident had left the facility. Missing resident procedures were initiated and the resident was located at 10:23 AM by the facilities FNP (Family Nurse Practitioner) and the SDC (Staff Development Coordinator) approximately 1 mile from the facility walking in a residential area. On 8/8/24 at 9:55 AM, RCNA (Rehabilitation Certified Nursing Assistant) noted that resident was not sitting in the chair by the rehab door. The CNA searched the therapy gym area then went back to the Serenity Unit to see if resident was there. Rehab CNA asked staff if resident had returned to the unit: staff noted resident had not returned. All staff immediately began to search for resident on the Serenity Unit. At this time the LPN #1 (Licensed Practical Nurse) on the unit directed all staff to conduct a search of all areas of the building and perimeter. On 8/8/24 at 10:00 AM, code W (elopement) initiated protocols which notified all staff to begin searching. Staff members were assigned by Administrator and DON (Director of Nursing) to search inside and outside of building. Staff members were directed to search the outside perimeters in the direction of the woods and surrounding residential areas. On 8/8/24 at 10:23 AM, LPN #2 and the NP called DON to report the resident safely walking in a residential area about 1 mile east of the facility. Resident was returned to the facility at 10:30am. On 8/8/24 at 10:25 AM, staff completed a headcount compared to the daily census and all residents were accounted for. On 8/8/24 at 10:30 AM, the Nursing Home Administrator notified state agency of the elopement. On 8/8/24 at 10:35 AM, the resident was returned to her unit, assessed by LPN #1 and full body audit was completed. No signs or symptoms of injury, face was noted to be flushed, and resident took fluids cooperatively. NP assessed resident on unit, ordered labs, and UA (resulted negative). NP contacted the psychological NP for medication after ruling out acute episode. Resident is own Resident Representative (RR) no next of kin to notify. On 8/8/2024 at 10:45 AM, the resident was assessed by the LSW (Licensed Social Worker) with no psychosocial harm found. On 8/8/24 at 11:00 AM, the Administrator and DON checked all doors and keypads for proper functioning, all were secure with no issues found. On 8/8/24 at 11:15 AM, inside door code changed and will be used for emergency exit only. Entrance and exit through therapy door are now restricted to visitors and staff. All visitors must enter and exit through facility's main entrance. All staff must enter and exit through back door of facility. On 8/8/2024 at 12:00 PM, the Administrator notified the Attorney General's office of the incident. On 8/8/24 at 12:30 PM, Quality Assessment and Performance Improvement (QAPI) committee meeting was held involving missing resident. Staff in attendance were Medical Director, Administrator, Director of Nursing (DON), Assistant DON (ADON)/Infection Preventionist, Housekeeping Supervisor, Regional Nurse Consultant, Business Office Manager, Certified Dietary Manager, Social Services Director, Social Services Assistant, Admissions, Staff Development Coordinator, Medical Records. It was determined through staff interviews and resident interview that the resident exited the facility through the Rehabilitation (gym) door as visitors and staff frequently enter and exit these doors. Through root cause analysis by the DON and Administrator, we determined that the resident exited by following another person out the door before the door was able to close completely; the resident was sitting in a chair five feet from the door. The resident has been known to wander on her unit and exit seek. The resident also stated to the Social Worker on 8/8/24 during their interview that she went for a walk and exited the door. On 8/8/24 the QAPI committee reviewed the incident, actions taken, and the policy was reviewed with no recommendations for change. On 8/8/24, 100% facility staff in-service completed by Staff Development Coordinator, ADON, and Housekeeping Supervisor began regarding elopement/missing resident policies prior to returning to work. On 8/8/24, 100% of all residents assessed for elopement risk by ADON and Staff Development. Twenty-seven new residents added to elopement/wandering list. On 8/8/24, 100% audit performed of care plans for those identified for elopement risk to include visual monitoring and arm bands conducted by Regional Nurse Consultant. Twenty-seven new residents added to elopement/wandering list. On 8/8/24, 100% audit of wandering residents book completed by Social Services to ensure all pictures are current. On 8/8/24, Elopement drills were performed on all shifts (7A-3P, 3P-11P, 11P-7A) by the Director of Nursing and the Staff Development Coordinator and will continue for 4 weeks then monthly for QAPI review and recommendations. Any findings will be addressed immediately by the Administrator or DON. On 8/8/24, outside keypad to therapy door disabled and removed. Inside door code changed and will be used for emergency exit only. On 8/8/24, entrance and exit through therapy door is restricted to visitors and staff. All visitors must enter and exit through facility's main entrance. All staff must enter and exit through back door of facility. All corrective actions were completed on 8/8/24 and the facility alleges the IJ was removed on 8/9/24. Validation: The State Agency (SA) validation of the Removal Plan was made on-site during the Complaint Investigation (CI) MS #26122 through record review and interviews on the 8/14/24. The SA determined all corrective actions were completed on 8/8/24 and the IJ was removed on 8/9/24.

Based on interviews, record reviews, and facility policy review, the facility failed to implement care plan interventions related to wandering/elopement risk for one (1) of four (4) resident care plans reviewed. Resident #1. The facility's failure to implement care plan interventions resulted in Resident #1 exiting the facility unsupervised and unnoticed by facility staff. Facility staff took Resident #1 to the therapy gym at approximately 9:50 AM on 8/8/24. She was determined to be missing at 9:55 AM and was found at 10:23 AM, about one (1) mile from the facility. During the investigation, the SA identified an Immediate Jeopardy (IJ) which began on 8/8/24 and existed at 42 CFR: 483.21(b) Comprehensive Care Plans - F656 - Scope and Severity J. This situation placed Resident #1 and other residents at risk for wandering and elopement, at risk for likelihood of serious injury, serious harm, serious impairment, or death. The SA notified the facility's Administrator of the IJ on 8/13/24 at 3:00 PM and provided the Administrator with the IJ template. Based on the facility's implementation of corrective actions on 8/8/24, the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on 8/9/24, prior to the SA's entrance on 8/12/24. Findings Include: A review of the facility's policy, Care Plans, Comprehensive Person-Centered, reviewed on 10/2022, revealed, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . A record review of the Comprehensive Care Plan date initiated 6/28/24 revealed Focus: I am an elopement risk/wanderer r/t (related to) impaired safety awareness, I wander aimlessly .Interventions/Tasks: Distract resident from wandering by offering pleasant diversions such as structured activities, food, conversation, television, book. Date initiated 06/28/2024 . A record review of the Admission Record revealed the facility admitted Resident #1 on 06/17/2024 with current diagnoses Altered Mental Status. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/23/24 revealed Section E identified that the resident wandered on one (1) to three (3) days, but the wandering was not considered to have a significant impact on the resident. A record review of the . Wander Evaluation dated 06/28/2024 revealed the resident was at risk for wandering. A record review of the Progress Notes revealed that on 06/28/2024 at 3:48 PM, Social Services (SS) moved the resident to a new unit due to exit-seeking behavior on the Rehabilitation unit. A record review of the facility's investigation, Resident Incident Timeline, revealed that on 08/08/24 at 9:55 AM, the staff identified that Resident #1 was not in the therapy gym where she had been escorted to receive therapy services. The staff were notified that the resident was missing. After searching the building and perimeter, it was determined that the resident had left the facility. The facility called a Code W (elopement) within the facility. The missing resident procedures were initiated, and the resident was located at 10:23 AM, approximately 1 mile from the facility, walking in a residential area. On 08/13/2024 at 1:30 PM, during an interview with Licensed Practical Nurse (LPN) #1, who was also the Care Plan Coordinator, she confirmed that Resident #1 was not identified as an elopement risk upon admission. However, following the 06/28/2024 Wander Evaluation, the resident was identified as being at risk. LPN #1 confirmed that Resident #1's care plan was individualized to ensure the resident's safety. She explained that care plans are designed to provide individualized care for residents and summarize a person's health condition, treatment, and care. She added that she expected all nursing staff in the facility to implement care plan interventions for the residents' safety. During an interview on 08/13/2024 at 2:00 PM with the Director of Nursing (DON), she confirmed that care plans are very important and should be individualized for each resident. She emphasized that care plans tell the story of the resident's condition and treatment plan. The DON stated that she expected the care plan nurse to perform correctly and individualize each resident's care plan, and for all care staff to follow the care plans. She confirmed that the facility staff failed to follow the care plan by not distracting and monitoring the resident as required. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 8/12/24: On 8/13/2024 at 3:00 PM, the State Agency presented an IJ template which notified the Administrator that the facility failed to provide supervision necessary to prevent an elopement for Resident #1, a vulnerable resident, who left the facility unnoticed and unsupervised and failed to implement care plan interventions related to wandering/elopement risks. On 8/8/2024 at 9:55 AM, the staff identified that the resident was not in the therapy gym where she was escorted to receive therapy services. The staff were notified that the resident was missing, after searching the building and perimeter, it was determined that the resident had left the facility. Missing resident procedures were initiated and the resident was located at 10:23 AM by the facilities FNP (Family Nurse Practitioner) and the SDC (Staff Development Coordinator) approximately 1 mile from the facility walking in a residential area. On 8/8/24 at 9:55 AM, RCNA (Rehabilitation Certified Nursing Assistant) noted that resident was not sitting in the chair by the rehab door. The CNA searched the therapy gym area then went back to the Serenity Unit to see if resident was there. Rehab CNA asked staff if resident had returned to the unit: staff noted resident had not returned. All staff immediately began to search for resident on the Serenity Unit. At this time the LPN #1 (Licensed Practical Nurse) on the unit directed all staff to conduct a search of all areas of the building and perimeter. On 8/8/24 at 10:00 AM, code W (elopement) initiated protocols which notified all staff to begin searching. Staff members were assigned by Administrator and DON (Director of Nursing) to search inside and outside of building. Staff members were directed to search the outside perimeters in the direction of the woods and surrounding residential areas. On 8/8/24 at 10:23 AM, LPN #2 and the NP called DON to report the resident safely walking in a residential area about 1 mile east of the facility. Resident was returned to the facility at 10:30 AM. On 8/8/24 at 10:25 AM, staff completed a headcount compared to the daily census and accounted for all residents. On 8/8/24 at 10:30 AM, the Nursing Home Administrator notified state agency of the elopement. On 8/8/24 at 10:35 AM, the resident was returned to her unit, assessed by LPN #1 and a full body audit was completed. No signs or symptoms of injury, face was noted to be flushed, and resident took fluids cooperatively. NP assessed resident on unit, ordered labs, and UA (result negative). NP contacted the psychological NP for medication after ruling out acute episode. Resident is own Resident Representative (RR) and there was no next of kin to notify. On 8/8/2024 at 10:45 AM, the resident was assessed by the LSW (Licensed Social Worker) with no psychosocial harm found. On 8/8/24 at 11:00 AM, the Administrator and DON checked all doors and keypads for proper functioning. All were secure with no issues found. On 8/8/24 at 11:15 AM, the inside door code was changed and will be used for emergency exit only. Entrance and exit through therapy door are now restricted to visitors and staff. All visitors must enter and exit through facility's main entrance. All staff must enter and exit through back door of facility. On 8/8/2024 at 12:00 PM, the Administrator notified the Attorney General's office of the incident. On 8/8/24 at 12:30 PM, Quality Assessment and Performance Improvement (QAPI) committee meeting was held involving missing resident. Staff in attendance were Medical Director, Administrator, Director of Nursing (DON), Assistant DON (ADON)/Infection Preventionist, Housekeeping Supervisor, Regional Nurse Consultant, Business Office Manager, Certified Dietary Manager, Social Services Director, Social Services Assistant, Admissions, Staff Development Coordinator, Medical Records. It was determined through staff interviews and resident interview that the resident exited the facility through the Rehabilitation (gym) door as visitors and staff frequently enter and exit these doors. Through root cause analysis by the DON and Administrator, we determined that the resident exited by following another person out the door before the door was able to close completely; the resident was sitting in a chair five feet from the door. The resident has been known to wander on her unit and exit seek. The resident also stated to the Social Worker on 8/8/24 during their interview that she went for a walk and exited the door. On 8/8/24 the QAPI committee reviewed the incident, actions taken, and the policy was reviewed with no recommendations for change. On 8/8/24, 100% facility staff in-service completed by Staff Development Coordinator, ADON, and Housekeeping Supervisor began regarding elopement/missing resident policies prior to returning to work. On 8/8/24, 100% of all residents assessed for elopement risk by ADON and Staff Development. Twenty-seven new residents were added to elopement/wandering list. On 8/8/24, 100% audit performed of care plans for those identified for elopement risk to include visual monitoring and arm bands conducted by Regional Nurse Consultant. Twenty-seven new residents added to elopement/wandering list. On 8/8/24, 100% audit of wandering residents book completed by Social Services to ensure all pictures are current. On 8/8/24, Elopement drills were performed on all shifts (7A-3P, 3P-11P, 11P-7A) by the Director of Nursing and the Staff Development Coordinator. On 8/8/24, outside keypad to therapy door disabled and removed. Inside door code changed and will be used for emergency exit only. On 8/8/24, entrance and exit through therapy door is restricted to visitors and staff. All visitors must enter and exit through facility's main entrance. All staff must enter and exit through back door of facility. All corrective actions were completed on 8/8/24 and the facility alleges the IJ was removed on 8/9/24. Validation: The State Agency (SA) validation of the Removal Plan was made on-site during the Complaint Investigation (CI) MS #26122 through record review and interviews on the 8/14/24. The SA determined all corrective actions were completed on 8/8/24 and the IJ was removed on 8/9/24.

