Every finding on record at Tippah County Nursing Home

Based on review of personnel records and staff interviews, the facility failed to ensure that the Dietary Manager was qualified by obtaining or enrolling in a Certified Dietary Manager (CDM) program for three (3) of 3 days of survey. Review of facility policies related to dietary staff qualifications was requested. Facility staff were unable to provide a policy outlining requirements for Certified Dietary Manager (CDM) certification.During an interview on 2/18/26 at 10:55 AM, the Dietary Manager stated he had not completed a Certified Dietary Manager (CDM) program, and he was unaware that he was required to obtain certification.Record review of personnel records revealed the Dietary Manager was hired approximately two years ago and has not completed or enrolled in a CDM program.During an interview on 2/19/26 at 11:25 AM, the Administrator stated she was unaware the Dietary Manager was required to obtain CDM certification.

Based on observations, staff interviews, and facility policy review, the facility failed to implement infection prevention and control practices to prevent the transmission of infections. Specifically, the facility failed to ensure staff used Enhanced Barrier Precautions (EBP) during catheter care and failed to perform hand hygiene during wound care for two (2) of three (3) resident care opportunities. (Residents #3 and #6) Findings include:Review of facility policy titled, Enhanced Barrier Precautions, dated 5/27/2024, revealed, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.'Indwelling medical devices' would include, indwelling urinary catheters.Enhanced Barrier Precautions are recommended for residents with indwelling medical devices.Review of facility policy titled, Handwashing, dated 1/3/2019, revealed, .When to wash hands.after handling any contaminated items.Resident #3During a wound care observation for Resident #3 on 2/19/2026 at 8:30 AM with Licensed Practical Nurse (LPN) #2, LPN #2 failed to follow infection control practices by not performing hand hygiene after removing Resident #3's soiled dressing and before donning clean gloves.During an interview on 2/19/2026 at 8:45 AM, LPN #2 stated she forgot to perform hand hygiene during the wound care procedure. She stated hand hygiene should be performed before donning gloves to help prevent the possible spread of infection.Record review of the Order Summary Report for Resident #3 revealed, .Cleanse Stage 2 pressure injury to coccyx area with wound cleanser, pat dry, and apply Triad and Opti foam daily until healed every day shift for pressure injury, dated 1/16/2026.Record review of the admission Record for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified. A record review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/13/26, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment.Resident #6During an observation on 2/18/26 at 3:00 PM of catheter care with Resident #6, Certified Nursing Assistant (CNA) #2 was observed failing to use Enhanced Barrier Precautions during the procedure, when she failed to wear a gown.During an interview on 2/18/26 at 3:10 PM, CNA #2 stated she was aware Enhanced Barrier Precautions should have been used during catheter care; however, she stated she forgot. CNA #2 stated Enhanced Barrier Precautions are used to prevent the spread of infection between the staff and residents and between residents. She further confirmed failure to follow Enhanced Barrier Precautions could place Resident #6 at risk for infection.Record review of Order Summary Report for Resident #6, revealed, Clean Foley with soap and water daily every day shift, dated 1/12/2026.Record review of the admission Record revealed Resident #6 was admitted to the facility on [DATE] with medical diagnoses including Disorder of Muscle, unspecified and Retention of Urine, unspecified. Record review of Resident #6's quarterly MDS with an ARD of 1/19/2026, revealed under Section C a BIMS score of 8, indicating moderate cognitive impairment. During an interview on 2/19/26 at 9:00 AM, the Administrator and Director of Nursing (DON) confirmed Enhanced Barrier Precautions should have been used during catheter care and that hand hygiene should be performed before donning gloves. They confirmed staff had been trained on these practices and stated these measures are intended to prevent the spread of infection. They further confirmed failure to use Enhanced Barrier Precautions and to perform hand hygiene could place Residents #3 and #6 at increased risk for infection.

Based on observations, staff interviews, record reviews, and facility policy review, the facility failed to ensure medications were accurately labeled and corresponded with the physician's order for one (1) of three (3) residents observed during medication pass (Resident #38) Findings Include:Review of facility policy titled, Medication Administration with revision date 6/7/2016, revealed, .Procedures.5. If there is a discrepancy between the Emar and the label, check physician/NP (nurse practitioner) orders before administering the medication. 6. If label is wrong, call resident's personal pharmacy for a new label. If the Emar is wrong, correct the order in the computer system.An observation during medication administration on 2/18/2026 at 8:55 AM revealed Licensed Practical Nurse (LPN) #1 retrieved a pharmacy-prepared blister pack labeled Gabapentin Oral Tablet 300 milligrams (mg) from the locked narcotic box in the medication cart and punched out two (2) tablets. She stated the order on the Medication Administration Record (MAR) read, Gabapentin Oral Tablet 600 mg. Give one (1) tablet by mouth two times a day for Pain so I have to give two (2) tablets to equal the 600 mg dosage. Record review of the MAR confirmed the order was for Gabapentin 600 mg tablet, give one (1) tablet. During this observation, the LPN retrieved another pharmacy-prepared blister pack labeled Propranolol HCl ER Oral Capsule Extended Release 24-hour 80 mg and punched out two (2) capsules. Again, she stated that the order on the MAR read, Propranolol HCl ER Oral Capsule Extended Release 24-hour 160 mg. Give one (1) capsule by mouth two times a day for Hypertension. Record review of the MAR confirmed the order was for Propranolol HCl ER Oral Capsule Extended Release 24-hour 160 mg, give one (1) capsule. The LPN stated that these two blister packs have been labeled like this since admission. The LPN administered the medications along with other morning medications to Resident #38. Medication Administration Record (MAR) did not match the Gabapentin Oral Tablet 300 mg tablets or the Propranolol HCl ER Oral Capsule Extended Release 24-hour 80 mg on hand in the blister packs, revealing a discrepancy between the physician's order and the labeled medication for Resident #38.Record review of Resident #38's Medication Administration Record (MAR) revealed an order dated 2/9/2026 for Gabapentin Oral Tablet 600 mg. Give one (1) tablet by mouth two times a day for Pain and an order dated 2/9/2026 for Propranolol HCl ER Oral Capsule Extended Release 24-hour 160 mg. Give one (1) capsule by mouth two times a day for Hypertension.Review of Resident #38's pharmacy-prepared blister pack of Gabapentin 300 mg tablets revealed, Gabapentin Oral Tablet 300 mg. Give two (2) tablets by mouth two (2) times a day for Pain. Review of Resident #38's pharmacy-prepared blister pack revealed Propranolol HCl ER Oral Capsule Extended Release 24-hour 80 mg. Give two (2) capsules by mouth two times a day for Hypertension.During an interview on 2/18/26 at 9:00 AM, LPN #1 confirmed Resident #38's physician order and medication label did not match. She stated the discrepancy had been present since admission on [DATE] and stated, I've never thought to get it changed. During an interview on 2/19/2026 at 9:00 AM with the Administrator and Director of Nursing (DON), the Administrator and DON revealed they were unaware of the discrepancy and that nursing staff should have reported so it could have been corrected. The DON stated this could cause a medication error when the blister pack medication strength does not match what is ordered on the MAR. Record review of Resident #38's admission Record revealed the facility admitted the resident on 2/9/2026 with diagnoses including Disorder of muscle, unspecified, Pain, unspecified, and Essential Primary Hypertension. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/16/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 13 which indicated Resident #38 was cognitively intact.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care to maintain personal hygiene for one (1) of 13 sampled residents. (Resident #2). Findings include: Review of facility policy titled Activities of Daily Living (ADL) Care, revised 4/9/2018, revealed, Purpose: To ensure all ADL care is provided on a daily basis as needed to ensure that all the residents' needs are met .Policy: 6. Nail care is provided every week and as needed to all residents with the exception of diabetics. Only the Registered Nurse (RN) can perform diabetic nail care . Resident #2 During observation and interview on 2/17/2026 at 10:32 AM, Resident #2 was observed to have noticeably long, jagged fingernails measuring approximately one (1) inch in length and a few scattered long facial hairs on her chin, approximately one and one-half inches in length. The resident stated her nails were too long and needed to be trimmed and that she did not want facial hair and would like for that to be trimmed as well. During an interview and observation on 2/18/2026 at 9:45 AM, Licensed Practical Nurse (LPN) #1 confirmed Resident #2 had long, jagged fingernails that could cause the resident to sustain a skin tear. She stated that because Resident #2 has diabetes, a Registered Nurse (RN) is required to trim the resident's nails. She further stated diabetic nail care is scheduled on the Treatment Administration Record (TAR) every Tuesday to be completed by the RN. Additionally, she confirmed that Resident #2 did have several long chin hairs. She stated that the shower aide should have taken care of this when she got her shower. Record review of the TAR dated 2/1/2026-2/28/2026, revealed, .Diabetic Nail Care on Tuesday every day shift every Tuesday TO BE COMPLETED BY RN . During an interview on 2/18/2026 at 9:50 AM, the Administrator stated diabetic nail care was scheduled for Tuesdays to be completed by the Registered Nurse and that it should have been completed the previous day. She confirmed the resident could sustain a skin tear if she scratched herself with the overgrown nails. She further stated that female residents should not have unwanted facial hair. She further stated that the shower aide should have trimmed those while she had her in the shower. Record review of the admission Record indicated Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included Encephalopathy, unspecified and Type Two (2) Diabetes Mellitus without complications. Record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/13/25, revealed under section C a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #2 was cognitively intact.