Based on observation, staff interview, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated with a use-by-date, food items without an identifying label, and produce that was overly ripe and exposed for one (1) of two (2) kitchen observations. Findings include: A review of the facility's policy, Food Storage, revised [DATE], revealed, Policy .Any expired or outdated food products should be discarded .Procedure .All products should be inspected for safety and quality and dated upon receipt, when open, and when prepared .Any expired or outdated food products should be discarded .Fresh Fruits .1. Fresh fruit should be checked and sorted for ripeness . On [DATE] at 07:44 AM, an observation of the kitchen and interview with the Certified Dietary Manager (CDM), revealed the following: Refrigerator #2 had one (1) portioned glass of orange juice, undated; One (1) portioned glass of apple juice, undated; Three (3) trays containing 24 portioned glasses each of what the CDM identified as sweet tea, with no label or date; One (1) opened 46-ounce carton of thickened lemon-flavored water with no opened date; one (1) opened 46-ounce carton of thickened lemon-flavored water with no opened date; one (1) opened 46-ounce carton of thickened lemon-flavored water with no opened date, and a manufacturer's use by date of [DATE]. The CDM acknowledged the unlabeled, undated, and expired foods and stated whoever opened the food items were responsible for labeling them with the date they were opened. An observation of the freezer revealed three (3) frozen pie crusts in tins, with no use-by date and no manufactures date. An observation of the pantry revealed five (5) bananas in which the peelings were discolored black, not intact, and exposed the inside of the bananas. The CDM acknowledged the bananas were overly ripe. The CDM reported it was her responsibility to inventory foods for quality and this was typically done twice weekly when the food truck made deliveries to the facility. She stated that she held in-service training's monthly with the kitchen staff regarding food safety. On [DATE] at 08:20 AM, in an interview with the Dietary Aide Supervisor (DAS) he reported it was the responsibility of the CDM to inventory foods for expiration dates. The DAS confirmed that the person who opened a food item was responsible for putting an open date on that item. The DAS also confirmed the kitchen dietary staff receive in-service training monthly. On [DATE] at 2:30 PM, in an interview with the Administrator, she acknowledged there was a lapse in the protocol by the kitchen staff to monitor for unlabeled, undated, and expired food items. The Administrator reported she expected the staff to make a daily inventory of the kitchen foods to assure food quality standards were safe for the residents.

Based on interviews, record review, and facility policy review the facility failed to ensure resident council concerns were resolved in a timely manner for six (6) of 6 months reviewed. (November 2023, December 2023, January 2024, February 2024, March 2024, April 2024) Findings Include: Review of the facility's policy, Grievances and/ or Concerns, dated 11/23/2016, revealed, Policy Statement: It is the policy of this facility to support each resident's right to voice grievances to the facility . After receiving a concern or grievance, the facility will actively seek a resolution and keep the resident appropriately appraised of its progress toward resolution .Upon receipt, the grievance or concern will be reviewed within 24 hours of receipt. The resident has the right to obtain a written decision regarding the grievance or concern within 10 working days . Record review of the documentation instructions on the Guidelines for Documentation of Resident Council Responses form revealed, Please review attached list of issues brought up at Resident Council and write your response in the appropriate section. Be sure to sign and date your response and give sheet to a department head who has not yet filled in his/her section. The response form should go to the administrator last before going to the social worker. Please help keep this form moving along as the responses should be returned to the council within two weeks of the above date . Housekeeping Record review of the Guidelines for Documentation of Resident Council Responses, dated 1/4/24, revealed the resident council voiced a concern related to toilet paper. The form did not include a date or signature of the responding department and did not include a resolution. Record review of the Guidelines for Documentation of Resident Council Responses, dated 2/2024, revealed the resident council voiced a concern related to just pulling trash. There was no date or signature of the responding department and did not include a resolution to the concern. Record review of the Guidelines for Documentation of Resident Council Responses, dated 3/5/2024, revealed the resident council voiced a concern related to not cleaning. There was no date or signature of the responding department and did not include a resolution to the concern. Laundry Record review of the Guidelines for Documentation of Resident Council Responses, dated 12/2023, revealed the resident council voiced a concern related to clothes not coming back. There was no date or signature of the responding department and did not include a resolution to the concern. Record review of the Guidelines for Documentation of Resident Council Responses, dated 1/4/24, revealed the resident council voiced a concern related to clothes don't come back on time. The form did not include a date or signature of the responding department and did not include a resolution. Record review of the Guidelines for Documentation of Resident Council Responses, dated 2/2024, revealed the resident council voiced a concern related to bringing other laundry to the wrong person. There was no date or signature of the responding department and did not include a resolution to the concern. Record review of the Guidelines for Documentation of Resident Council Responses, dated 3/5/2024, revealed the resident council voiced a concern related to put clothes in wrong room . clothes comes back on time but not getting the right things. There was no date or signature of the responding department and did not include a resolution to the concern. Dietary Record review of the Guidelines for Documentation of Resident Council Responses, dated 11/2023, revealed the resident council voiced a concern related to no fried chicken no more. The form did not include a date or signature of the responding department and did not include a resolution. Record review of the Guidelines for Documentation of Resident Council Responses, dated 1/4/24, revealed the resident council voiced a concern related to requests for big bowl of grits and ribs. The form did not include a date or signature of the responding department and did not include a resolution. Record review of the Guidelines for Documentation of Resident Council Responses, dated 2/2024, revealed the resident council voiced a concern related to different food and hot dogs, hamburgers, green bean casserole. There was no date or signature of the responding department and did not include a resolution to the concern. Record review of the Resident Council Meeting minutes, dated 4/2/24, recorded on a notebook pad revealed Food. There was no indication that Old Business was discussed and there was no follow up from the previous month's minutes. On 04/02/24 at 10:00 AM, during the resident council meeting, the resident council members revealed they have complained for over 6 months about the poor flavor of the food, including complaints the meat was tough and vegetables were unseasoned. The residents said they had expressed their concerns to the Dietary Manager on several occasions. Each month they voiced concerns regarding food and the lack of flavor. They stated they never heard back from the facility with any responses for their dietary concerns and they were not pleased with the lack of follow-up. During an interview on 04/2/24 at 11:00 AM, with the Activities Director (AD), she confirmed the residents had complained about the food for the last six (6) months. The AD stated that she did not record the food complaints every month because she had been eating the food at the facility sometimes and she thought it tasted better. The AD confirmed that she did not complete the Old Business section of the meeting minutes and did not include information that would let the residents know how the facility was attempting to resolve their concerns. The AD explained that she reported the concerns of the resident council to the department heads and the Administrator. On 4/2/24 at 1:00 PM, in an interview with the Dietary Manager (DM), she confirmed the residents had complained about the food being tough and lacking flavor. The DM also said that she attended several of the resident council meetings to discuss the food concerns with the residents. The DM confirmed she received a copy of the resident council concerns monthly. On 04/4/24 at 1:30 PM, in an interview with the Administrator and the Director of Nursing (DON), they confirmed the residents had complained about the food for the last six months. The Administrator stated she had not attended a resident council meeting in several months, however she had talked to the residents individually in their rooms. The Administrator said she was unaware the residents had concerns regarding the food and thought the dietary issue had been resolved. The Administrator confirmed that she received a copy of the resident council concerns monthly.

Based on observation, interviews, record review, and the facility policy review the facility failed to ensure residents' rights were honored for a clean and comfortable environment, as evidenced by, soiled privacy curtains for two (2) of 30 sampled residents. Resident #6 and Resident #27 Findings include: A record review of the facility's policy Resident Rights , dated 11/23/16, revealed, . It is the policy of this facility to promote and protect the rights of residents residing in this facility. Procedure . 3. The facility will make every effort to provide resident homelike environment . Resident #6 On 04/02/24 at 11:00 AM, during an observation and interview with Resident #6, the privacy curtain had long, brown streaks in several areas. Resident #6 explained that he had not paid attention to the curtains and was unable to determine how long they had been soiled. A record review of Admission Record revealed the facility admitted Resident #6 on 04/21/20 with current diagnoses including Hemiplegia and Hemiparesis. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/28/24, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated his cognition was moderately impaired. Resident #27 During an observation and interview, on 4/2/24 at 11:15 AM, the privacy curtain for Resident #27 had several circular brown spots. Resident #27 confirmed the privacy curtain was soiled but was unsure how long it had been that way. A record review of the Admission Record revealed the facility admitted Resident #27 on 3/27/23 with current diagnoses including Chronic Heart Failure. A record review of the Quarterly MDS with an ARD of 02/08/24 revealed Resident #27 had a BIMS score of 15, which indicated he was cognitively intact. On 4/4/24 at 12:55 PM, during an interview and observation with Housekeeper #2, she confirmed the privacy curtains were soiled for Resident #6 and Resident #27. She stated that she expected the housekeeping staff to check all curtains daily while cleaning resident rooms and notify the floor technician when curtains needed to be changed. She explained that she would ensure the soiled curtains were changed for these residents. On 4/4/24 at 12:40 PM, during an interview with the Administrator, she explained she was not aware there were soiled privacy curtains in the resident's rooms. She stated that she expected the staff to keep the facility clean and home-like for the residents.

Based on observation, staff interview, and facility policy review, the facility failed to provide an opened date for a multi-use medication vial and failed to ensure medications, food, and biohazard substances were not stored together for two (2) of four (4) medication rooms. Findings include: Record review of the facility's policy Storage of Drugs and Biologicals, dated [DATE], revealed, Policy Statement: It is the policy of this facility that all drugs and biologicals be properly stored . During an interview with Registered Nurse (RN) #2, on [DATE] at 11:20 AM, she stated nurses were responsible for putting the date on vials when opening multi-dose vials, specifically the nurse that first opened them. She explained that nurses were responsible for checking the dates on all medications on the carts and medication storage rooms and for discarding any expired or undated, opened medications every shift. An observation and interview on [DATE] at 11:30 AM, with Licensed Practical Nurse (LPN) #2 in the Central Unit medication room, revealed a refrigerator marked as Biohazard. Opening the refrigerator revealed a container of food, Med Pass (type of Nutritional Supplement), and Grape Juice inside. RN #3 entered the medication room and had vials of blood inside a biohazard plastic bag. RN #3 opened the refrigerator and placed the vials of blood inside the refrigerator with the food items. When asked, RN #3 stated that all nurses were responsible for ensuring biologicals were stored properly. She re-opened the refrigerator, removed, and discarded the food products. RN #3 confirmed that it was an unsafe practice to store food products in a designated biohazard refrigerator because of the risk for contamination. In an interview and observation with the Director of Nursing (DON), on [DATE] at 10:30, in the Rehab medication room, there was a vial of Acetylcysteine 20%. The vial had been opened and there was no date indicating when the vial was opened. There was no resident's name on the vial and the DON disposed of it. The DON revealed that all opened multiuse vials should be labeled with the date it was opened. The DON also confirmed that food products should not be stored in a biohazard refrigerator because it was an unsafe practice due to contamination.

Based on record review and interview the facility's Quality Assurance and Performance Improvement (QAPI) 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 March 2022. This was for two (2) recited deficiencies originally cited in March 2022 on an annual recertification survey. The deficiencies were in the area of residents' rights/environment and investigations. 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 16 deficient practice citations. Findings Include: Record review of the facility's policy, Quality Assessment and Performance Improvement, undated, revealed, .The facility will implement and maintain a Quality Assessment and Performance Improvement program. Overview: The Quality Assurance and Performance Improvement (QAPI) committee will implement a process that is ongoing .The primary purpose of the committee is to identify and analyze actual or potential quality issues, develop and implement appropriate plans to improve performance, to address identified quality issues, and monitor the effectiveness of implemented changes . F584: Based on observation, interviews, record review, and the facility policy review the facility failed to ensure residents' rights for a clean and comfortable environment were honored regarding soiled privacy curtains for two (2) of 30 sampled residents. Resident #6 and Resident #27 F610: Based on interviews, record review, and facility policy review, the facility failed to complete a thorough investigation regarding an injury of unknown origin for one (1) of six (6) residents reviewed for accidents. Resident #242 Record review of the Statement of Deficiencies and Plan of Correction (Form 2567) from the previous annual survey in March 2022, revealed F584 was cited due to shower rooms and resident wheelchairs in disrepair and F610 was cited regarding an investigation of misappropriation. During an interview with the facility's Administrator on 4/4/24 at 2:00 PM, she stated she was not working for the company at the time of the recertification survey that occurred in March 2022. The Administrator confirmed the interdisciplinary team met monthly for a QAPI meeting and discussed the high-risk issues in the facility and provided interventions. She confirmed she had reviewed Form 2567 and was aware of the facility's previous citations. The Administrator stated the QAPI committee had not discussed the soiled privacy curtains because she was unaware there was an issue. She also stated the QAPI committee did not discuss the pelvic fracture investigation because she felt she completed a thorough investigation and had ruled out neglect and abuse during the investigation.

Based on resident interview, staff interview, record review, and facility policy review, the facility failed to ensure a resident was free from verbal abuse for one (1) of seven (7) residents reviewed for abuse, Resident #1. On [DATE], Certified Nursing Assistant (CNA) #1 was witnessed by staff being verbally abusive to Resident #1 in the dining room. CNA #1 was heard calling Resident #1 a mother [***] , told him not to put his mother [***] ing hands on her or she would box him. The incident was reported by Licensed Practical Nurse (LPN) #1 to the on-call nurse, LPN #2, on the day of the incident. LPN #2 spoke with the Director of Nursing (DON), who then instructed LPN #2 to assign CNA #1 to a different area and not have contact with Resident #1. CNA #1 continued to work on [DATE], as well as provided care to Resident #7, who was Resident #1's roommate. CNA #1 was allowed to work at the facility from [DATE] until 12/23/2019, without being suspended. The facility failed to report the verbal abuse to the appropriate State Agencies timely, and failed to protect Resident #1 and all other residents. The facility's failure to protect Resident #1 from verbal abuse and allowing a staff member to work in the facility, without reporting an incident of witnessed verbal abuse, placed Resident #1 and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the verbal abuse occurred. The SA notified the facility of the IJ and SQC on 01/22/2020 at 4:20 PM, and the IJ template was provided to the Administrator. The facility provided a credible Removal Plan on 0[DATE]20, in which the facility alleged all corrective actions were completed as of 0[DATE]20 and the IJ was removed on 01/24/2020. The SA validated the Removal Plan and determined the IJ was removed on 01/24/2020, prior to exit. Therefore, the scope and severity for 43 CFR(s): 4[AGE].12(a)(1), F[AGE]0, Freedom from Abuse, Neglect, and Exploitation, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy, undated, revealed: The resident has the right to be free from abuse. The policy defined Verbal Abuse as the oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. A review of the facility's Resident Rights policy, dated November 28, 2016, revealed: The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Review of a facility reported incident, submitted to the SA on 01/06/2020, documented on [DATE], CNA #1 verbally abused Resident #1. The report included a typed investigation, on the facility's letterhead, dated 1[DATE] and signed by the Administrator. The investigation documented on [DATE], Licensed Practical Nurse (LPN) #1 reported to the on-call nurse (LPN #2), an incident involving a verbal altercation between Resident #1 and CNA #1, which occurred in the dining room. The report documented LPN #1 stated Resident #1 became upset with CNA #1 about his meal, stood up from his chair, and yelled, I am going to beat your mother [***] ing ass. LPN #1 reported CNA #1 responded, You're not going to put your mother[***] ing hands on me. The investigation documented LPN #2 notified the Director of Nursing (DON) and gave instructions for CNA #1 to be reassigned and have no contact with Resident #1 until further notice. The investigation documented on 12/23/2019, the DON interviewed the Dietary Manager (DM), who witnessed the exchange between Resident #1 and CNA #1 on [DATE]. The DM reported CNA #1 entered the kitchen and told him that he needed to talk with Resident #1 about his meal. The DM further reported he asked CNA#1 what was the issue with Resident #1's meal, and she stated, Something isn't right with it, just his usual bullshit. I ain't got time to deal with his[***]today. The DM reported Resident #1 approached CNA #1 and told her You need to shut your [***] ing mouth and get the [***] out of my face. I'll whoop your ass. The DM reported CNA #1 responded, Mother [***] put your hands on me and watch what happens. The DM reported he asked another CNA to get the nurse while he redirected Resident #1 and CNA #1. The investigation report documented actions taken by the facility included Resident #1 was visited by the Social Worker and Nurse Practitioner on 12/23/2019, in-services initiated to staff regarding abuse policy and prevention on 12/24/2019, and the Administrator reviewed CNA #1's personnel file and background. A review of a typed statement by the Dietary Manager, dated and signed 12/23/2019, documented that on [DATE] at approximately 7:55 AM, the DM witnessed the incident between CNA #1 and Resident #1. The DM revealed CNA #1 came to the kitchen door to tell the dietary staff of an issue regarding Resident #1's meal. The DM documented CNA #1 stated loudly (within the presence of residents and staff), Something isn't right with it, just his usual bullshit, I ain't got time to deal with his[***]today. The DM documented Resident #1 approached CNA #1, in his wheelchair, and told her to shut your [***] ing mouth and I'll whoop your ass. The DM further documented, CNA #1 had her hands in fists at her sides, and stated to Resident #1, Mother[***] , put your hands on me and watch what happens. The DM revealed he intervened by stepping between Resident #1 and CNA #1, and instructed Resident #1 to return to his table and for CNA #1 to leave the dining room immediately. The DM revealed he asked another CNA to get a nurse to the dining room immediately. The DM documented when LPN #1 entered the dining room, he informed her of the situation, how it started, and what was said by Resident #1 and CNA #1. During an interview, on 1/21/2020 at 10:30 AM, the Administrator stated what she understood was when the incident occurred on [DATE], LPN #2, the on-call nurse, called the Director of Nursing (DON) to report the incident. The Administrator revealed the DON was informed CNA #1 told Resident #1, You're not going to put your mother [***] ing hands on me. The Administrator stated at the time of the incident, they needed more information about what happened and didn't know all the details. She revealed she needed to get further clarification, before coming to a conclusion, regarding the incident. The Administrator stated she believed at the time of occurrence, they removed CNA #1 from Resident #1, placed her on another hall in the building, thus protecting Resident #1. During an interview, on 01/21/2020 at 12:15 PM, Resident #1 revealed on [DATE], he was sitting in the cafeteria waiting on his breakfast tray and having a conversation with another resident. Resident #1 stated CNA #1 was all up in his business, and he told her to get the hell out of his business. Resident #1 stated CNA #1 went in the kitchen door and he heard her call him a Mother [***] . Resident #1 stated the man in charge of the kitchen (Dietary Manager) was standing right beside CNA #1 when she said that to him. Resident #1 stated he and his mother were not a Mother [***] and nobody was going to call him by that name. Resident #1 stated he also heard CNA #1 call him a Son of a [***] . Resident #1 stated he never threatened to hit CNA #1, but was just upset when she called him those names. Resident #1 stated when he heard what CNA #1 had called him, it made him feel damn low down. On 01/21/2020 at 12:38 PM, during an interview, the DON stated she received a call from LPN #2, on [DATE], regarding an incident in the dining room between Resident #1 and CNA #1, where they had cussed at each other. The DON stated she informed LPN #2 to tell LPN #1 for CNA #1 not to have any further contact with Resident #1. The DON revealed that was the last thing she heard about the issue until she returned to the facility on [DATE]. The DON stated she didn't think much about it, because it wasn't unusual for Resident #1 to curse staff, but it was uncommon for staff to curse him back. The DON stated after reading the written statements, when she returned on 12/23/2019, she realized that she should have sent CNA #1 home on [DATE]. The DON stated she would consider the incident to be verbal abuse. During a telephone interview, on 01/21/2020 at 1:00 PM, LPN #2 confirmed she was the on-call nurse on [DATE]. LPN #2 stated LPN #1 called and told her Resident #1 was in the dining room threatening CNA #1. LPN #2 stated LPN #1 told her Resident #1 stood up from his wheelchair and stated he was going to whip CNA #1's mother [***] ing ass. LPN #2 revealed LPN #1 further stated CNA #1 told Resident #1 he was not going to lay a mother [***] ing hand on her. LPN #2 stated she instructed LPN #1 to get CNA #1 to swap out residents with another CNA, and CNA #1 was not to have any contact with Resident #1. LPN #2 stated she called the DON and told her exactly what LPN #1 told her regarding the incident. LPN #2 revealed the DON instructed her to tell LPN #1 to swap CNA #1 out with another CNA taking care of Resident #1 as well. LPN #2 stated that she felt like CNA #1 cursing Resident #1 was considered verbal abuse. LPN #2 revealed the facility's policy stated it's not acceptable for staff to curse a resident. LPN #2 stated she felt the right decision was made on [DATE] when they moved CNA #1 away from Resident #1 until a thorough investigation could be done. During an interview, on 01/21/2020 at 2:45 PM, the Dietary Manager (DM) confirmed he was working the day of the incident ([DATE]). The DM stated Resident #1 was sitting in his normal place, when CNA #1 came to the kitchen door and said y'all need to talk to Resident #1 about his breakfast. The DM stated he asked CNA #1 what was wrong with Resident #1's breakfast and she stated just Resident #1 and his bullshit. The DM revealed what CNA #1 said, was loud enough to be heard by Resident #1. The DM revealed he saw Resident #1 push back from the table and start rolling in his wheelchair towards the kitchen door where CNA #1 was standing. The DM stated when Resident #1 approached CNA #1, Resident #1 told CNA #1 she needed to shut her [***] ing mouth and didn't need to be talking about him or he was going to whip her [***] ing ass. The DM stated he saw CNA #1 ball her fists up, but kept them at her side. The DM stated CNA #1 told Resident #1, Look here you mother [***] ing son of a [***] , if you come towards me, I'll knock you the [***] out. The DM stated he intervened and separated Resident #1 and CNA #1. The DM revealed he instructed CNA #1 to leave the dining room immediately, but she refused. The DM stated when CNA #1 refused to leave the dining room, he instructed another CNA in the dining room, to go and get a nurse. The DM revealed he instructed Resident #1 to go back to his table. The DM stated LPN #1 came to the dining room, and he pulled her aside and told her about the incident between Resident #1 and CNA #1. During an interview, on 01/21/2020 at 3:11 PM, CNA #2 stated that she was in the dining room, passing out meal trays, on [DATE], when the incident happened between Resident #1 and CNA #1. CNA #2 stated Resident #1 opened his tray up and said, I don't want this[***] and slid the tray across the table. CNA #2 stated she heard CNA #1 tell someone in the kitchen that they needed to come and see what was wrong with Resident #1's tray. CNA #2 stated Resident #1 was sitting at the table and suddenly pushed back and rolled to the kitchen door where CNA #1 was standing. CNA #2 stated told CNA #1, I heard what you said twice, along with a bunch of cuss words. CNA #2 revealed Resident #1 stood up from his wheelchair and stood over her (taller than CNA #1) and told CNA #1 he would beat her ass. CNA #2 stated she ran over to Resident #1 and intervened by telling the resident no and tried to assist him back into his wheelchair. CNA #2 stated CNA #1 told Resident #1, If you put your hands on me today, I'm going to box your ass. CNA #2 stated the Dietary Manager came out of the kitchen and told Resident #1 to go back to his seat. CNA #2 confirmed the Dietary Manager told CNA #1 to leave the dining room. A review of a written statement given by CNA #2, undated and provided by the facility, CNA #2 documented on 12/21/19 she heard CNA #1 curse Resident #1. The statement documented CNA #1 told Resident #1, (Name of Resident #1) if you put your hands on me, I will box your mother [***] ing ass. During an interview via phone on 1/21/20 at 4:29 PM, LPN #1 stated that Resident #1 and CNA #1 were in the dining room and she was called to the dining room by another CNA, who stated Resident #1 was threatening CNA #1. LPN #1 stated when she arrived, the Dietary Manager was talking to Resident #1. LPN #1 stated she noticed Resident #1 and CNA #1 were upset. LPN #1 stated CNA #1 told her Resident #1 had threatened to hit her. LPN #1 stated she told CNA #1 to come out of the dining room and she sent another CNA to the dining room to take CNA #1's place. LPN #1 revealed CNA #1 told her that Resident #1 didn't like what he got on his tray, got upset and threatened to hit her. LPN #1 stated she called the on-call phone nurse, LPN #2, and told her about the incident in the dining room with Resident #1 and CNA #1. LPN #1 stated LPN #2 told her to get CNA #1 out of the dining room and that she would call either the Administrator or the Director of Nursing (DON). LPN #1 stated she couldn't remember who called her back, but she was told to make sure CNA #1 didn't have any contact with Resident #1. During an interview, on 01/21/2020 at 4:37 PM, CNA #1 stated the incident with Resident #1 occurred on a weekend (Saturday, [DATE]). CNA #1 stated Resident #1 was in the dining room at breakfast, and he started fussing and cursing. CNA #1 stated she told him if he didn't stop, he would have to leave the dining room. CNA #1 stated she went to the kitchen to see about oatmeal for another resident and told the Dietary Manager to come and talk to Resident #1 because he was fussing about his food. CNA #1 stated while her back was turned, Resident #1 came over in his wheelchair, stood up and stated, I'm fixing to beat this black [***] . CNA #1 stated she told Resident #1, Don't put your mother [***] ing hands on me. CNA #1 confirmed CNA #2 came over, got between them, and tried to get Resident #1 to sit down in his chair. CNA #1 stated the Dietary Manager told her to get out of the dining room and that she couldn't talk to a resident like that. CNA #1 stated she told the Dietary Manager that Resident #1 was about to hit her, and she felt threatened. CNA #1 stated the Dietary Manager told her twice to leave the dining room, but she refused because she hadn't done anything. CNA #1 stated she left the dining room and told LPN #1 what had happened. CNA #1 revealed LPN #1 told her she was going to have to call the on-call nurse (LPN #2). CNA #1 stated LPN #2 called back and instructed LPN #1 to have her stay away from Resident #1. CNA #1 stated she continued to work on the hall, on [DATE], where Resident #1 resided and cared for Resident #1's roommate (Resident #7), who was non-verbal. CNA #1 stated if Resident #1 was in the room, she would leave and return when he wasn't present in the room. CNA #1 stated on 1[DATE]19, LPN #2 called the facility and told her not to work the dining room since Resident #1 ate in there. CNA #1 stated she was called to the Administrator's office on 12/23/2019 to discuss what had occurred on [DATE] with Resident #1 and to write a statement. CNA #1 stated she told the Administrator that she did curse Resident #1, even if it costed her job. A review of the Activity of Daily Living (ADL) look back report for Resident #7, who was Resident #1's roommate, revealed, CNA #1 provided care for Resident #7 on 12/21/19 at 10:44 AM. Care was provided after the incident in the dining room with Resident #1. Review of the time sheet for CNA #1, revealed she clocked in for work at the facility on [DATE], 1[DATE]19, and 12/23/2019. A review of the facility's Job Description for a Certified Nursing Assistant (CNA), signed on 06/17/19 by CNA #1, revealed: Assist in maintaining a positive physical and psychosocial environment for the residents. Essential duties and responsibilities included to maintain positive relationships with the residents. Review of the personnel file for CNA #1 revealed, a copy of the facility's Freedom for Abuse, Neglect, and/or Exploitation Prevention Plan Education, dated 06/17/2019 and signed by CNA #1. There were no prior discipline records noted. Review of a Sign In Sheet for an in-service, on Abuse and Neglect Prevention, dated 10/03/ , revealed CNA #1 signed as being in attendance. During an interview, on 01/22/2020 at 10:54 AM, the Administrator stated she felt like CNA #1 verbally abused Resident #1. On 01/22/2020 at 12:31 PM, during an interview, the DON stated she felt that CNA #1 cursing Resident #1 was verbal abuse, and she should have sent CNA #1 home pending further investigation. The DON stated she did not protect Resident #1 or any of the other residents by not sending CNA #1 home. A review of a typed statement by the DON, dated 12/23/2019, documented during an interview with CNA #1, she stated she had cursed Resident #1. During an interview, on 01/22/2020 at 3:15 PM, CNA #3 stated she was in the dining room on [DATE]. CNA #3 stated she heard CNA #1 tell Resident #1 not to put his mother [***] ing hands on her. CNA #3 stated the Dietary Manager came out of the kitchen and told CNA #1 to leave the dining room because she didn't have any business talking to Resident #1 like that. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which indicated cognitively intact. The facility submitted a credible Removal Plan on 0[DATE]20, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. 1. Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. On [DATE]20 100% of facility residents were assessed by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The Facility Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. A meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The Administrator, SSD, DON and Assistant DON initiated in- service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. On 12/30/2019, The Attorney General Office online report was submitted by the Facility Administrator. 7. On 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. On 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. On 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed and the jeopardy abated as of 0[DATE]20. The SA validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ. 1. The State Agency (SA) validated through record review, Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. The SA validated through record review, that on 0[DATE]20, a 100% assessment of facility residents by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The SA validated through interview and record review, the Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. The SA validated through interview and record review, a meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The SA validated through interview and record review, the Administrator, SSD, DON and Assistant DON initiated in- service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. The SA validated through interviews and record review, a Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. The SA validated through record review, on 12/30/2019, the Attorney General Office online report was submitted by the Facility Administrator. 7. The SA validated through interview and record review, on 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. The SA validated through interview and record review, on 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. The SA validated through interviews and record review, on 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed as of 0[DATE]20, and the IJ removed as of 01/24/2020.