Based on observation, staff interview, and facility policy review, the facility failed to maintain a safe, clean, and homelike environment by ensuring window coverings were intact and in good repair for two (2) of the twenty-nine resident rooms observed. (room [ROOM NUMBER] and #232). Findings Include:Record review of the facility policy titled, Homelike Environment dated 11/21/2024, revealed, Residents are provided with a safe, clean, comfortable, and homelike environment.During the initial tour on 2/17/26 between 10:37 AM and 10:43 AM, observation revealed the window blinds in rooms 230 and room [ROOM NUMBER] had broken and missing slats, leaving an approximate 30-inch gap at the bottom and exposing the outside elements.On 2/18/26 at 10:50 AM, Certified Nurse Aide (CNA) #1 stated that when disrepair is noted in a resident room, nursing staff are notified so maintenance can be contacted. CNA #1 confirmed she observed the window blinds in room [ROOM NUMBER] with multiple broken and missing slats and reported the issue that morning. She further confirmed the blinds in room [ROOM NUMBER] were broken with missing slats, exposing the room to outside elements.On 2/18/26 at 11:10 AM, the Administrator confirmed the window blinds in rooms [ROOM NUMBERS] were broken, looked unsightly, and did not meet the facility's expectation of providing a homelike environment.On 2/18/26 at 1:30 PM, the Maintenance Director stated that maintenance needs are addressed when a work order is submitted. He reported he was notified that morning about replacing the blinds in room [ROOM NUMBER] and confirmed they were broken with missing slats. He stated he had not been made aware of the need to inspect or repair the blinds in room [ROOM NUMBER].

Based on observations, resident and staff interviews, record reviews, and facility policy review, the facility failed to implement comprehensive care plans for one (1) of 13 sampled residents. (Resident #2) Findings include: Review of the facility policy titled Minimum Data Set (MDS) 3.0; Care Plans with review date 6/23/2016, revealed, .The services provided or arranged by the facility must meet professional standards of quality; and be provided by qualified persons in accordance with each resident's written plan of care . Resident #2 Record review of Care Plan for Diabetes Mellitus, initiated 8/26/2024, revealed, .Diabetic nail care on Tuesdays . Record review of Activities of Daily Living (ADL) Care Plan, initiated 8/26/2024, revealed, .Personal Hygiene .The resident is able to perform care with cueing and supervision . On 2/17/2026 at 10:32 AM, during observation and interview Resident #2 was observed to have noticeably long, jagged fingernails measuring approximately one (1) inch in length and a few scattered long facial hairs on her chin, approximately one and one-half inches in length. The resident stated her nails were too long and needed to be trimmed and that she did not want facial hair and would like that to be trimmed. On 2/18/2026 at 9:45 AM,during an interview and observation Licensed Practical Nurse (LPN) #1 confirmed Resident #2 had long, jagged fingernails that could cause the resident to sustain a skin tear. She stated that because Resident #2 has diabetes, a Registered Nurse (RN) is required to trim the resident's nails. She further stated diabetic nail care is scheduled on the Treatment Administration Record (TAR) every Tuesday to be completed by the Registered Nurse (RN). Additionally, she confirmed that Resident #2 did have several long chin hairs. She stated that the shower aide should have taken care of this when she got her shower. During an interview on 2/19/2026 at 10:11 AM, the Minimum Data Set (MDS) Nurse confirmed the ADL and Diabetes Mellitus care plans were not implemented. She stated the purpose of the care plans were to give guidance for individualized care for each resident. Record review of the admission Record indicated Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included Encephalopathy, unspecified and Type Two (2) Diabetes Mellitus without complications. Record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/13/25, revealed under Section C a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #2 was cognitively intact.

Based on staff and family interview, facility policy review and record review, the facility failed to act on and resolve grievances related to maintaining Activity of Daily Living (ADL) needs for incontinent residents for one (1) of three (3) family interviews conducted. Resident #27 Findings Include: Review of the facility policy titled Activities of Daily Living (ADL) Care, dated 04/09/2018, stated, To ensure all ADL care is provided on a daily basis as needed to ensure that all the residents' needs are met. On each shift all residents are checked every two hours, and adult brief is changed if needed. An interview conducted via telephone with Resident #27's caregiver on 2/18/26 at 8:53 AM, revealed the caregiver reported Resident #27 had been left in a soiled brief on more than one occasion while she was visiting daily. The caregiver stated staff informed her that residents were not to be changed during meals times and meal tray passes. The caregiver expressed concern that her mother remained in a soiled brief for several hours hour until meal service was completed. Review of Resident Council meeting minutes dated 9/09/25, revealed administration instructed staff not to provide incontinence care during mealtimes. During interviews conducted on 2/18/26 at 10:32 AM with Certified Nursing Assistants (CNA) #1 and CNA #2 confirmed staff were expected to complete tray pass and feeding residents before providing incontinence care during meal service. On 2/18/26 at 10:40 AM, during an interview with Licensed Practical Nurse (LPN) #1, she stated that incontinence care is not to be completed during mealtimes. During an interview on 2/19/26 at 11:00 AM, the Administrator stated the expectation was for staff to provide incontinence care every two hours and as needed, including during mealtimes. The Administrator stated residents should not remain in soiled briefs and that she would make sure to address the grievance and work to resolve it and was unaware that it was still an ongoing problem. Review of the admission Record indicated Resident #27 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction. Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/20/25, revealed under section C a Brief Interview for Mental Status (BIMS) summary score of 07, indicating Resident #27 has severely impaired cognition.