Based on staff interview, record review, and facility policy review, the facility failed to prevent further potential abuse and mistreatment from occurring, after a witnessed incident of staff to resident abuse, for one (1) of seven (7) residents reviewed, Resident #1. On [DATE], Certified Nursing Assistant (CNA) #1 was witnessed by staff being verbally abusive to Resident #1 in the dining room. CNA #1 was heard calling Resident #1 a mother [***] , told him not to put his mother [***] ing hands on her or she would box him. The incident was reported by Licensed Practical Nurse (LPN) #1 to the on-call nurse, LPN #2, on the day of the incident. LPN #2 spoke with the Director of Nursing (DON), who then instructed LPN #2 to assign CNA #1 to a different area and not have contact with Resident #1. CNA #1 continued to work on [DATE], as well as provided care to Resident #7 (Resident #1's roommate). CNA #1 was allowed to work at the facility from [DATE] until 12/23/2019, without being suspended. The facility failed to report the verbal abuse to the appropriate State Agencies timely and failed to protect Resident #1 and all other residents. The facility's failure to thoroughly investigate a witnessed staff to resident incident of verbal abuse, and prevent further potential abuse by allowing the staff member to continue working at the facility, placed Resident #1 and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the verbal abuse occurred. The SA notified the facility of the IJ and SQC on 01/22/2020 at 4:20 PM, and the IJ template was provided to the Administrator. The facility provided a credible Removal Plan on 0[DATE]20, in which the facility alleged all corrective actions were completed as of 0[DATE]20 and the IJ was removed on 01/24/2020. The SA validated the Removal Plan and determined the IJ was removed on 01/24/2020, prior to exit. Therefore, the scope and severity for 43 CFR(s): 4[AGE].12(c)(2)-(4), F610, Investigate/Prevent/Correct Alleged Violation, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy, undated, revealed: The resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, serving the resident. The facility's goal is to protect the resident from abuse. The facility has developed and implemented written policies and procedures designed to prohibit and prevent mistreatment. The prohibition plan includes the following components: Abuse and neglect prevention, identification of events, patterns or trends that may constitute abuse, investigation of allegations, protecting of the resident during investigations, reporting and responding. The facility will report alleged violations, conduct investigations of alleged violations, report the results to proper authorities, and take necessary corrective actions. A review of the facility policy titled, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan - Protection policy, undated, revealed, residents will be protected during an investigation whether it is abuse, neglect, exploitation, or mistreatment. The Administrator or the person in charge shall separate the alleged victim and the accused person immediately and maintain that separation until investigations are completed. While the investigation is being conducted, the employee accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator. Review of a facility reported incident, submitted to the SA on 01/06/2020, documented on [DATE], CNA #1 verbally abused Resident #1. The report included a typed investigation, on the facility's letterhead, dated 1[DATE] and signed by the Administrator. The investigation documented on [DATE], Licensed Practical Nurse (LPN) #1 reported to the on-call nurse (LPN #2), an incident between Resident #1 and CNA #1, which occurred in the dining room. The report documented LPN #1 stated Resident #1 became upset with CNA #1 about his meal, stood up from his wheelchair, and yelled, I am going to beat your mother [***] ing ass. LPN #1 reported CNA #1 responded, You're not going to put your mother [***] ing hands on me. The investigation documented LPN #2 notified the Director of Nursing (DON) and was given instructions for CNA #1 to be reassigned to another hall, and to have no contact with Resident #1. The investigation report documented the actions taken by the facility included a visit by the Social Worker and Nurse Practitioner with Resident #1 on 12/23/2019, in-services with staff regarding abuse policy and prevention initiated on 12/24/2019, and the Administrator reviewed CNA #1's personnel file and background. There was no documentation of CNA #1 being suspended or sent home on the day of the incident ([DATE]). During an interview, on 01/21/2020 at 10:30 AM, the Administrator stated if she would have known the detailed statements, CNA #1 would have been suspended the day the incident occurred. The Administrator stated her understanding was that LPN #2 called the DON to report CNA #1 told Resident #1, You are not going to put your mother [***] ing hands on me. The Administrator stated at the time the DON was notified, they needed more information about what happened and didn't know all the details. The Administrator stated CNA #1 worked at the facility on [DATE], 1[DATE]19 and 12/23/2019, until she was called to the office, on 12/23/2019, to make a statement regarding the incident. The Administrator stated CNA #1 got mad and left during the interview. The Administrator stated the facility's policy revealed it is their responsibility to protect residents immediately. The Administrator stated she believed at the time of the incident ([DATE]), they removed CNA #1 away from the resident, and placed her on another hall in the building, thus protecting Resident #1. During an interview, on 01/21/2020 at 12:38 PM, the Director of Nursing (DON) stated she received a call from Licensed Practical Nurse (LPN) #2, on [DATE], regarding an incident in the dining room between Resident #1 and CNA #1, where they had cursed at each other. The DON stated she told LPN #2 to instruct LPN #1 not to allow CNA #1 to have any further contact with Resident #1. The DON stated that was the last thing she heard about the issue until she returned to the facility on [DATE]. The DON revealed she didn't think much about it, because it wasn't unusual for Resident #1 to curse staff, but it was uncommon for staff to curse back at the resident. The DON stated after she read the written statements, when she returned on 12/23/2019, she realized she should have sent CNA #1 home on [DATE]. During an interview, on 01/21/2020 at 4:37 PM, CNA #1 stated, on [DATE], she was assigned to two (2) rooms on the 100 Hall, which included Resident #1's room. CNA #1 stated she stayed on the 100 hall and took care of Resident #1's roommate (Resident #7). CNA #1 stated she saw Resident #1 about three (3) more times, after the incident in the dining room. CNA #1 stated if Resident #1 was in the room, when she went to do patient care with Resident #7, she would leave and come back. An observation of Resident #7, by the State Agency, revealed the resident was non-verbal. A review of the time sheet for CNA #1 revealed she worked at the facility on [DATE], 1[DATE]19 and 12/23/2019. A review of the facility's assignment sheet, dated [DATE], revealed CNA #1 was assigned to Resident #1's room and one other room on the 100 Hall. Review of the facility's Activities of Daily Living look back report for Resident #7 (roommate of Resident #1), dated [DATE], revealed CNA #1 provided care for Resident #7 at 10:44 AM, which was approximately two (2) hours after the incident with Resident #1 in the dining room. The facility submitted an acceptable Removal Plan on 0[DATE]20, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. 1. Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. On [DATE]20, 100% of facility residents were assessed by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The Facility Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. A meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The Administrator, SSD, DON and Assistant DON initiated in-service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. On 12/30/2019, The Attorney General Office online report was submitted by the Facility Administrator. 7. On 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. On 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. On 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed and the jeopardy abated as of 0[DATE]20. The SA validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ. 1. The State Agency (SA) validated through record review, Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. The SA validated through record review, that on 0[DATE]20, a 100% assessment of facility residents by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The SA validated through interview and record review, the Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. The SA validated through interview and record review, a meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The SA validated through interview and record review, the Administrator, SSD, DON and Assistant DON initiated in- service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. The SA validated through interviews and record review, a Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. The SA validated through record review, on 12/30/2019, the Attorney General Office online report was submitted by the Facility Administrator. 7. The SA validated through interview and record review, on 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. The SA validated through interview and record review, on 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. The SA validated through interviews and record review, on 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed as of 0[DATE]20, and the IJ removed as of 01/24/2020.

Based on staff interview, record review, and facility policy review, the facility failed to report an allegation of staff to resident abuse within the two (2) hour required timeframe, for one (1) of seven (7) residents reviewed, Resident #1. On [DATE], Certified Nursing Assistant (CNA) #1 was witnessed by staff being verbally abusive to Resident #1 in the dining room. CNA #1 was heard calling Resident #1 a mother [***] , told him not to put his mother [***] ing hands on her or she would box him. The incident was reported by Licensed Practical Nurse (LPN) #1 to the on-call nurse, LPN #2, on the day of the incident. LPN #2 spoke with the Director of Nursing (DON), who then instructed LPN #2 to assign CNA #1 to a different area and not have contact with Resident #1. CNA #1 continued to work on [DATE], as well as provided care to Resident #7, who was Resident #1's roommate. CNA #1 was allowed to work at the facility from [DATE] until 12/23/2019, without being suspended. The facility failed to report the witnessed incident of verbal abuse to the appropriate State Agencies in a timely manner and failed to protect Resident #1 and all other residents. The facility's failure to notify the appropriate state agencies in a timely manner of an incident of witnessed verbal abuse, to ensure proper measures had been addressed, and allowing the staff member to continue working at the facility, placed Resident #1 and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the verbal abuse occurred. The SA notified the facility of the IJ and SQC on 01/22/2020 at 4:20 PM, and the IJ template was provided to the Administrator. The facility provided a credible Removal Plan on 0[DATE]20, in which the facility alleged all corrective actions were completed as of 0[DATE]20 and the IJ was removed on 01/24/2020. The SA validated the Removal Plan and determined the IJ was removed on 01/24/2020, prior to exit. Therefore, the scope and severity for 43 CFR(s): 4[AGE].12(c)(1)(4), F[AGE]9, Reporting of Alleged Violations, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan - Reporting/Response policy, revised 08/23/2017, revealed: If a covered individual of the facility becomes aware of information that gives him/her the reasonable suspicion that a crime has occurred against a resident or individual receiving care from this facility, he/she must notify the Administrator of the facility, the State Survey Agency and Attorney General's Office, and local Law Enforcement Agency. Reports must be within two (2) hours (if the allegation involves abuse or there is serious bodily injury) after forming reasonable suspicion. A review of an on-line submission record, sent to the Medicaid Fraud Control Unit (MFCU), revealed the Administrator submitted the report, on 12/30/2019, regarding the alleged verbal abuse incident, which occurred on [DATE]. Review of a facility reported incident to the State Agency, submitted on 01/06/2020, revealed an incident of verbal abuse occurred at the facility on [DATE], between CNA #1 and Resident #1. A review of a typed document, undated and signed by the Administrator revealed, the incident of verbal abuse, which occurred on [DATE], was reported to the Mississippi State Department of Health ([CONDITION]DH) hotline on 12/23/2019. The final investigative report was mailed to [CONDITION]DH and the Attorney General's Office on 1[DATE]. The State Agency (SA) confirmed via phone interview with SA Triage office, the Administrator reported the verbal abuse incident, which occurred on [DATE], on 12/23/2019. During an interview, on 01/21/2019 at 2:30 PM, the Administrator stated she did not call the incident of verbal abuse (which occurred on [DATE]), into the State Survey Agency until 12/23/2019, after she started the investigation. The Administrator stated she thought she had 24 hours to report the incident, since there was no known injury. The Administrator revealed she did not know an incident of alleged abuse had to reported within two (2) hours. During an interview, on 01/22/2020 at 12:14 PM, the Administrator revealed she did not report the incident to any local Law Enforcement Authority. The Administrator stated that she called the incident of verbal abuse to the State Survey Agency on 12/23/2019, and to the Attorney General's (AG) Office on 12/30/2019. The Administrator stated she mailed the final investigation information to the AG's office and State Agency on 1[DATE]. A review of the facility's Job Description for the Nursing Home Administrator (NHA), dated 08/10/2017, revealed: The NHA will be responsible for the overall operations, leadership, management and success of the facility in accordance with resident/employee needs, government regulations, and company policy. Essential duties and responsibilities included, to oversee facility investigations and [MEDICATION NAME], and to carry out supervisory responsibilities in accordance with the organizations policies and applicable laws. The facility submitted a credible Removal Plan on 0[DATE]20, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. 1. Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. On [DATE]20 100% of facility residents were assessed by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The Facility Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. A meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The Administrator, SSD, DON and Assistant DON initiated in-service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. On 12/30/2019, The Attorney General Office online report was submitted by the Facility Administrator. 7. On 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. On 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. On 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed and the jeopardy abated as of 0[DATE]20. The SA validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ. 1. The State Agency (SA) validated through record review, Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. The SA validated through record review, that on 0[DATE]20, a 100% assessment of facility residents by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The SA validated through interview and record review, the Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. The SA validated through interview and record review, a meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The SA validated through interview and record review, the Administrator, SSD, DON and Assistant DON initiated in- service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. The SA validated through interviews and record review, a Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. The SA validated through record review, on 12/30/2019, the Attorney General Office online report was submitted by the Facility Administrator. 7. The SA validated through interview and record review, on 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. The SA validated through interview and record review, on 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. The SA validated through interviews and record review, on 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed as of 0[DATE]20, and the IJ removed as of 01/24/2020.