Based on observation, staff interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for residents' use as evidenced by both facility's shower rooms being in disrepair for two (2) entrance areas of two (2) shower rooms in the facility. Findings include: Record review of facility's letterhead notification signed by the Administrator and dated 11/5/24, revealed, (Proper name of facility) does not have a specific policy for environment of care, concerning walls, etc. A policy is being developed immediately. During interviews and a tour with the Administrator and the Director of Nursing (DON) on 11/4/24 at 3:55 PM, it was revealed that each of the two locked shower rooms had an entrance area from the resident hallways that led to the shower area. Upon entrance into each of these areas, damage to walls and ceilings was observed. In the east hall shower room, the outside corner of the wall where people would walk or be assisted in a chair to the shower area had a large open area of missing plaster with visible metal grill like material. The ceiling around an air vent was also noted to be damaged with some plaster hanging down and a black substance on the open areas of the ceiling. In the south hall shower room, the ceiling surrounding the air vent was noted to have a large amount of damage and opened areas to the plaster with a dark substance noted near those open areas. The area behind the door where the doorknob met the wall was noted to be damaged with a large hole of missing plaster and metal noted inside. The DON stated the location and the necessity to pass through this area to enter the shower could lead to the potential for an injury and the areas needed repair. The Administrator revealed the entrance area to each of the two shower rooms had not been remodeled. She stated it had been mentioned to the maintenance department, but it was not repaired. She stated there was the potential for an injury to occur from this and it needed to be repaired. She confirmed the facility failed to provide a safe, functional, and sanitary environment for the residents' shower areas. During an interview and walk through observation with the Maintenance Director on 11/6/24 at 1:50 PM, it was revealed that he was aware of the damaged areas in each of the shower rooms. He stated he had been unsuccessful in finding someone to come in to do the necessary repairs, but he was attempting to contact another person to get the needed repairs completed. The Maintenance Director measured the damaged areas and in the east hall shower room, an area of an outer corner leading into the shower area measured approximately 22 inches from the top of the baseboard up the outer corner wall with a width of approximately 5 inches on one side of corner and 4 inches on the other side of the corner. This damaged area had a metal grill like material that was exposed. He confirmed the ceiling was missing plaster with open areas around air vent. This damaged area was measured approximately 25 inches x 18 inches with an open area with a black substance next to the air vent measuring approximately 8 inches by 1 inch. In the south hall shower room, the ceiling damage measured approximately 24 inches by 20 inches, with two open areas of a black substance next to the air vent measuring approximately 9 inches by 3 inches for one and approximately 2 inches by one inch for the other one. He stated he was unsure of what the dark substance on the open areas of ceiling was, but it could have been caused by the moisture. The area behind the south hall shower room door where doorknob met wall with an open area measuring approximately 5 inches by 4 inches with metal noted in the open area. The Maintenance Director confirmed he was aware of these damaged areas and that the areas needed to be repaired for safety.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure the proper storage of a nebulizer facial mask and tubing to prevent contamination and the possibility of infection for one (1) of fourteen sampled residents. Resident #21. Findings Include: Record review of the facility policy titled Oxygen/Nebulizer and Continuous Positive Airway Pressure (CPAP) Supplies with a revision date of 03/13/18 revealed .Place Oxygen/Nebulizer tubing/supplies and CPAP mask/supplies in plastic bag after each use An observation on 11/04/24 at 10:40 AM, revealed a nebulizer machine on the nightstand next to Resident #21's bed and the facial mask and tubing were not in a plastic protective covering. An interview with Licensed Practical Nurse (LPN) #1 on 11/05/24 at 11:40 AM, confirmed that Resident #21's nebulizer mask and tubing were placed on top of the nightstand and were not inside a plastic protective bag. She revealed that a respiratory mask left open to air was an infection control issue, the mask could become contaminated with different germs and could cause respiratory infections. LPN #1 confirmed that the nebulizer facial mask and tubing should be in a protective covering when not in use. An observation and interview with the Administrator (ADM) on 11/05/24 at 11:45 AM revealed that nebulizer facial masks and tubing should be in a protective bag when not in use to prevent infection. She confirmed that Resident #21's nebulizer mask and tubing were placed on top of the nightstand and were not in a protective plastic bag. She revealed that leaving the nebulizer facial mask and tubing out and open to air could cause the spread of germs and respiratory infection. Record review of Resident #21's Order Summary Report revealed an order with a start date of 07/01/24 for Albuterol Sulfate Solution Nebulizer 0.5% (5 milligrams per milliliter) 1 dose inhale orally via nebulizer every six hours as needed for coughing/wheezing. Record review of Resident #21's November Respiratory Record revealed that she received an albuterol breathing treatment by nebulizer on 11/04/24 at 8:23 AM and on 11/04/24 at 5:09 PM. Record review of Resident #21's Admission Record revealed an admitted [DATE] and that she had diagnoses that included Shortness of Breath, Unspecified Dementia, and Chronic Obstructive Pulmonary Disease. Record review of Resident #21's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/05/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 06 which indicated that she had severe cognitive deficits.

Based on staff interviews, record review, and facility policy review, the facility failed to develop a care plan for hospice service for one (1) of 14 sampled residents' care plans reviewed. Resident #15 Findings include: Record review of the facility policy titled, MDS 3.0: Care Plans (Minimum Data Set) dated 6/23/16, revealed, The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following: 1. The services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being as required, 2. Any services that would otherwise be required. Record review of Resident # 15's physician's Order Details revealed an order dated 5/9/24 to Admit to (proper name of hospice company) hospice. Record review of the care plans for Resident #15 revealed there was no care plan for hospice care and services. During an interview on 11/6/24 at 11:45 AM, the Minimum Data Set (MDS) Coordinator revealed Resident #15 was receiving hospice services and was assessed for hospice on the MDS assessment, but a care plan was not developed. She acknowledged any resident receiving hospice services should have a care plan for that care, and she was uncertain why this one was not done. She stated the resident had been on and off of hospice and this care plan just slipped through the cracks and was not done. An interview with the Administrator on 11/6/24 at 11:55 AM, confirmed Resident #15 was receiving hospice services, therefore, a care plan for this was needed. She stated that she was uncertain why the care plan was not developed. She acknowledged the care plan provided the staff with a guide for the care of each resident and should include the plans/treatments/preferences for each resident and the facility failed to develop a hospice care plan for this resident. Record review of Resident #15's Transfer/Discharge Report revealed the facility admitted the resident to the facility on [DATE]. Record review of Resident #15's MDS Section O with Assessment Reference Date (ARD) of 8/12/24, revealed the resident was receiving hospice services. Section C revealed the Brief Interview for Mental Status (BIMS) should not be conducted due to resident is rarely/never understood.

Based on staff interviews, record review and facility policy review, the facility failed to provide the necessary behavior health care and services to a resident with a diagnosis of major mental illness for one (1) of 12 sampled residents. Resident #23 Findings Include: Record review of the facility policy titled Behavioral; Health Services with a revision date of 4/28/16 revealed, Purpose: Services are provided to meet resident's psychological needs. Resident behavior and emotional needs are closely monitored and evaluated to ensure that they do not become obstacles to treatment goals. (Proper Name of Facility) provides care and services to prevent and manage behavioral problems . Record review of the Departmental Notes for Resident #23 revealed the following entries: 11/5/23, Resident called for help repeatedly to get up and lay down. 11/7/23, He does not participate in many activity programs due to him having anxiety when around groups of people. 11/7/23, Resident did have behavior issues today. Resident refused lunch and states I will just starve to death. Hollering and cussing and saying he wants to die. 11/8/23, Resident makes statements like He's coming to the end of the road, He'll just starve to death . 11/9/23, Resident has been hollering this am, he has been upset wanting someone to help him with his breakfast . 11/11/23, Resident has been yelling Help, and I am blind. Record review of Doctor's Progress Notes for Resident #23 revealed an entry dated 11/14/23, Pt (patient) with some suicidal talk. He has on/off talk about depression. Will ref (refer) to behavior if this doesn't improve . Record review of the Departmental Notes for Resident #23 dated 11/15/23 revealed the resident was transferred to behavior health due to suicidal ideation and returned to the facility on [DATE]. An interview on 1/24/24 at 2:00 PM, with the Administrator (ADM) revealed we do not currently have a contract with any Psychiatric services. She revealed we are in the process of getting new behavioral health services; the company we were using voided our contract without notice due to their staffing shortages. She confirmed the facility had been without behavioral health services since Sept. 11, 2023. She revealed, to her knowledge, Resident #23 was not getting any psychiatric services before and following his recent behavioral health stay. She confirmed that with the resident's diagnosis of bipolar disorder, he would have benefited from these specialized services. An interview with Social Services on 1/25/24 at 8:30 AM, revealed that she was notified by the staff that Resident #23 was making suicidal threats. She revealed that she went down to talk with the resident that day, and he stated he did not plan to hurt himself. She revealed that she did a suicide risk assessment on the resident and rated him not suicidal. She revealed that she called the resident's wife regarding the issue, and she stated that the resident had never threatened to harm himself in the past, and this was new behavior. She revealed a referral was then sent to behavioral health. The Survey Agency inquired whether the resident was receiving psychiatric services before the recent behavioral health stay in November 2023, and she revealed he had not received any kind of psychiatric services since he was admitted to the facility. She revealed that when the resident was sent back from behavior health, all she knew was that he was not deemed suicidal during his stay. She revealed that behavioral health did not make any recommendations on discharge. She confirmed that the resident would have benefited from specialized psychiatric services before and following the behavior stay, due to his mental illness diagnosis. She revealed that the Administrator had been working to get psychiatric services in the building, but currently had not been able to find anyone. She confirmed that the facility was not providing services and support based on individualized resident needs. Record review of Resident #23's Medication Administration Record (MAR) revealed an order dated 11/29/23, Seroquel 50 mg tablet take one tablet by mouth twice day for Bipolar with behaviors. Also revealed an order dated 11/27/23, Zoloft 25 mg tablet one tablet by mouth daily for Major Depressive Disorder. Record review of the Face Sheet revealed the Resident #23 was admitted to the facility on [DATE] with medical diagnoses that included Anxiety Disorder, Bipolar Disorder and Major Depression. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of six (6) which indicates Resident #23 is severely cognitively impaired. Also, revealed under Behavioral Symptoms in section E, the resident had verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) that occurred 4 to 6 days, but less than daily during the MDS look back period.

Based on observation, staff interviews, record review and facility policy review, the facility failed to provide or arrange for the necessary mental/psychosocial counseling services for a resident with a history of mental illness and suicidal ideation for one (1) of twelve sampled residents. Resident #23 Findings Include: Record review of the facility policy titled Social Service Program with a revision date of 5/10/16 revealed under, Policy: It is the policy of this facility to provide medically related social services to attain or maintain the highest practicable physical, mental, or psychosocial well-being of each resident. Also revealed under, Program Description: The Social Work Services Department is responsible for: . 4. Monitoring the resident's progress in improvement of physical, mental, and psychosocial functioning .6. Providing counseling services to residents and families . Record review of the Departmental Notes for Resident #23 dated 11/15/23 revealed the resident was transferred to behavior health due to suicidal ideation and returned to the facility on [DATE]. An observation of Resident #23 on 1/23/24 at 10:04 AM, revealed him lying in bed. The resident asked, Where am I? An interview on 1/24/24 at 2:00 PM, with the Administrator (ADM) revealed, to her knowledge, Resident #23 was not getting any psychiatric services before and following his recent behavioral health stay for suicidal ideation. She confirmed that with the resident's diagnosis of bipolar disorder, he would have benefited from these specialized services. She revealed the facility did not currently have a contract with any psychiatric services, and no referrals for Resident #23 to be seen by an outside source. An interview with Social Services on 1/25/24 at 8:30 AM revealed that when the resident was discharged back from behavior health, all that she knew about his stay was that he was not deemed suicidal. An interview with Social Services on 1/25/24 at 3:15 PM revealed that when Resident #23 returned from behavior health, she did go down to see him every morning, but she didn't document anything in the notes. She revealed that she didn't have a set schedule of when she visited Resident #23 and that she usually checks on every resident in the morning, but she didn't always document the things she had done. She confirmed that if the assessment was not charted, then it wasn't done. She confirmed that with no documentation, the facility could not show proof of providing services and support based on individualized resident needs. She revealed that no referrals had been made to any outside sources for the resident's mental health needs. Record review of Departmental Notes dated 11/29/23 revealed Social Services met with Resident #23 and his wife following behavior health stay. No documentation to support a psychosocial assessment was conducted. Record review of the Face Sheet revealed that Resident #23 was admitted to the facility on [DATE] with medical diagnoses that included Anxiety Disorder, Bipolar Disorder and Major Depression. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 6 which indicates Resident # 23 is severely cognitively impaired. Also, revealed under Behavioral Symptoms in section E, the resident had verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) that occurred 4 to 6 days, but less than daily during the MDS look back period.

Based on observation, staff interviews, record review and facility policy review, the facility failed to appropriately clean and disinfect a blood glucose meter between resident use for three (3) of nine (9) residents who require blood glucose finger sticks. Findings Include: Record review of the facility policy titled, Glucose Checks with a revision date of 6/07/16 revealed, .Procedure: . 8. Clean glucometer after use for a wet time of 2 (two) minutes using purple top sani-wipe . An observation of Registered Nurse (RN) #1 on 1/23/24 at 11:02 AM, revealed after she completed a blood glucose check for Resident # 3 using a multi-use glucometer, she used a Sani-cloth (purple top) disinfecting wipe to briskly wipe down the glucometer machine for approximately five (5) seconds and placed the machine on a napkin barrier to air dry. RN #1 then performed blood glucose checks for Resident #183 and Resident # 12 and followed the same process for disinfecting the blood glucose monitor after resident use. An interview with Registered Nurse (RN) #1 on 1/23/24 at 11: 45 AM, revealed that she usually wipes the glucometer down front and back and allows it to air dry according to the recommendation on the disinfecting wipes. She revealed she was unsure of the recommended wet time, but after reading the label on the wipes, she verified the wet time was 2 minutes. She revealed that she did not know that the wet time meant the blood glucose machine should remain wet (in contact with the disinfecting wipe) for a total of 2 minutes. She confirmed that she did not disinfect the machine properly and this was an infection control concern. An interview with the Director of Nursing (DON) on 1/24/24 at 9:02 AM, revealed the facility used Sani-cloth germicidal disposable wipes and the glucometers were to be cleaned between resident use. She revealed the nurses were to wipe the glucometers good and allow it to sit inside the wipe for 2 minutes. She confirmed improper disinfecting of the blood glucose monitor could spread infection. She revealed that all nurses had been recently in-serviced on the proper cleaning and disinfection of the multi-use glucometer. Record review of the Staff Meeting conducted December 2023 revealed, . cleaning equipment, including glucometers, with 2 min wet time for purple wipes. Registered Nurse (RN) #1 was in attendance. Record review of the Staff Meeting conducted for January 2024 revealed under, . cleaning equipment, including glucometers, with 2 min wet time for purple wipes. Registered Nurse (RN) #1 was in attendance.

Based on observation, staff interviews, record review and facility policy review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents during two (2) of 10 medication observations. Findings Include: Record review of the facility policy titled, Medication Administration with a revision date of 6/07/16 revealed, .Essential Points: . 3. Never leave medication on top of medication cart unattended . During an observation of medication pass with Registered Nurse (RN) #1 on 1/23/24 at 11:15 AM, Resident #3 was ordered Novolog Insulin per sliding scale for a blood glucose reading of 285 mg/dl (milligrams/deciliter). RN #1 revealed the insulin was not stored on the medication cart, and she must go get the prescribed insulin from the medication room. Upon returning to the medication cart, RN #1 placed a clear open storage container on top of the med cart that contained nine (9) boxes of insulin and one (1) insulin pen. RN #1 entered Resident #3's room and administered the prescribed insulin and left the container filled with insulin on top of the medication cart unattended. RN #1 then entered Resident #12's room twice to perform a blood glucose check and then returned to give the prescribed sliding scale insulin while the plastic container filled with insulin remained unattended on top of the medication cart. An interview with RN #1 on 1/23/24 at 11:45 AM, revealed that they do not store insulin on the medication carts. She revealed the insulin was kept in the med room refrigerator in the plastic container. She revealed when they have glucometer checks, they bring the entire container of insulin out and return it to the medication room refrigerator when they are finished. She revealed that she left the insulin on top of the cart because the container was too big to fit inside the cart. RN #1 confirmed that the insulin should not have been left unattended on top of the cart due to the risk of a resident wandering by and picking it up. An interview with the Director of Nursing (DON) on 1/24/24 at 8:52 AM, revealed that anything could happen when medications were left on top of the medication cart unattended and confirmed that a resident could come by and take them. Record review of the Staff Meeting conducted December 2023 and January 2024 revealed, . No meds on top of med carts. Registered Nurse (RN) #1 was in attendance for both meetings.