Based on staff interview, record review and facility policy review, the facility failed to implement their Abuse policy for protection of residents from verbal abuse, failed to protect other residents, and failed to report the allegation of abuse in a timely manner, for one (1) of seven (7) residents, Resident #1. This was evidenced by the facility allowing Certified Nursing Assistant (CNA) #1 to return to work following an incident of witnessed verbal abuse toward Resident #1. The facility failed to report the allegation of abuse to the required state agencies within the two (2) hour timeframe, per policy, to ensure appropriate actions were taken. On [DATE], CNA #1 was witnessed being verbally abusive to Resident #1 in the dining room, by staff members. CNA #1 was overheard calling Resident #1 a mother [***] , told him not to put his mother [***] ing hands on her or she would box him. The incident was reported by Licensed Practical Nurse (LPN) #1 to the on-call nurse, LPN #2, on the same day of the incident. LPN #2 reported the incident to the Director of Nursing (DON), who then informed LPN #2 to assign CNA #1 to a different hall, and for CNA #1 not to have any contact with Resident #1. CNA #1 was allowed to continue working on [DATE], and provided care to Resident #1's roommate, Resident #7. CNA #1 continued to work at the facility from [DATE] until 12/23/2019, without being suspended. The facility failed to report the verbal abuse to the appropriate State Agencies in a timely manner and failed to protect Resident #1 and all other residents. The failure of the facility to protect residents from verbal abuse by allowing a staff member to remain working at the facility, and failure to report an incident of witnessed verbal abuse within to two (2) hours to the designated State Agencies, per facility policy, placed Resident #1 and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the verbal abuse occurred. The SA notified the facility of the IJ and SQC on 01/22/2020 at 4:20 PM, and the IJ template was provided to the Administrator. The facility provided a credible Removal Plan on 0[DATE]20, in which the facility alleged all corrective actions were completed as of 0[DATE]20 and the IJ was removed on 01/24/2020. The SA validated the Removal Plan and determined the IJ was removed on 01/24/2020, prior to exit. Therefore, the scope and severity for 43 CFR(s): 4[AGE].12(b)(1)-(3), F[AGE]7, Develop/Implement Abuse/Neglect Policies was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy, undated, revealed: The resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, serving the resident. The facility's goal is to protect the resident from abuse. The facility has developed and implemented written policies and procedures designed to prohibit and prevent mistreatment. The prohibition plan includes the following components: Screening prospective employees, staff training, abuse and neglect prevention, identification of events, patterns or trends that may constitute abuse, investigation of allegations, protecting of the resident during investigations, reporting and responding. The facility will report alleged violations, conduct investigations of alleged violations, report the results to proper authorities, and take necessary corrective actions. Review of a facility reported incident, submitted to the SA on 01/06/2020, documented on [DATE], CNA #1 verbally abused Resident #1. The report included a typed investigation, on the facility's letterhead, dated 1[DATE] and signed by the Administrator. The investigation documented on [DATE], Licensed Practical Nurse (LPN) #1 reported to the on-call nurse (LPN #2), an incident between Resident #1 and CNA #1, which occurred in the dining room. The report documented LPN #1 stated Resident #1 became upset with CNA #1 about his meal, stood up from his wheelchair, and yelled, I am going to beat your mother [***] ing ass. LPN #1 reported CNA #1 responded, You're not going to put your mother [***] ing hands on me. The investigation documented LPN #2 notified the Director of Nursing (DON) and was given instructions for CNA #1 to be reassigned to another hall, and to have no contact with Resident #1 until further notice. The investigation report documented the actions taken by the facility included a visit by the Social Worker and Nurse Practitioner with Resident #1 on 12/23/2019, in-services initiated with staff regarding abuse policy and prevention on 12/24/2019, and the Administrator reviewed CNA #1's personnel file and background. There was no documentation of CNA #1 being suspended or sent home on the day of the incident ([DATE]). During an interview, on 01/21/2020 at 10:30 AM, the Administrator stated if she had known the detailed statements regarding the incident on [DATE] between CNA #1 and Resident #1, she would have suspended CNA #1. The Administrator stated it is the facility's policy to protect residents immediately. Upon review of the facility's Abuse policy, the Administrator stated they didn't follow the policy for reporting abuse. Review of the facility's Job Description for the Nursing Home Administrator (NHA), revealed: The NHA is responsible for the overall operations, leadership, management and success of the facility. Essential duties and responsibilities included to implement and communicate policies and procedures and oversee facility investigations and [MEDICATION NAME]. During an interview, on 01/21/2020 at 12:15 PM, Resident #1 revealed on [DATE], he was having a conversation with another resident and CNA #1 was all up in his business. Resident #1 stated he told CNA #1 to get the hell out of his business. Resident #1 stated CNA #1 went over to the kitchen door, and he heard her call him a Mother [***] . Resident #1 stated the Dietary Manager was standing right beside CNA #1 when she said it. Resident #1 stated he nor his mother was a Mother [***] and nobody was going to call him by that name. Resident #1 stated CNA #1 also called him a Son of a [***] . Resident #1 revealed he never threatened to hit CNA #1, but was upset when she called him those names. During an interview, on 01/21/2020 at 12:38 PM, the Director of Nursing (DON) stated the facility did not follow the policy to protect Resident #1 when CNA #1 was not sent home for cursing Resident #1. During an interview, on 01/21/2020 at 4:37 PM, CNA #1 confirmed that on the day of incident, she told Resident #1, Don't put your mother [***] ing hands on me. CNA #1 stated she told the Administrator on 12/23/2019 that she had cursed Resident #1. CNA #1 stated that she stayed on the 100 Hall on 12/21/19 and took care of Resident #7 (Resident #1's roommate). CNA #1 stated she saw Resident #1 probably three (3) more times after the incident in the dining room. CNA #1 stated Resident #1 was in the room when she went in to do patient care with Resident #7, but she left and came back when Resident #1 was gone from the room. A review of the time sheet for CNA #1 revealed she worked in the facility 12/21/19, 12/22/19 and [DATE]. A review of the facility scheduling document dated 12/21/19 revealed CNA #1 was assigned to resident rooms on the 100 Hall, which included Resident #1's room. During an interview, on 01/21/20 at 2:30 PM, the Administrator stated that she did not call the allegation of verbal abuse into the State Survey Agency until [DATE], after she started the investigation. The Administrator stated she thought she had 24 hours to report since there was no known injury. She stated she did not know she had to report an alleged abuse within two (2) hours. The Administrator revealed she did not report the incident of abuse to any local Law Enforcement Authority. She stated she called the incident of abuse to the State Survey Agency on 12/23/2019, to the Attorney General's Office (AG) on 12/30/2019 and mailed the final investigation information to the AG's office and to the State Agency on 1[DATE]. The facility submitted an acceptable Removal Plan on 0[DATE]20, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. 1. Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. On [DATE]20, 100% of facility residents were assessed by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The Facility Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. A meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The Administrator, SSD, DON and Assistant DON initiated in-service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. On 12/30/2019, The Attorney General Office online report was submitted by the Facility Administrator. 7. On 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. On 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. On 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed and the jeopardy abated as of 0[DATE]20. The SA validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ. 1. The State Agency (SA) validated through record review, Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. The SA validated through record review, that on 0[DATE]20, a 100% assessment of facility residents by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The SA validated through interview and record review, the Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. The SA validated through interview and record review, a meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The SA validated through interview and record review, the Administrator, SSD, DON and Assistant DON initiated in- service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. The SA validated through interviews and record review, a Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. The SA validated through record review, on 12/30/2019, the Attorney General Office online report was submitted by the Facility Administrator. 7. The SA validated through interview and record review, on 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. The SA validated through interview and record review, on 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. The SA validated through interviews and record review, on 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed as of 0[DATE]20, and the IJ removed as of 01/24/2020.

CI MS # Based on observation, interview, record review, policy review, and facility investigation review, the facility failed to provide adequate supervision to prevent the elopement of Resident #1 and Resident #2 out of an identified malfunctioning locked door for two (2) of six (6) sampled residents reviewed for supervision. The facility identified Resident #1 as at risk for Elopement on 10/16/15 and the facility identified Resident #2 as at risk for Elopement on 5/17/16. On 6/12/16 at approximately 6:45 PM, a member of the community entered the facility and alerted facility staff that two confused ladies had walked down the street to his garage and were unable to tell him where they lived. The facility was not aware that Resident #1 and Resident #2 had exited the building without supervision until the community member arrived. The facility investigation revealed Resident #1 and Resident #2 exited the building from a malfunctioning back hallway door of the locked ladies unit. Observation of the outdoor area revealed Resident #1 and Resident #2 walked away from the building, through a large wooden gate, down a side street, crossing a busy two lane city street, down another street leading into a subdivision to the eighth house on the left. This was a total of 787 walked steps from the back door of the building. The facility's failure to report a malfunction of a locked exit door and failure to supervise residents with a risk for elopement placed Resident #1 and Resident #2 in a situation that was likely to cause serious harm, injury, impairment, or death. This was determined to be an Immediate Jeopardy (IJ) that began on 6/12/16 when Resident #1 and Resident #2 eloped from the facility through a malfunctioning door that was supposed to remain locked. The State Agency notified the facility on 6/14/16 of the Immediate Jeopardy (IJ) and Substandard Quality of Care at 42 CFR 483.25 (h) Accident Hazards (F323). The facility submitted an acceptable Allegation of Compliance (AoC) on 6/17/16. The State Agency surveyor validated the facility's AoC on 6/17/16 prior to exit and determined the IJ was removed on 6/16/16. The scope and severity for the IJ at 42 CFR 483.25(h) Accident Hazards (F323) was lowered to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of systemic changes. Findings include: Review of the facility's policy, entitled, Elopement/Unsafe Wandering Plan, dated February 7, 2012, revealed, It is the policy of this facility to protect the resident from harm while providing care in a manner that promote quality of life in a safe environment . Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Review of the facility's elopement investigation of events on 6/12/16 for Resident #1 and Resident #2 revealed the last time both residents were seen in the facility was at 6:15 PM when Licensed Practical Nurse (LPN) #1 gave Resident #2 her 6:00 PM medications. The investigation read that after the elopement, Certified Nurses Assistant (CNA) #1 reported that on 6/12/16 at 5:00 PM, Resident #2 shook the back door vigorously about three (3) times and the door opened. CNA #1 reported that she closed the door back and redirected Resident #2. Review of the facility's time line revealed the back door of the locked unit was not functioning properly and the door would open freely from both sides without using the door keypad. The investigation showed that the facility placed staff at the back door from 6/13/16 until an ordered part arrived and the door was repaired by the electrician on 6/17/16. On 6/14/16 between 6:15 PM and 6:30 PM at the time of day of the elopement, the State Agency (SA) surveyor counted a total of eighty-seven (87) cars passed on the busy city street that Resident #1 and Resident #2 crossed unsupervised on 6/12/16. Resident #1 Observation and interview on 6/17/16 at 9:26 AM with Resident #1 revealed when asked what she liked to do, Resident #1 stated, Real nice, and when asked her profession, Resident #1 responded, I put on red pants. Resident #1 was pleasantly confused and unable to answer questions. Resident #1 stated while looking out of the window, it was so pretty outside and pointed to the building across the street. Resident #1 was walking around the main dining room, neatly dressed, and pleasantly confused. An interview on 6/15/16 at 11:32 AM with Resident #1's Responsible Party (RP) was unsuccessful and a message was left to return call. Resident #1's RP did not return call. Review of the facility's Wandering Risk Evaluation, dated 2/22/16, revealed Resident #1 was checked as a known wanderer/history of wandering. Review of the facility's Medical Professional Progress Note on 6/12/16 at 11:29 PM, for Late Entry 6:30 PM to 7:00 PM by LPN #1 documented Resident #1 was returned to the female locked unit after being outside without proper leave/supervision and was returned safely. Review of the Face Sheet revealed the facility admitted Resident #1 on 7/17/15 with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of 4/4/16, revealed Resident # 1 scored three (3) on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. Resident #2 Review of the facility's Wandering Risk Evaluation, dated 5/17/16, revealed Resident #2 was checked as a known wanderer/history of wandering. Review of the facility's Medical Professional Progress Note dated 6/12/16 at 10:14 PM, as a Late Entry 6:00 PM to 7:00 PM by LPN #1 documented Resident #2 was returned to the locked female unit after being outside without proper leave/supervision and was returned safely. In a telephone interview on 6/15/16 at 11:38 AM with Resident #2's Responsible Party (RP), the RP revealed she was notified of the elopement when she returned from out of the country on Monday night, 6/13/16. Resident #2's RP stated Resident #2 likes to go outside. Observation and interview with Resident #2 on 6/15/16 at 2:20 PM revealed resident in room and neatly dressed with a yellow armband on, but with no name on her arm band per policy. Resident #2 was pleasantly confused and unable to be interviewed. When asked if she remembered the man from down the street, Resident #2 responded, Could be. Could be. That's been a while. He was pleasant. Review of the Face Sheet revealed the facility admitted Resident #2 on 5/5/16 with the [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of 5/5/16, revealed Resident # 2 scored four (4) on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. Review of a statement, dated 6/12/16 and signed by CNA #2 revealed, around 6:45 PM a stranger came to CNA #2 and asked if the facility was missing two ladies. CNA #2's documented reply was, I am not sure, why? CNA #2 documented the man stated there were two ladies who came into his garage, and the ladies didn't want to leave. CNA #2 stated she could see two people in the distance. CNA #2 documented, The ladies were about four (4) to five (5) houses out when my co-worker and I got to them. We assisted them back to the building and as we entered the front lawn, the nurse for (Unit Hall) came to meet us. CNA #2 stated, they entered the building around 7:15 PM and CNA #2 left the ladies on (Unit Hall) with the Nurse. Interview on 6/15/16 at 6:43 PM with the member of the community revealed on 6/12/16 he found two ladies wandering into his garage and they were confused and unable to provide any information. He stated the two ladies did not want to leave. He stated he then remembered there was a nursing home at the end of the street, and he drove there to see if the staff knew the ladies. Interview on 6/14/16 at 4:50 PM with LPN #1 revealed on 6/12/16 while working the 3:00 PM to 11:00 PM shift, one of the CNAs came up to him and asked if anyone was missing from his unit, the female locked unit? LPN #1 stated he responded to them that he was not sure. LPN #1 stated the staff reported that two (2) ladies were just returned to the facility. LPN #1 stated he left the unit to the parking lot and recognized Resident #1 and Resident #2 from his unit. LPN #1 stated he remembered seeing both residents on the unit between 4:00 PM and 5:00 PM. LPN #1 confirmed both Resident #1 and Resident #2 were identified as being at risk for elopement. LPN #1 stated body audits were completed on both residents with no injuries noted. LPN #1 stated the back door was not open when checked but the back gate was ajar. Interview on 6/15/16 at 11:05 AM with LPN #2 revealed on the day of the elopement, she witnessed Resident #1 walking up and down the hall on the female locked unit stating, I've got to go home. I've got to go home. LPN #2 stated she did not see Resident #1 attempting to leave the unit prior to the elopement. LPN #2 stated if she saw a resident on the locked unit attempting to leave the unit, she would try to distract them. Interview on 6/14/16 at 4:35 PM with CNA #2 revealed she worked the 3:00 PM to 11:00 PM shift on 6/12/16 when Resident #1 and Resident #2 eloped from the building. CNA #2 stated she was bringing supper trays back to the desk when this gentleman came to the hallway and stated there was two (2) ladies in his garage and stated he was able to redirect them out of his garage. CNA #2 stated she checked to see if anyone was missing before she left and said no staff reported they had missed anyone. CNA #2 stated when she got down the street she recognized Resident #1 and Resident #2 and walked them back to the facility. CNA #2 stated LPN #1 met them in the parking lot and walked Resident #1 and Resident #2 into the Rehabilitation Unit side door into the facility. Interview on 6/14/15 at 11:35 AM with the Director of Nursing (DON) revealed the investigation noted CNA #1 witnessed Resident #2 shaking the back door to the locked female unit and it came open without the use of the key pad. The DON stated the investigation revealed CNA #1 pulled the door shut but failed to report the door malfunction to anyone. The DON stated if she had been contacted and informed of the door malfunction the elopement of Resident #1 and Resident #2 would not have occurred. The DON stated the staff on the locked female unit failed to supervise the residents after the back door malfunction that lead to the elopement of Resident #1 and Resident #2. Interview on 6/17/16 at 8:20 AM with Maintenance Staff #1 stated he was called to the building on 6/12/16 and changed the code to the key pad around 10:00 PM and stated the door was working properly at that time. The Maintenance Staff #1 stated the key pad to the back door on the female locked unit then completely lost power on 6/13/16 and would not lock. He stated he notified a local electrician vender who then ordered the parts and repaired the door after parts arrived. The Maintenance Staff #1 confirmed the facility had problems with doors loosing power to the key pads in the past. He also confirmed he made daily rounds checking the doors. Review of a work invoice, dated 6/17/16, from a local electrician/vender revealed a statement for a repaired door keypad wiring. This invoice stated the power supply had been replaced and all doors are working properly. Review of the facility's Elopement Prevention Plan, undated, revealed Elopement is any confused wandering resident who leaves the facility's premises without facility staff awareness. This plan revealed the facility will identify residents which are at risk for elopement and ensure that the resident has an at risk for elopement identifier on at all times to include the resident's name and the name, address and phone number of the facility . Identifying systems may be, but not limited to a Wanderguard bracelet, a smiley face sticker on the residents' name band, a yellow wristband etc. Interview with CNA #1 on 6/14/16 at 2:40 PM confirmed that prior to Resident #1 and Resident #2's elopement on 6/12/16, she witnessed at about 5:00 PM the back door to the female locked unit opened when Resident #2 vigorously shook it about three (3) times. CNA #1 stated she shut the door and redirected Resident #2. CNA #1 stated she the became distracted, went to the dining room, and forgot to report the door malfunction to anyone. CNA #1 stated when residents are at risk for elopement they are supposed to have on a yellow arm band, but at the time of elopement Resident #1 and Resident #2 did not have a yellow arm band with the resident's name, facility name, address and phone number. CNA #1 confirmed Resident #1 nor Resident #2 had an arm band of any kind on prior to the elopement. CNA #1 stated she was not aware that both Resident #1 and Resident #2 were elopement risk because they did not have on yellow arm bands, and she was not aware of any prior exit-seeking behaviors of these two residents. CNA #1 stated she could not remember the last time the facility had placed the yellow arm band on a resident that was at risk for elopement. CNA #1 stated each CNA had an assigned area to count residents every half-hour but was not sure if it was done on 6/12/16. Interview on 6/15/16 at 2:00 PM with CNA #5 revealed at the time of the elopement, two (2) of eight (8) residents on the female locked unit did not have on yellow arm bands. CNA #5 stated, supervision of the residents is part of our responsibility. Interview with LPN #1 on 6/14/16 at 4:50 PM confirmed the LPN did not see a yellow arm band or identification bracelet on Resident #1 or Resident #2 before or after the elopement. Interview on 6/14/16 at 8:45 AM with the facility Administrator confirmed both Resident #1 and Resident #2 left the facility through the back door on the female locked unit on 6/12/16 and exited the facility property through the back gate and down the street. The Administrator stated the facility had been aware that the facility had problems with the locked door keypads loosing power and malfunctioning. The Administrator explained the facility had replaced the keypad a couple of other doors prior to this elopement through the locked female unit exit door. The Administrator explained that the doors would work off and on periodically, so Maintenance did daily checks of the doors. The Administrator also explained that due to concerns with dignity, the facility had stopped using the yellow arm bands to identify a resident as being an elopement risk; however the facility policy was not revised. The Administrator stated the facility reinstated the use of the yellow arm bands following the facility's Quality Assurance (QA) meeting reviewing the policies related to the elopement jeopardy. Interview on 6/16/16 at 2:45 PM with the Medical Director revealed the facility had notified him of the Elopement of Resident #1 and Resident #2 on Sunday 6/12/16. The Medical Director stated a QA meeting was held and the facility staff present discussed safety and supervision of the residents. The Medical Director stated the facility reviewed it's policy for elopement and determined the facility failed to use the yellow armbands on residents deemed at risk for elopement. The Medical Director stated he was not sure where the breakdown occurred related to the use of the yellow armbands. The facility submitted the following Allegation of Compliance on 6/17/16: 1. On June 12, 2016 at 5:00 pm CNA 1 observed Resident 2 vigorously shaking the door leading to the back porch of the hallway. After approximately three shakes by Resident 2, the door popped open. Resident 2 did not exit the building at this time because CNA 1 closed the door immediately. CNA 1 failed to report the door popping open when it was shaken by Resident 2. This was discovered during the investigation of the elopement. CNA 1 was suspended pending the findings of the finalization of the elopement investigation. 2. On June 12, 2016 at 6:45 pm an unidentified male entered the front door of the building and stated to CNA 2 and CNA 3 that two ladies came up to his garage, and he redirected the ladies towards the building. This was the first knowledge that the staff had of a possible elopement. CNA 2 then alerted RN 1 that two female residents could possibly be across the street. RN 1 then alerted RN 2 and LPN 1 about a possible elopement. The missing resident procedure was initiated by CNA 2 and CNA 3. 3. On June 12, 2016 between 6:45 pm and 7:15 pm CNA 2 and CNA 3 walked across a two lane city street then down a two lane street 4 or 5 houses into a subdivision approximately 0.2 miles from the building, and identified two ladies as Resident 1 and Resident 2. CNA 2 and CNA 3 escorted Resident 1 and Resident 2 back towards the building and LPN 1 met them on the front lawn. LPN 1 and CNA 2 then supervised Resident 1 and Resident 2 back to the building together. A head count on each unit was completed for a total of 120 residents by RN 3 at 7:30 pm. 4. On June 12, 2016 at 7:30 pm Vital signs taken by LPN 1 for Resident 1 were Blood Pressure 128/76, Respirations 20, Pulse 72, and Temperature 98.6 and body audit for Resident 1 was completed by LPN 1 with no negative findings, Resident 1 has a BIMS score of 3.0. Vital signs taken by LPN 1 for Resident 2 were Blood pressure 130/70, Respirations 18, Pulse 77, and Temperature 97.3, and body audit for Resident 2 was completed by LPN 1 with no negative findings, Resident 2 has a BIMS score of 4.0 (Brief Interview for Mental Status. 5. On June 12, 2016 between 8:01 pm and 8:15 pm LPN 1 notified physician of Resident 1 and Resident 2 and the facility Medical Director of the elopement, with no new orders received. Daughter of Resident 1 was called and notified by LPN 1 of elopement at 9:45 pm as stated by Daughter. The Daughter of Resident 2 was called at 9:00 pm by LPN 1 with no answer. The Daughter of Resident 2, RP was called again by DON at 11:30 am on June 13, 2016 with no answer and again at 12:26 pm, message left by DON for a return phone call at both attempts. The Second daughter listed for Resident 2 was called with no answer and no voicemail at 11:30 am on June 13, 2016. The Daughter of Resident 2, RP called back on June 14, 2016 at 11:24 am and spoke with DON. 6. On June 12, 2016 at 8:15 pm Director of Nursing called RN 3 and became aware of the elopement. Director of Nursing instructed RN 3 to place CNA 1 in the hallway and at the door where Resident 1 and Resident 2 reside. Monitoring began on the hallway where Resident 1 and Resident 2 reside and continued until June 15, 2016 at 8:45 am. 7. On June 12, 2016 at 8:19 pm Director of Nursing notified the Administrator of the elopement. Administrator instructed for the RN 3 to begin in-services regarding the elopement, the elopement prevention plan, missing resident procedure, missing resident return procedure, door safety, and notification of any unusual incident to include elopements. The Administrator notified the Corporate QA nurse of the elopement at 8:30 pm. 8. On June 12, 2016 at 8:37 pm Administrator informed Maintenance 1 of the elopement. Maintenance 1 arrived at the building at 9:17 pm to inspect the building's doors for proper functioning. All doors were found to be functioning properly during the inspection by Maintenance 1. Maintenance 1 and Maintenance 2 changed all codes on the doors between 9:17 pm and 10:30 pm. 9. On June 12, 2016 between 9:00 pm and 11:30 pm RN 3 in-serviced 3 LPNs, 1 RN, and 8 CNAs from evening shift regarding the elopement, elopement prevention plan, missing resident procedure, missing resident return procedure, door safety, and notification of any unusual incident to include elopement. Prior to any Night shift staff being allowed to work, RN 3 in-serviced 2 LPNs, 2 RNs, and 8 CNAs from night shift regarding the elopement, elopement prevention plan, missing resident procedure, missing resident return procedure, door safety, and notification of unusual incident to include elopements. No employee was allowed to work without being in-serviced. 10. On June 13, 2016 at 7:00 am CNA 6 conducted in-services with 6 RNs, 9 LPNs, 1 Admission Clerk, 1 Medical Record Clerk, 14 CNAs, 2 Dietary Aides, 1 Dietary Manager, 1 Marketing Liaison, 1 Therapy Director, 1 LPTA, 1. OT, 1 Nurse Practitioner, and 1 Business Office Clerk prior to starting their shift regarding the elopement, elopement prevention plan, missing resident procedure, missing resident return procedure, door safety, and notification of any unusual incident to include elopements. 11. On June 13, 2016 at 9:40 am QA meeting held with Medical Director (via telephone), Administrator, Director of Nursing, Social Services Director, MDS coordinator, Admissions Nurse, and Medical Records. The topics of discussion for QA meeting were Supervision of residents and the elopement that occurred on June 12, 2016, elopement prevention plan, missing resident return procedure, proper notification of elopement, elopement book policy review, and any system changes discussed and implemented. 33 residents throughout the building are identified as an elopement risk in the elopement book. Current photographs of the 33 identified residents were in the elopement book. Upon physical review of all 33 residents at risk for elopement they did not have a yellow arm band on per facility policy. Social services and DON placed identifying arm bands on 33 residents throughout the building 9 pm on June 13, 2016. The yellow arm band is to identify a resident at risk for elopement. Care plans for all 33 residents at risk for elopement were updated and reviewed. The facility did not have a wonder guard system in place. 