Based on staff interviews and record review, the facility failed to monitor a resident receiving anticoagulant medication for signs of bruising and bleeding for one (1) of five (5) residents reviewed for unnecessary medications. Resident #23 Findings Include: The facility provided the State Agency (SA) documentation on letterhead, (Proper Name of Facility) does not have a specific policy for monitoring for signs and symptoms of bleeding/bruising for residents on anticoagulant therapy. Record review of Resident #23's Medication Administration Record (MAR) revealed an order dated 7/14/23, Coumadin 7.5 mg (milligrams) by mouth every day except Wednesday for Circulation. Also revealed an order dated 10/20/23,Coumadin 2.5 mg tablet take one tablet by mouth on Wednesday for circulation. Both physician orders had a discontinuation date of 1/20/24. Record review of Resident #23's MAR revealed an order dated 1/21/24, Warfarin Sodium 5 mg tablet by mouth daily at 5 PM for circulation. Record review of the Physician order list and the Medication Administration Record (MAR) revealed there was not a monitoring tool for staff to monitor for signs of bruising and bleeding with the anticoagulant medication Coumadin. An interview with Licensed Practical Nurse (LPN) #1 on 1/24/24 at 1:20 PM, revealed that Resident #23 recently had a Coumadin dose change. She confirmed that they do not have a monitoring tool on the MAR to document any signs of bleeding or bruising. She revealed that when the aides put the residents to bed, they usually come and tell the nurse if they observed any bruising on the skin. An interview with Registered Nurse (RN) #1 on 1/24/24 at 1:25 PM, revealed they do not have a monitoring tool to alert the nurses to observe a resident on an anticoagulant medication for signs of bruising/bleeding. She stated, It's just something known. An interview with LPN #2 on 1/24/24 at 1:28 PM, revealed the facility does weekly body audits on all the residents and the aides were good at reporting any bruising or bleeding. An interview with the Director of Nursing (DON) on 1/24/24 at 2:50 PM, revealed the only monitoring they provided for the residents taking anticoagulant medication was a weekly skin audit. She confirmed lack of monitoring for anticoagulants placed the residents at risk for bleeding and death. Record review of the Face Sheet reveled the Resident #23 was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Atrial Fibrillation, Long Term (current) use of Anticoagulants, and Personal history of other Venous Thrombosis and Embolism. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 6 which indicates Resident # 23 is severely cognitively impaired.

Based on staff interviews, record review and facility policy review, the facility failed to submit a Level II Preadmission Screening and Resident Review (PASARR) to the State Mental Health (SMH) Authority for a resident with a mental disorder (MD) following a significant change in mental condition for one (1) of three (3) PASARR's reviewed. Resident #23 Findings Include: Record review of the facility policy titled Pre-admission Screening with a revision date of 2/21/19 revealed, Policy: . c. If after admission, a resident is found to have a mental illness or the physician orders a psychotropic medication for the resident a Mississippi PASRR Level 2 Change in Status request will be submitted . Record review of the Medical Doctor progress notes dated 11/14/23 revealed that Resident #23 was placed on an intervention of one on one for suicide watch due to suicidal ideation's. Record review of the Nurses Notes dated 11/25/23 revealed that Resident #23 was transferred to Behavior Health. An interview on 1/25/24 at 8:25 AM, with Social Services revealed she sends in a status change when a resident has a new mental illness diagnosis added or has a change in mental or physical condition. She confirmed that she did not send in a status change for Resident #23 when he transferred to behavior health. She revealed that the resident was admitted to the facility with bipolar disorder and behavior health did not deem the resident as suicidal upon discharge, so she did not see this as a significant change in mental condition. She confirmed that the resident would benefit from psychiatric services. An interview with the Director of Nursing (DON) on 1/25/24 at 9:15 AM confirmed that with Resident #23's mental diagnosis of bipolar disorder and new symptoms of suicidal ideation, the resident should have had a change in status submitted to the SMH Authority. She revealed the resident would benefit from psychiatric services. Record review of the Face Sheet revealed that Resident #23 was admitted to the facility on [DATE] with medical diagnoses that included Anxiety Disorder, Bipolar Disorder and Depression Unspecified. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 6 which indicates Resident #23 is severely cognitively impaired.

Based on staff interviews, record review and facility policy review, the facility failed to implement a comprehensive care plan for monitoring a resident for suicidal ideation for one (1) of twelve care plans reviewed. Resident #23 Findings Include: Review of the facility policy titled MDS (Minimum Data Set) 3.0; Care Plans with a revision date of 6/23/16 revealed, Policy: The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following: 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required . Record review of Resident #23's Psychosocial Care Plan revealed under interventions, Monitor for suicidal ideation and was assigned to the role of Social Services. Record review of Resident #23's Anxiety Care Plan revealed, under interventions, Monitor for suicidal Ideation and was assigned to the role of Social Services. An interview with MDS Nurse on 1/25/24 at 2:15 PM, revealed the purpose of the care plan was to address the problem and diagnosis and develop a measurable goal to reach. She confirmed that Resident #23's care plan was not followed for monitoring for suicidal ideation. An interview with Social Services on 1/25/24 at 3:15 PM, revealed that she develops the Care Plans related to social services. She revealed that she did go by to see Resident #23 every morning, but she did not document anything. She confirmed that she didn't have any documentation to support that she monitored for suicidal ideation and confirmed the target care plan was not followed. Record review of the Face Sheet reveled the Resident #23 was admitted to the facility on [DATE] with medical diagnoses that included Anxiety Disorder, Bipolar Disorder, and Depression. Record review of the MDS with an Assessment Reference Date (ARD) of 12/04/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 6 which indicates Resident # 23 is severely cognitively impaired.

Based on record review and staff interview the facility failed to notify the resident and/or resident's representative in writing of the reason for the transfer/discharge to the hospital for three (3) of four (4) residents reviewed. Resident #8, Resident #22, and Resident #39 Findings include: Resident #8: Record review of a typed letter on facility letterhead, dated 9/15/22 and signed by the Administrator revealed, To Whom It May Concern: This facility has looked and we cannot find a policy on notifying family members in writing when a resident is transferred from this facility. This facility notifies family members by telephone anytime a resident is sent to emergency room or to any other facility and this is documented in the medical record. This facility will immediately get a policy to notify family members in writing anytime a resident in transferred from this facility. Record review of the Departmental Notes dated 06/21/22 revealed Resident #8 was congested and had a cough, wheezing and crackles auscultated and his oxygen levels at 90% on 3 liters of oxygen when checked and was sent to the emergency room (ER) to be assessed. Record review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Representative (RR) was notified by phone of transfer to the hospital. Record review of Emergency Transfer Log for the Office of the State Long-Term Care Ombudsman revealed resident transferred to hospital on 6/21/22 and returned on 6/24/22 and Ombudsman was notified. Record review of Face Sheet revealed that Resident #8 was admitted to facility on 12/22/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #22 Record review of a Departmental Note dated 7/12/22 at 2:58 PM, revealed the resident was difficult to arouse and had difficulty speaking and was sent to the ER for an evaluation. Record review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Face Sheet revealed Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #39 Record review of the Departmental Notes dated 8/6/22 at 3:44 PM, revealed a late entry for 8/5/22 that indicated Resident #39 had diminished breath sounds and complained of shortness of breath and was sent to the ER for evaluation. Record review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 9/15/22 at 9:15 AM, with the Administrator confirmed Resident #8 was admitted to the hospital on 6/21/22, Resident #22 was admitted to the hospital on 7/12/22, Resident #33 was admitted to the hospital on 7/31/22 and Resident #39 was admitted to the hospital on 8/5/22. She confirmed the RR's were not notified in writing of the reason for the transfer. The Administrator confirmed she was unaware of this requirement and the facility failed to provide the written notification with the reason for transfer to the resident or the RR. She confirmed the facility had no policy on this requirement.