12. On June 13, 2016 between 10:30 am and 12:30 pm 27 residents were being supervised on the hallway where Resident 1 and Resident 2 reside by LPN 4. 17 of the 27 residents being supervised were an elopement risk. 13. On June 13, 2016 at 12:30 pm LPN 3 discovered that the back door could be opened. LPN 3 notified the DON that there was a door malfunction and the DON went to the door and verified that there was a door malfunction. 14. On June 13, 2016 between 12:30 pm and 12:45 pm Maintenance 2, Administrator, Maintenance 3, and the Alarm Company were all notified by the DON and Administrator of the back door malfunction. At no time was the hallway or the door where Resident 1 and Resident 2 reside and the door left unsupervised. 15. On June 13, 2016, at 3:30 pm the Alarm Company arrived at the building and determined that the power supply to the back door on the hallway where Resident 1 and Resident 2 reside had been compromised and a part was ordered for repairs. 17. On June 13, 2016 at 6:30 pm elopement notification was made to the Department of Health via telephone voice message left by facility Administrator. 18. On June 14, 2016 at 9:50 am Notification of the elopement was made to the Department of Health via fax by facility Director of Nursing. 19. On June 14, 2016 at 6:20 pm All staff were in-service regarding supervision of residents for safety and elopement, Administrator, MDS Coordinator, and Admissions Clerk conducted the in-service for 11 LPNs, 9 RNs, 34 CNAs,1 Social Worker, 1 Maintenance employee, 1 Dietary Manager, 6 Dietary aides, 2 Front Office Clerks, 1 Marketing Liaison, 3 Laundry Workers, 1 Administrator,4 Housekeeping employees, 1 Therapy Tech, 1 Therapy Manager, 3 Speech Therapist, 3 Occupational Therapist, 1 LPTA, 1 Physical Therapist, and , 1 Medical Record Clerk. No staff was allowed to work until in-serviced on supervision of residents for safety and elopement. 20. On June 15, 2016 at 8:45 am the alarm company arrived along with Maintenance 2 and Maintenance 3 and repaired the door. 22. On June 16, 2016 CNA 1 was terminated. 21. On June 16, 2016 the facility believes that the alleged IJ was removed. AoC Validation On 6/17/16, the State Survey Agency (SA) surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy: The SA surveyor validated by interview that the facility first became aware of Resident #1 and Resident #2's elopements on 6/12/16 at approximately 6:45 PM when an unidentified male entered the facility and told CNA #2 and CNA #3, two (2) ladies came into his garage and then redirected the ladies toward the facility. The SA surveyor validated by record and documentation review that the facility completed a head count on each unit for 120 resident on 6/12/16 at 7:30 PM. The SA surveyor validated by record review that LPN #1 initiated body audits and vital signs for Resident #1 with a BIMS of three (3) and Resident #2 with a BIMS of four (4) with no identified injuries or concerns. The SA surveyor validated by interview that RN #3 texted the DON to notify of the elopement, by text message. The SA surveyor validated by record review and physician interview that LPN #1 notified the physician and the Medical Director on 6/12/16 at approximately 8:15 PM of the elopement of Resident #1 and Resident #2. The SA validated by interview that LPN #1 notified the Daughter of Resident 1 of the elopement on 6/12/16 at 9:45 PM, and the RP for Resident #2 on 6/14/16 at 11:24 AM when the RP returned from being out of the country. The SA surveyor validated by interview that RN #3 placed CNA #1 on the hallway at the door where Resident #1 and Resident #2 resided and the facility placed a staff member at the hallway door until 6/15/16 at 8:45 AM when the door was repaired. The SA surveyor validated by record review that the DON notified the Administrator of the elopement on 6/12/16 at 8:19 PM. The SA surveyor validated by review of in-service sign- in sheets that RN #3 in-serviced staff regarding the elopement, elopement prevention plan, missing resident procedure and missing resident return procedure, door safety, and notification of any unusual incident to include elopements. The SA surveyor validated by interview and record review that Maintenance #1 was informed of the elopement by the facility Administrator on 6/12/16 at 8:37 PM and changed all door codes between 9:17 PM and 10:30 PM. The SA surveyor validated by review of the in-service sign-in sheets, on 6/12/16 between 9:00 PM and 11:30 PM, RN #3 in-serviced three (3) LPNs, one (1) RN, and eight (8) CNAs from the evening shift, were in-serviced regarding the elopement, elopement prevention plan, missing resident procedure, missing resident return procedure, door safety and notification of any unusual incident to include elopement. The SA surveyor validated by sign-in sheets, RN #3 in-serviced two (2) LPNs, two (2) RNs, and eight (8) CNAs from the night shift prior to being allowed to work on regarding the elopement, elopement prevention plan, missing resident procedure, missing resident return procedure, door safety and notification of any unusual incident to include elopement. The SA surveyor validated by review of inservice and time sheets that no staff were allowed to work without being in-serviced. The SA validated by sign-in sheets the in-service conducted on 6/13/16 at 7:00 AM with six (6) RNs, nine (9) LPNs, one (1) Admission Clerk, one (1) Medical Record Clerk, 14 CNAs, two (2) Dietary Aides, one (1) Dietary Manager, one (1) Marketing Liaison, one (1) Therapy Director, one (1) Licensed Physical Therapist Assistant, one (1) Occupational Therapist, one (1) Nurse Practitioner and one (1) Business Office Clerk prior to starting their shift regarding the elopement, elopement prevention plan, missing resident procedure, missing resident return procedure, door safety and notification of any unusual incident to include elopement. The SA surveyor validated by review of QA sign in sheets that the facility held a QA meeting on 6/13/16 at 9:40 AM with the Medical Director via phone, the Administrator, the DON, Social Service Director, MDS Coordinator, Admissions Nurse and Medical Records Nurse and discussed Supervision of the residents and the elopement of Resident #1 and Resident #2 on 6/12/16. The SA surveyor validated by interview that the facility discussed elopement prevention plan, missing resident procedure, missing resident return procedure, proper notification of elopement, elopement book policy review and system changes discussed and implemented. The SA surveyor validated by sign-in sheets, 27 residents were supervised on the hallway where Resident #1 and Resident #2 resided from 6/13/16 between 10:30 AM to 12:30 PM and 17 of the 27 residents were identified as an elopement risk. The SA surveyor validated by interview that on 6/13/16 at 12:30 PM, the DON was notified by LPN #3 that the back door of the female locked unit malfunctioned and did not lock. The SA surveyor verified by interview that on 6/13/16 at 12:45 PM, the DON notified Maintenance #2, Maintenance #3, Administrator, and the Alarm Company of the back door malfunction, and that the hallway door was not left unsupervised by documented door checks. The SA surveyor validated the Alarm Company arrived on 6/13/16 at 3:30 pm ordered parts for repairs. The SA surveyor validated by record review that the facility notified the SA on 6/13/16 at 6:30 PM via the telephone voice message system. The SA surveyor validated the facility confirmation of the notification of the elopement to the SA by fax. The SA surveyor validated by sign-in sheets and staff interviews, the facility's Administrator, MDS Coordinator and the Admissions Clerk in-serviced the staff regarding supervision of residents for safety and elopement to include 11 LPNs, nine (9) RNs, 34 CNAs, one (1) Social Worker, one (1) Maintenance Employee, one (1) Dietary Manager, six (6) Dietary Aides, two (2) Front Office Clerks, One (1) Marketing Liaison, three (3) Laundry Workers, one (1) Administrator, four (4) Housekeeping Employees, One (1) Therapy Tech, one (1) Therapy Manager, three (3) Speech Therapist, three (3) Occupational Therapist, one (1) Licensed Physical Therapy Assistant, one (1) Physical Therapist and one (1) Medical Record Clerk. The SA validated no staff were allowed to work until in-serviced on supervision of residents for safety and elopement. The SA surveyor validated by interview and document review that the alarm company, Maintenance #2, and Maintenance #3 repaired the door on 6/15/16 at 8:45 AM. The SA surveyor validated suspended CNA #1 resigned on 6/16/16 and was relieved immediately of employment. The SA surveyor validated on 6/17/16 that as of 6/16/16 the IJ was removed.

CI MS # Based on observation, interview, record review, policy review and facility investigation review, the facility failed to follow care plan interventions related to risk of elopement for Resident #1 and Resident #2 for two (2) of six (6) sampled residents reviewed for elopement risk. The facility identified and care planned Resident #1 as a risk for Elopement on 10/16/15 and the facility identified and care planned Resident #2 as a risk for Elopement on 5/17/16. On 6/12/16 at approximately 6:45 PM, a member of the community entered the facility and alerted facility staff that two ladies walked down the street to his garage and were confused and did not know where they lived. The facility was not aware that Resident #1 and Resident #2 had exited the building without supervision until the community member arrived. The facility investigation revealed Resident #1 and Resident #2 exited the building from the back hallway door of the locked ladies unit. Observation revealed Resident #1 and Resident #2 walked away from the building, through a large wooden gate, down a side street, crossing a busy two lane city street, down another street leading into a subdivision to the eighth house on the left. This was a total of 787 walked steps from the back door of the building. The facility's failure to follow the care plan for a risk for wandering placed Resident #1, Resident #2, and other residents with elopement risk in a situation that was likely to cause serious harm, injury, impairment, or death. This was determined to be an Immediate Jeopardy (IJ) that began on 6/12/16 when Resident #1 and Resident #2 eloped. The State Agency notified the facility on 6/14/16 of the Immediate Jeopardy (IJ) at 42 CFR 483.20 (k) (3) (ii) Services per Care Plan (F282). The facility submitted an acceptable Allegation of Compliance (AoC) on 6/17/16. The State Agency surveyor validated the facility's AoC on prior to exit and determined the IJ was removed 6/16/16. All activities to abate the IJ were completed as of 6/15/16. The scope and severity for the IJ at 42 CFR 483.20 (k) (3) (ii) Services per Care Plan (F282) was lowered to a D while the facility develops and Implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of systemic change. Findings include: Review of the facility's policy, entitled, Care Plans-Comprehensive, dated 6/1/2000, stated it is the policy of this facility to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. This policy stated the comprehensive care plan had been designed to incorporate identified problem areas; incorporate risk factors associated with identified problems; build on the resident's strengths; reflect treatment goals and objectives in measurable outcomes; identify the professional services that are responsible for each element of care; prevent declines in the resident's functional status and/or functional levels; and enhance the optimal functioning of the resident by focusing on a rehabilitative program. Review of the facility's elopement investigation and time line of events for the elopement of Resident #1 and Resident #2 on 6/12/16 revealed Resident #1 and Resident #3 eloped from the facility. A member of the community found the residents approximately 0.2 miles from the facility, after crossing a busy street and down another street into a subdivision. This investigation revealed, the last know time both residents had been seen in the facility was at 6:15 PM, when Licensed Practical Nurse (LPN) #1 gave Resident #2 her 6:00 PM medications. Resident #1 Review of Resident #1's Care Plan initiated on 10/16/15, revised on 3/10/16, and a target date of 4/10/16 for elopement risk revealed a goal for Resident #1 to not leave the facility unattended through the review date. Interventions included distract resident from wandering by offering pleasant diversions, identify pattern of wandering, and monitor yellow arm band every shift for placement. Replace if armband missing. Observation on 6/17/16 at 9:26 AM revealed Resident #1 in the main dining room, walking around, neatly dressed and pleasantly confused. Resident #1 was unable to answer questions or follow conversation. Review of the Face Sheet revealed the facility admitted Resident #1 on 7/17/15 with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of 4/4/16, revealed Resident # 1 scored three (3) on the Brief Interview for Mental Status (BIMS), which indicated the resident had severe cognitive impairment. Resident #2 Review of Resident #2's Care Plan initiated on 5/17/16 and a target date of 8/3/16 revealed Resident #2 was at risk for elopement. The Care Plan listed the goal for Resident #2 to not leave the facility unattended through the review date. Interventions included distract resident from wandering by offering pleasant diversions, identify pattern of wandering, and monitor yellow arm band every shift for placement. Replace if armband missing. Observation revealed Resident #2 on 6/15/16 at 2:20 PM in room and neatly dressed with a yellow armband. Resident #2 was pleasantly confused and unable to be interviewed. Review of the Face Sheet revealed the facility admitted Resident #2 on 5/5/16 with the [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of 5/5/16, revealed Resident #2 scored four (4) on the Brief Interview for Mental Status (BIMS), which indicated the resident had severe cognitive impairment. Interview on 6/14/16 at 4:50 PM with LPN #1 confirmed both Resident #1 and Resident #2 had a Care Plan that listed both residents at risk for elopement. LPN #1 stated on 6/12/16 prior to the elopement both Resident #1 and Resident #2 did not have on a yellow armband or identification bracelet prior to the elopement, per facility policy. Interview on 6/14/16 at 2:40 PM revealed Certified Nurse Assistant (CNA) #1 stated she was unaware if resident Care Plans addressed the risk of elopement and increased need for supervision. CNA #1 stated, It should be on the Activities of Daily Living (ADL). Sometimes, I look at the Care Plan and look at the risk factors, their conditions. Interview on 6/15/16 at 2:00 PM revealed CNA #5 stated if a resident is at risk for elopement according to the Care Plan the CNAs are to do 15 to 20 minute checks, keep the residents occupied, bring them to the dining room where they can do activities so their minds won't be on trying to get out. CNA #5 stated residents' Care Plans are in the CNA book or on the Kiosk. Interview on 6/14/15 at 11:35 AM revealed the Director of Nursing (DON) stated the Care Plan covers the elopement risk and interventions; however, the staff on the locked female unit failed to supervise the residents after the back door malfunction that lead to the elopement of Resident #1 and Resident #2. Interview on 6/14/16 at 8:45 AM with the facility Administrator revealed that due to some concerns with possible loss of dignity, the facility had stopped using the yellow arm bands to identify a resident as being an elopement risk some time back but failed to update the facility's documentation or policy. The Administrator stated the facility has reinstated the use of the yellow arm bands following the facility's Quality Assurance (QA) meeting following the elopement jeopardy. The facility submitted the following Allegation of Compliance on 6/17/16: 1. On June 12, 2016 at 5:00 pm CNA 1 observed Resident 2 vigorously shaking the door leading to the back porch of the hallway. After approximately three shakes by Resident 2, the door popped open. Resident 2 did not exit the building at this time because CNA 1 closed the door immediately. CNA 1 failed to report the door popping open when it was shaken by Resident 2. This was discovered during the investigation of the elopement. CNA 1 was suspended pending the findings of the finalization of the elopement investigation. 2. On June 12, 2016 at 6:45 pm an unidentified male entered the front door of the building and stated to CNA 2 and CNA 3 that two ladies came up to his garage, and he redirected the ladies towards the building. This was the first knowledge that the staff had of a possible elopement. CNA 2 then alerted RN 1 that two female residents could possibly be across the street. RN 1 then alerted RN 2 and LPN 1 about a possible elopement. The missing resident procedure was initiated by CNA 2 and CNA 3. 3. On June 12, 2016 between 6:45 pm and 7:15 pm CNA 2 and CNA 3 walked across a two lane city street then down a two lane street 4 or 5 houses into a subdivision approximately 0.2 miles from the building, and identified two ladies as Resident 1 and Resident 2. CNA 2 and CNA 3 escorted Resident 1 and Resident 2 back towards the building and LPN 1 met them on the front lawn. LPN 1 and CNA 2 then supervised Resident 1 and Resident 2 back to the building together. A head count on each unit was completed for a total of 120 residents by RN 3 at 7:30 pm. 4. On June 12, 2016 at 7:30 pm Vital signs taken by LPN 1 for Resident 1 were Blood Pressure 128/76, Respirations 20, Pulse 72, and Temperature 98.6 and body audit for Resident 1 was completed by LPN 1 with no negative findings, Resident 1 has a BIMS score of 3.0. Vital signs taken by LPN 1 for Resident 2 were Blood pressure 130/70, Respirations 18, Pulse 77, and Temperature 97.3, and body audit for Resident 2 was completed by LPN 1 with no negative findings, Resident 2 has a BIMS score of 4.0 (Brief Interview for Mental Status. 5. On June 12, 2016 between 8:01 pm and 8:15 pm LPN 1 notified physician of Resident 1 and Resident 2 and the facility Medical Director of the elopement, with no new orders received. Daughter of Resident 1 was called and notified by LPN 1 of elopement at 9:45 pm as stated by Daughter. The Daughter of Resident 2 was called at 9:00 pm by LPN 1 with no answer. The Daughter of Resident 2, RP was called again by DON at 11:30 am on June 13, 2016 with no answer and again at 12:26 pm, message left by DON for a return phone call at both attempts. The Second daughter listed for Resident 2 was called with no answer and no voicemail at 11:30 am on June 13, 2016. The Daughter of Resident 2, RP called back on June 14, 2016 at 11:24 am and spoke with DON. 6. On June 12, 2016 at 8:15 pm Director of Nursing called RN 3 and became aware of the elopement. Director of Nursing instructed RN 3 to place CNA 1 in the hallway and at the door where Resident 1 and Resident 2 reside. Monitoring began on the hallway where Resident 1 and Resident 2 reside and continued until June 15, 2016 at 8:45 am. 7. On June 12, 2016 at 8:19 pm Director of Nursing notified the Administrator of the elopement. Administrator instructed for the RN 3 to begin in-services regarding the elopement, the elopement prevention plan, missing resident procedure, missing resident return procedure, door safety, and notification of any unusual incident to include elopements. The Administrator notified the Corporate QA nurse of the elopement at 8:30 pm. 8. On June 12, 2016 at 8:37 pm Administrator informed Maintenance 1 of the elopement. Maintenance 1 arrived at the building at 9:17 pm to inspect the building's doors for proper functioning. All doors were found to be functioning properly during the inspection by Maintenance 1. Maintenance 1 and Maintenance 2 changed all codes on the doors between 9:17 pm and 10:30 pm. 9. On June 12, 2016 between 9:00 pm and 11:30 pm RN 3 in-serviced 3 LPNs, 1 RN, and 8 CNAs from evening shift regarding the elopement, elopement prevention plan, missing resident procedure, missing resident return procedure, door safety, and notification of any unusual incident to include elopement. Prior to any Night shift staff being allowed to work, RN 3 in-serviced 2 LPNs, 2 RNs, and 8 CNAs from night shift regarding the elopement, elopement prevention plan, missing resident procedure, missing resident return procedure, door safety, and notification of unusual incident to include elopements. No employee was allowed to work without being in-serviced. 10. On June 13, 2016 at 7:00 am CNA 6 conducted in-services with 6 RNs, 9 LPNs, 1 Admission Clerk, 1 Medical Record Clerk, 14 CNAs, 2 Dietary Aides, 1 Dietary Manager, 1 Marketing Liaison, 1 Therapy Director, 1 LPTA, 1. OT, 1 Nurse Practitioner, and 1 Business Office Clerk prior to starting their shift regarding the elopement, elopement prevention plan, missing resident procedure, missing resident return procedure, door safety, and notification of any unusual incident to include elopements. 11. On June 13, 2016 at 9:40 am QA meeting held with Medical Director (via telephone), Administrator, Director of Nursing, Social Services Director, MDS coordinator, Admissions Nurse, and Medical Records. The topics of discussion for QA meeting were Supervision of residents and the elopement that occurred on June 12, 2016, elopement prevention plan, missing resident return procedure, proper notification of elopement, elopement book policy review, and any system changes discussed and implemented. 33 residents throughout the building are identified as an elopement risk in the elopement book. Current photographs of the 33 identified residents were in the elopement book. Upon physical review of all 33 residents at risk for elopement they did not have a yellow arm band on per facility policy. Social services and DON placed identifying arm bands on 33 residents throughout the building 9 pm on June 13, 2016. The yellow arm band is to identify a resident at risk for elopement. Care plans for all 33 residents at risk for elopement were updated and reviewed. The facility did not have a wonder guard system in place. 12. On June 13, 2016 between 10:30 am and 12:30 pm 27 residents were being supervised on the hallway where Resident 1 and Resident 2 reside by LPN 4. 17 of the 27 residents being supervised were an elopement risk. 13. On June 13, 2016 at 12:30 pm LPN 3 discovered that the back door could be opened. LPN 3 notified the DON that there was a door malfunction and the DON went to the door and verified that there was a door malfunction. 14. On June 13, 2016 between 12:30 pm and 12:45 pm Maintenance 2, Administrator, Maintenance 3, and the Alarm Company were all notified by the DON and Administrator of the back door malfunction. At no time was the hallway or the door where Resident 1 and Resident 2 reside and the door left unsupervised. 15. On June 13, 2016, at 3:30 pm the Alarm Company arrived at the building and determined that the power supply to the back door on the hallway where Resident 1 and Resident 2 reside had been compromised and a part was ordered for repairs. 17. On June 13, 2016 at 6:30 pm elopement notification was made to the Department of Health via telephone voice message left by facility Administrator. 18. On June 14, 2016 at 9:50 am Notification of the elopement was made to the Department of Health via fax by facility Director of Nursing. 19. On June 14, 2016 at 6:20 pm All staff were in-service regarding supervision of residents for safety and elopement, Administrator, MDS Coordinator, and Admissions Clerk conducted the in-service for 11 LPNs, 9 RNs, 34 CNAs,1 Social Worker, 1 Maintenance employee, 1 Dietary Manager, 6 Dietary aides, 2 Front Office Clerks, 1 Marketing Liaison, 3 Laundry Workers, 1 Administrator,4 Housekeeping employees, 1 Therapy Tech, 1 Therapy Manager, 3 Speech Therapist, 3 Occupational Therapist, 1 LPTA, 1 Physical Therapist, and , 1 Medical Record Clerk. No staff was allowed to work until in-serviced on supervision of residents for safety and elopement. 20. On June 15, 2016 at 8:45 am the alarm company arrived along with Maintenance 2 and Maintenance 3 and repaired the door. 21. On June 16, 2016 the facility believes that the alleged IJ was removed. AoC Validation On 6/17/16, the State Survey Agency (SA) surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy: The SA surveyor validated by interview that the facility first became aware of Resident #1 and Resident #2's elopements on 6/12/16 at approximately 6:45 PM when an unidentified male entered the facility and told CNA #2 and CNA #3, two (2) ladies came into his garage and then redirected the ladies toward the facility. The SA surveyor validated by record and documentation review that the facility completed a head count on each unit for 120 resident on 6/12/16 at 7:30 PM. The SA surveyor validated by record review that LPN #1 initiated body audits and vital signs for Resident #1 with a BIMS of three (3) and Resident #2 with a BIMS of four (4) with no identified injuries or concerns. The SA surveyor validated by interview that RN #3 texted the DON to notify of the elopement, by text message. The SA surveyor validated by record review and physician interview that LPN #1 notified the physician and the Medical Director on 6/12/16 at approximately 8:15 PM of the elopement of Resident #1 and Resident #2. The SA validated by interview that LPN #1 notified the Daughter of Resident 1 of the elopement on 6/12/16 at 9:45 PM, and the RP for Resident #2 on 6/14/16 at 11:24 AM when the RP returned from being out of the country. The SA surveyor validated by interview that RN #3 placed CNA #1 on the hallway at the door where Resident #1 and Resident #2 resided and the facility placed a staff member at the hallway door until 6/15/16 at 8:45 AM when the door was repaired. The SA surveyor validated by record review that the DON notified the Administrator of the elopement on 6/12/16 at 8:19 PM. The SA surveyor validated by review of in-service sign- in sheets that RN #3 in-serviced staff regarding the elopement, elopement prevention plan, missing resident procedure and missing resident return procedure, door safety, and notification of any unusual incident to include elopements. The SA surveyor validated by interview and record review that Maintenance #1 was informed of the elopement by the facility Administrator on 6/12/16 at 8:37 PM and changed all door codes between 9:17 PM and 10:30 PM. The SA surveyor validated by review of the in-service sign-in sheets, on 6/12/16 between 9:00 PM and 11:30 PM, RN #3 in-serviced three (3) LPNs, one (1) RN, and eight (8) CNAs from the evening shift, were in-serviced regarding the elopement, elopement prevention plan, missing resident procedure, missing resident return procedure, door safety and notification of any unusual incident to include elopement. The SA surveyor validated by sign-in sheets, RN #3 in-serviced two (2) LPNs, two (2) RNs, and eight (8) CNAs from the night shift prior to being allowed to work on regarding the elopement, elopement prevention plan, missing resident procedure, missing resident return procedure, door safety and notification of any unusual incident to include elopement. The SA surveyor validated by review of in-service and time sheets that no staff were allowed to work without being in-serviced. The SA validated by sign-in sheets the in-service conducted on 6/13/16 at 7:00 AM with six (6) RNs, nine (9) LPNs, one (1) Admission Clerk, one (1) Medical Record Clerk, 14 CNAs, two (2) Dietary Aides, one (1) Dietary Manager, one (1) Marketing Liaison, one (1) Therapy Director, one (1) Licensed Physical Therapist Assistant, one (1) Occupational Therapist, one (1) Nurse Practitioner and one (1) Business Office Clerk prior to starting their shift regarding the elopement, elopement prevention plan, missing resident procedure, missing resident return procedure, door safety and notification of any unusual incident to include elopement. The SA surveyor validated by review of QA sign in sheets that the facility held a QA meeting on 6/13/16 at 9:40 AM with the Medical Director via phone, the Administrator, the DON, Social Service Director, MDS Coordinator, Admissions Nurse and Medical Records Nurse and discussed Supervision of the residents and the elopement of Resident #1 and Resident #2 on 6/12/16. The SA surveyor validated by interview that the facility discussed elopement prevention plan, missing resident procedure, missing resident return procedure, proper notification of elopement, elopement book policy review and system changes discussed and implemented. The SA surveyor validated by sign-in sheets, 27 residents were supervised on the hallway where Resident #1 and Resident #2 resided from 6/13/16 between 10:30 AM to 12:30 PM and 17 of the 27 residents were identified as an elopement risk. The SA surveyor validated by interview that on 6/13/16 at 12:30 PM, the DON was notified by LPN #3 that the back door of the female locked unit malfunctioned and did not lock. The SA surveyor verified by interview that on 6/13/16 at 12:45 PM, the DON notified Maintenance #2, Maintenance #3, Administrator, and the Alarm Company of the back door malfunction, and that the hallway door was not left unsupervised by documented door checks. The SA surveyor validated the Alarm Company arrived on 6/13/16 at 3:30 pm ordered parts for repairs. The SA surveyor validated by record review that the facility notified the SA on 6/13/16 at 6:30 PM via the telephone voice message system. The SA surveyor validated the facility confirmation of the notification of the elopement to the SA by fax. The SA surveyor validated by sign-in sheets and staff interviews, the facility's Administrator, MDS Coordinator and the Admissions Clerk in-serviced the staff regarding supervision of residents for safety and elopement to include 11 LPNs, nine (9) RNs, 34 CNAs, one (1) Social Worker, one (1) Maintenance Employee, one (1) Dietary Manager, six (6) Dietary Aides, two (2) Front Office Clerks, One (1) Marketing Liaison, three (3) Laundry Workers, one (1) Administrator, four (4) Housekeeping Employees, One (1) Therapy Tech, one (1) Therapy Manager, three (3) Speech Therapist, three (3) Occupational Therapist, one (1) Licensed Physical Therapy Assistant, one (1) Physical Therapist and one (1) Medical Record Clerk. The SA validated no staff were allowed to work until in-serviced on supervision of residents for safety and elopement. The SA surveyor validated by interview and document review that the alarm company, Maintenance #2, and Maintenance #3 repaired the door on 6/15/16 at 8:45 AM. The SA surveyor validated suspended CNA #1 resigned on 6/16/16 and was relieved immediately of employment. The SA surveyor validated on 6/17/16 that as of 6/16/16 the IJ was removed.