Based on observation, staff interview, and record review the facility failed to adhere to proper hand hygiene measures during meal tray service as evidenced by failure to change gloves and use hand sanitizer or wash hands between resident rooms and failure to wear a mask properly for one (1) of one (1) meal service observed. Findings include: Review the facility's COVID-19 Prevention and Control policy, dated 3/12/2020 and updated 3/26/20, revealed this facility follows current guidelines and recommendations for the prevention and control of COVID-19. This facility will follow the CDC recommendations to assist in prevention of respiratory germs into the facility in relation to COVID-19. The facility will ensure employees clean their hands according to the facility policies and procedures including before and after contact with residents, after contact with contaminated surfaces or equipment, and after removing personal protective equipment (PPE). Gloves will be removed after contact followed by hand hygiene. An update, on 3/26/20, revealed the facility implemented the staff to wear N95 face masks when in the hallways, dining areas, nurses' station, resident rooms, etc. anywhere, except private offices. Staff will not take the mask off and on throughout the day, this causes contamination. An observation, on 2/8/21 at 11:32 AM, revealed Certified Nursing Assistant (CNA) #2 come out of room [ROOM NUMBER] wearing a pair of gloves. CNA #2 removed the gloves as she walked down the hall. She rolled them upholding them in her hand and entered room [ROOM NUMBER] without using hand sanitizer or washing her hands. She came out of room [ROOM NUMBER] putting on another pair of gloves and went to the meal cart. An observation on 2/8/21 at 11:33 AM, revealed CNA #3 delivered the lunch tray to room [ROOM NUMBER]. She came out of room [ROOM NUMBER] and did not wash her hands or use hand sanitizer. An observation, on 2/8/21 at 11:40 AM, revealed CNA#1 walking in the hallway with her face shield and her mask on, but her mask was not covering her nose. She was also wearing disposable gloves in the hallway. She entered room [ROOM NUMBER], then came out and closed the door with her gloved hands. She walked up the hall to the lunch cart obtained a lunch tray and took it into room [ROOM NUMBER] and assisted the resident with her meal. She did not change her gloves or wash her hands between rooms. An observation on 2/8/21 at 2:00 PM revealed CNA #1 was seated at the desk with her mask below her nose talking with other staff. An interview on 2/8/21 at 2:10 AM with Certified Nursing Assistant (CNA) #1 confirmed she had her mask below her nose during our interview. She stated she had trouble breathing sometimes and pulls it down because she has a face shield on. She confirmed that the face shield was for eye protection. She stated that she was supposed to wear her mask and eye shield at all times in the facility. She stated that she thought it would be okay to pull her mask down if she had her face shield on, but by not wearing her mask right, she could catch or give [MEDICAL CONDITION] to someone. CNA #1 confirmed she should not have worn gloves in the hallway and that they were contaminated when she touched the door. She stated that by not changing gloves and washing hands she could contaminate the lunch trays or the resident. An interview, on 2/8/21, at 2:20 PM, with CNA #2 revealed that she realized that she should not have taken her contaminated gloves down the hall and into another room. She stated they had been told by the administrator to wear gloves when they put trays out. CNA #2 stated that she realized she should change gloves between each room and wash her hands. She stated that this could give the residents more germs. She confirmed that she had in-serviced pertaining to hand hygiene. An interview, on 2/8/21, at 2:30 PM, with CNA #3 confirmed that she did not wash her hands or use hand sanitizer when she exited the resident's room. She stated that she was not sure about wearing gloves. CNA #3 stated that not using hand sanitizer or washing your hands between residents could spread germs or cross contaminate. She stated that she had in-service education on hand hygiene. An interview, on 2/8/21, at 2:55 PM, with the Infection Preventionist revealed the staff should never come out of a room into the hallway with gloves on. She stated that she did not know why they decided to wear gloves to put out trays. An interview, on 2/8/21, at 3:00 PM, with the Administrator revealed the staff should not be wearing gloves when putting out trays. She stated that she may have said something that led them to do that, but that they should take them off and wash their hands or use hand sanitizer when they remove the gloves. She also stated that all staff should always make sure their mask covers their nose and mouth properly. Record review revealed CNA #1 attended an in-service titled, Hand Hygiene on 3/8/20. CNA #1 also completed CMS Targeted COVID-19 Training for Frontline Nursing Home Staff on 10/7/20.

Based on observation, staff interview, standard practice review, and facility policy review, the facility failed to follow the professional standards of practice for administration of medications via Percutaneous Endoscopic Gastrostomy (PEG) tube for one (1) of one (1) residents observed for medication administration through a PEG tube, Resident #3. Findings Include: Review of the facility's policy, Nursing Home Medication; Administration by Gastrostomy Tube, revised 6/7/16, revealed if administering more than one (1) medication, flush with five (5) milliliter (ml) of water, or prescribed amount, between each medication. (MONTH) give a group of multiple medications as long as there are no known compatibility problems between medications mixed together. Review of Reference Information for Standard of Practice related to Medication Administration via PEG tube: Mosby's Pocket Guide to Nursing Skills and Procedures, Perry - Potter, Eighth Edition, Page 334, 14b. To administer more than one (1) medication, give each separately, and flush between medications with 15 to 30 milliliters (ml) of water. Rationale: Maintains patency of enteral tube and ensures that medication passes through tube to stomach. During a medication pass observation, on 2/22/19 at 7:30 AM, Registered Nurse, (RN) #2 was observed administering medications to Resident #3 via a Percutaneous Endoscopic Tube (PEG) tube. RN #2 was observed crushing Vitamin D3 400 International Units (IU) two (2) tablets, Aspirin 325 milligrams (mg), [MEDICATION NAME] 10 mg, [MEDICATION NAME] 15 mg and [MEDICATION NAME] 5 mg. RN #2 crushed all the medications and mixed them with 15 cubic centimeters (cc) of apple juice. RN #2 administered all of the medications at once via the feeding tube. On 02/22/19 at 08:42 AM, during an interview with RN #2, she stated, she always crushed his (Resident #3) medications and gave them together. RN #2 stated, she wasn't aware they were supposed to be given separately. RN #2 stated, she thought it was okay to mix and give them all together. 02/22/19 09:07 AM, interview with the Director of Nursing (DON), revealed she was not aware the standard of practice had changed to require PEG tube meds to be administered separately. The DON stated she was going to start an in-service with all the staff to include the standard of practice for administering meds via the feeding tube.

CI MS # Based on observation, interview, record review and policy review the facility failed to ensure that residents received adequate supervision consistent with one (1) of six (6) Resident's needs to prevent Resident #1 from leaving the facility, a safe environment, without staff supervision. The facility also failed to ensure that adequate measures/systems were in place to prevent residents from leaving the facility unassisted for four (4) residents reviewed who were deemed at risk for wandering/elopement. The systems that were not in place included documented assessments of the elopement risk, visual monitoring of resident location specific to wander/elopement risk; performance checks of code alert bracelets for function; code alert door checks daily to ensure proper function; and routine drills specifically for elopement of residents from the facility. This is for Resident's #1, #2, #3, and #4. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was assessed as being alert and oriented to person, place, and time on the "Admission Data Collection Tool" on 3/15/12 and required the use of a walker due to an unsteady gait for balance. Resident #1 was assessed on 3/22/12 with moderate cognitive impairment as per the Brief Interview for Mental Status (BIMS). Resident #1 used a wheelchair and walker for mobility and was receiving range of motion and ambulation exercises from restorative nursing for weakness and unsteady gait. Resident #1 told Certified Nursing Assistant (CNA) #3 that he needed to go to the jewelry store on 3/30/12 around 4:30 p.m. CNA #3 did not tell the Nursing Supervisor or report the statement to anyone until the resident was discovered missing at approximately 7:30 p.m. to 7:45 p.m. Resident #1 had become agitated when he did not receive a shower at the time he requested at 6:00 p.m. Resident #1 was last seen by CNA #3 at approximately 6:00 p.m. on 3/30/12. Resident #1 left the front porch of the facility without supervision and ambulated with a rolling walker approximately 0.2 miles from the facility on a paved road with no sidewalks. Resident #1 was picked up by a friend/family member and taken to her apartment with notification to the facility staff at approximately 8:10 p.m. of where Resident #1 was located. Licensed Practical Nurse (LPN) #1 picked Resident #1 up at the friend/family member's apartment and returned Resident #1 to the facility unharmed at approximately 8:20 p.m. on 3/30/12. The facility's failure to take appropriate measures to prevent Resident #1 from leaving the facility porch unsupervised and without staff knowledge; the facility's failure to ensure that appropriate measures of documented assessments of elopement risk; visual monitoring of resident with elopement risks; function checks of code alert bracelets; daily door checks; and routine elopement drills were in implemented was deemed an Immediate Jeopardy (IJ) on 4/10/11. The IJ began on 3/30/12 when Resident #1 left the facility without staff supervision. The Administrator was notified of the IJ on 4/10/11 at 8:30 a.m. The facility provided a Credible Allegation of Compliance (AoC) on 4/11/12. Based on the facility's implementation of corrective actions and an acceptable AoC, the IJ was removed as of 4/11/12, and lowered to a "D" level, which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor and evaluate interventions for effectiveness. Findings include: The facility reported the following information to the State Agency, (not all inclusive), about Resident #1's elopement: "Alleged Resident Abuse Report" dated 3/30/12: Date of alleged abuse/incident 3/30/12 and time 19:45 (7:45 p.m.). Summary of Incident: 3/30/11 Elopement - (Resident #1). 1630 (4:40 p.m.) - Resident #1 said to CNA #3, "I need to go to (Name of Jewelry Store)". CNA #3 told Resident #1 that it would soon be supper and then his shower time and that he needed to stay and eat. This conversation was not reported to anyone at this time. 1730 (5:30 p.m.) - Resident #1 finished his supper, went to his room and called back wanting a shower and when CNA #3 told him that she had to pick up supper trays first, Resident #1 became agitated. LPN #1 and LPN #2 reported that they had witnessed Resident #1 after supper coming and going from his room to the front porch several times. 1945 (7:45 p.m.) - LPN #1 discovered Resident #1 missing when she went to his room to give his medications. CNA #3 then reported the earlier conversation with Resident #1 about the jewelry store. LPN #1 drove to the jewelry store and did not find Resident #1 and called LPN #2 to alert security. 2008 (8:08 p.m.) - LPN #2 notified the DON and Administrator that Resident #1 was missing. 2010 (8:10 p.m.)- Friend/Family Member (Cousin) called facility and reported that Resident #1 was at her apartment, that she had picked Resident #1 up in her car beside Hwy 15 and the jewelry store and had refused to come back to the facility. LPN #1 had LPN #2 to call the police to meet her at the family member's apartment. 2018 - LPN #1 called LPN #2 and reported that she was bringing Resident #1 back to the facility. LPN #1 asked Resident #1 why he had left and the resident replied: "I got pissed off about the shower". Resident #1 also reported that he was trying to get to the house where he had been living to get his things because his daughter had been stealing everything that he had. After arriving back to the facility a code alert bracelet was placed on Resident #1 by LPN #1 and he was given a shower by CNA #3. The "Plan of Correction" included: Code alert bracelet placed on Resident #1, In-service of staff on the current Elopement/Wandering Policies, and attempting to locate Resident #1's belongings for him. " On 4/9/12 there were four (4) residents in the facility identified with wandering/elopement risk. This was for Resident #1, Resident #2, Resident #3 and Resident #4. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Nursing assessment dated [DATE] revealed that Resident #1 was alert and oriented to person, place and time; assistance needed for bathing/shower; assistance with walking-needed a walker-unsteady gait; and he was agitated and angry at times. There was no documentation related to a history of wandering. Review of a "Restorative Assessment and Progress Form" dated 3/18/12 revealed that Resident #1 was alert and oriented x 3 (person, place, time), continent of bowel/bladder, feeds self and has weakness and loss of balance at times. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/22/12 revealed that Resident #1 had moderate cognitive impairment with a BIMS score of 10. (A score of 8-12 is consistent with moderate impairment). Resident #1 was also coded with inattention with difficulty focusing that fluctuated. Resident #1 was independent with transfer and mobility with the use of a walker and wheelchair for mobility. Review of a "Social History & Initial Assessment" dated 3/15/12 revealed that Resident #1 had no place to live and was not able to care for himself. A BIMs was conducted on 3/16/12 by the Social Worker which indicated a score of 10, indicating that Resident #1 had some moderate cognitive impairment and was unable to recall the correct month, day of the week and had to be cued for questions that had been previously asked. Review of a Nurse's Note dated 3/17/12 at 1320 (1:20 p.m.) revealed that Resident #1 refused to be bathed and had been very agitated with staff earlier in the shift. Review of a Nurses' Progress Notes dated 3/22/12 (no time), revealed that Resident #1 was alert and oriented to person, place and time and during the interview he constantly looked around the room and responded to questions with irrelevant information. Review of a Nurse's Note dated 3/30/12 at 1945 (7:45 p.m.) for Resident #1, revealed that LPN #1 went to Resident #1's room to give 8:00 p.m. medications and the wheelchair was in the room but Resident #1 was not. LPN #1 looked in the bathroom and rooms up the hall and asked staff if they had seen the resident. CNA #3 informed LPN #1 that Resident #1 had told her earlier that he had to go to (Name of jewelry store). LPN #1 went to look outside and at the jewelry store, came back to the facility and security was notified as well as the DON/Administrator. A call was received from Resident #1's friend/family member that she had seen Resident #1 and picked him up around the jewelry store. LPN #2 informed the family member that someone would come get Resident #1. The police department was notified to meet facility staff at the friend/family member's apartment. LPN #1 went to the apartment and Resident #1 was very calm. LPN #1 asked Resident #1 why he left without telling anyone and Resident #1 replied that he had gotten pissed off that he didn't receive his shower when he wanted it. Resident #1 also stated that he had to go to his daughter because she was stealing his food stamps and money. LPN #1 assured Resident #1 that he could speak to the Social Worker about these things. Resident #1 came back willingly with LPN #1 to the facility. After arrival to the facility, CNA #3 showered Resident #1 and LPN #1 placed a body alarm to Resident #1's right ankle. Resident #1 stated that he was sorry that he'd left. Resident #1 stated that he would not take the alarm off of his ankle. Further nurse's notes dated 3/30/12 at 2130 (9:30 p.m.) revealed that Resident #1's physician was notified of the resident leaving the facility and new orders were received. There was no documentation in Resident #1's medical record that a physical/mental assessment was performed when he returned from leaving the facility on 3/30/12. There was no documented assessment for the need of the body alarm/code alert bracelet that was applied to Resident #1's ankle upon return to the facility. There was no documented visual monitoring of Resident #1's due to being an elopement risk. There was no documented checks for the functioning of the code alert bracelet that was applied to Resident #1's ankle after his return to the facility on [DATE]. Review of Resident #1's care plan revealed that there was no updated care plan to indicate Resident #1's elopement or risk for further elopements from the facility after his return to the facility on [DATE]. Review of a physician's orders [REDACTED]. Review of Resident #1's March and April 2012 Treatment (Tx) Record revealed "check code alert bracelet every (q) shift. (Interview with staff revealed this was to check that the bracelet was in place, not the functioning). The Tx Record documented fall precautions every shift. Review of a "End of Shift Report" used by the Nurses revealed "code alert" by Resident #1's name. Review of a "CNA Info List" used by the CNAs, revealed under the "alarm" section: "code alert 6/12" for Resident #1. (6/12 was the date of expiration). Observation on 4/9/12 at 1:00 p.m. revealed that it was approximately 0.2 miles from the facility's front porch to the Jewelry Store. Observation and interview with Resident #1 on 4/9/12 with the DON in attendance, revealed that Resident #1 was alert and oriented to person and place but not quite sure of month and date. He knew that it was 2012. Resident #1 answered questions appropriately but at times would be confused about the staff's names and times that events occurred. Resident #1 stated that he had lived with his daughter prior to coming to the facility and that she'd lived by the jewelry store taking the road to the right and it was on the left (per sister interview this was correct). Resident #1 stated that his daughter had been stealing him blind and that's where he was headed when he left the facility. Resident #1 stated that it had all started when that big fat white nurse had told him to go to his room, that he was supposed to get a shower but he didn't and it had made him mad. Resident #1 recalled leaving the front porch, that he had waited until everyone else left and he took off on his walker and walked almost all the way to the highway when his family member/friend (cousin) picked him up and took him to her house. Resident #1 stated that they sat out on the porch and talked, then (name) from the Sheriff's office came, and then the nurse came to get him. Resident #1 did not recall the name of the nurse who came and got him, maybe (name of the Administrator). Resident #1 jumped from one (1) subject to another, looking around the room. Resident #1 denied falls or injury while out of the facility. Resident #1 stated that he did get a shower when he returned to the facility. Resident #1 stated that he was not aware that he was supposed to sign out when he left the facility but thought that his ex-wife had signed him out when they left yesterday (had actually been on Friday instead of Sunday). Resident #1 had a code alert bracelet on his right ankle and he stated that it had been put on his ankle when he returned to the facility the night he'd left and understood why it was there and was okay with the bracelet. Resident #1 stated that he did not think that it was such a big deal and would not leave again. He understood that he could have been hit in the head or run over while he was out of the facility. Further interview with Resident #1 on 4/11/12 at 10:00 a.m. revealed that he was fairly consistent with his recollection of leaving the facility and contended that it was because of not getting his shower when he wanted it. He was also upset and wanted to get his things back from his daughter. Resident #1 stated that he'd "told that girl he was going one time." Interview with LPN #1 on 4/9/12 at 11:50 a.m. revealed that she worked the 3:00 p.m. to 11:00 p.m. shift on 3/30/12 and had last seen Resident #1 in the dining room around 5:30 p.m. LPN #1 stated that she went to Resident #1's room between 7:30 p.m. and 7:45 p.m. to give his medications and he wasn't in his room. However, the wheelchair was there. LPN #1 stated that she asked staff if they'd seen Resident #1. LPN #2 stated that she saw him earlier. CNA #3 stated that she had seen him earlier in the shift. CNA #3 stated that Resident #1 told her that he needed to go to (Name of Jewelry Store). She thought that Resident #1 was joking. LPN #1 stated that she got in her jeep and rode to the jewelry store at the corner of Hwy 15 and the hospital road and didn't see Resident #1. LPN #1 stated that she had LPN #2 to alert security and the DON/Administrator. LPN #1 stated that in the meantime, Resident #1's family member/friend (cousin) called and said that she had picked Resident #1 up on the highway and had taken him to her house because he didn't want to come back to the facility. LPN #1 stated that she had looked for Resident #1 approximately 20 minutes before the family member/friend called. LPN #1 stated that the police were notified and she went to pick Resident #1 up and bring him back to the facility. LPN #1 stated that when she got to the residence that Resident #1 and three (3) other people were sitting on the front porch. LPN #1 stated that she asked Resident #1 why he had left without telling her and Resident #1 said that the CNA was supposed to give him a shower and didn't. Resident #1 also thought that his daughter was stealing his money and everything out of his house and selling it. LPN #1 stated that Resident #1 was just going home to keep her from stealing his stuff. LPN #1 stated that she brought Resident #1 back to the facility and CNA #3 gave him a shower, around 8:30 p.m. LPN #1 stated that Resident #1 kept apologizing that he had left without telling anyone. LPN #1 stated that she had placed a code alert bracelet on Resident #1's ankle and that he had agreed to wear it. LPN #1 stated that Resident #1 told her that he had it planned, that he'd waited until everyone left from the porch and then he took off. LPN #1 stated that she put the code alert bracelet on Resident #1 because he had left the facility without telling anyone and the code alert bracelet would help them monitor when he went in and out of the facility. LPN #1 stated that the placement of the code alert bracelet was checked every shift, but not the functioning of the bracelet. LPN #1 stated that Resident #1 seemed upset that he didn't get his shower when he wanted it. LPN #1 stated that Resident #1 had not attempted or talked about leaving the facility prior. LPN #1 was not aware of any documented visual monitoring for residents at risk for elopement. LPN #1 stated that that staff usually checked residents every two (2) hours. LPN #1 stated that she had not participated in missing person/elopement drills but had done "Code Adam" for a missing child at the hospital (which adjoins the nursing home). Further interview with LPN #1 on 4/10/12 at 1:30 p.m. revealed that when Resident #1 was returned to the facility on [DATE] that he had no obvious cuts, scratches or bruises and denied falling. LPN #1 stated that when CNA #3 showered Resident #1 that she would have reported any concerns if there were any. LPN #1 stated that she had failed to document an assessment and didn't update the care plan regarding the elopement. LPN #1 stated that she should have updated the careplan and document the assessment. Interview with LPN #2 on 4/9/12 at 10:55 a.m. revealed that she had worked the 3:00 p.m. to 11:00 p.m. shift on 3/30/12. LPN #2 stated that LPN #1 came to the nurse's desk around 7:30 p.m. and said that Resident #1's wheelchair was in his room but that he wasn't there. LPN #2 stated that she saw Resident #1 around 6:00 p.m. when he came to the dining room to tell CNA #3 that he wanted his shower. LPN #2 stated that CNA #3 explained to Resident #1 that they had to finish supper trays before she could give him a shower. Resident #1 sat there a few minutes and then went back toward his room. LPN #2 stated that Resident #1 seemed agitated that he didn't get his shower right then. LPN #2 stated that she didn't hear him say anything about leaving to go to (Name of Jewelry Store). LPN #2 stated that CNA #3 did have that conversation but did not report it to anyone. LPN #2 stated that she and LPN #1 both told CNA #3 to always report anything that residents say like that, even if they think they are joking. LPN #2 stated that when LPN #1 reported that Resident #1 was missing, they called the CNAs together and started searching the rooms and the front porch because he had been out on the porch earlier after supper. LPN #2 stated that LPN #1 went to the jewelry store to look for Resident #1 after CNA #3 had reported the conversation about the jewelry store. LPN #2 stated that security and administration were notified that Resident #1 was missing. LPN #2 stated that a lady called the facility and identified herself as a friend of Resident #1 and said that she had picked Resident #1 up around Hwy 15 and that he was at her apartment and refused to come back to the nursing home. LPN #2 stated that she asked for the address and then called the police to meet staff there. LPN #2 stated that LPN #1 went to get Resident #1 and brought him back to the facility, which was around 8:30 p.m. LPN #2 stated that Resident #1 received a shower, and then, LPN #1 placed a code alert bracelet on him. LPN #2 stated that Resident #1 did not attempt to leave again and apologized for leaving. LPN #2 stated that Resident #1 had always been alert and oriented. LPN #2 stated that the residents identified at risk for leaving the facility without assistance wear a code alert bracelet. LPN #2 stated that they checked for the placement of the code alert bracelets every shift but not the function. LPN #2 stated that they tried to check on residents every two (2) hours. LPN #2 stated that she had not participated in missing person's drills. Interview with CNA #3 on 4/9/12 at 12:25 p.m. revealed that Resident #1 said something to her around 4:30 p.m. on 3/30/12 that he needed to go to (Name of Jewelry Store). Resident #1 didn't say a time or day that he needed to go. CNA #3 stated that she asked Resident #1 if he needed to get a bracelet or necklace for his girlfriend and laughed with him when he said "nah". Nothing else was said about the jewelry store. CNA #3 stated that Resident #1 came back to the dining room after eating supper about 5:30 p.m. or 6:00 p.m. He had his clothes in his lap and wanted his shower. CNA #3 stated that she explained that it would be awhile because she had to help with finishing supper and picking up trays, and then, she would come get him for a shower. CNA #3 stated that Resident #3 left and went back to his room. CNA #3 stated that before she could go get Resident #1 for his shower, a nurse was asking if we'd seen him because he wasn't in his room to take his medications. CNA #3 stated that they searched inside and outside for Resident #1. CNA #3 stated that she told LPN #1 of the previous conversation with Resident #1 about the jewelry store, and LPN #1 went to look for him there. CNA #3 stated that she didn't report the conversation earlier because she thought that Resident #1 was joking. CNA #3 stated that when LPN #1 brought Resident #1 back to the facility that she gave him a shower. CNA #3 stated that there were no scratches or skin tears. CNA #3 stated that Resident #1 told her that he was going to see his daughter. CNA #3 stated that a code alert bracelet was placed on Resident #1 and he did not make further attempts to leave. CNA #3 stated that she had not seen Resident #1 walk much on his walker, that he mostly used the wheelchair. CNA #3 stated that she had not participated in missing persons/elopement drills, but, was aware of the policy and procedure for missing persons. CNA #3 stated that she tried to eyeball residents every one (1) to two (2) hours but, did not document a visual check. Interview with the Social Worker on 4/9/12 at 4:15 p.m. revealed that each time she spoke to Resident #1 that he had some memory recall deficits and needed cueing. The Social Worker stated that Resident #1 had been a little anxious because he didn't have any place to go. She stated that he had not shown any tendency of wandering or elopement. The Social Worker stated that Resident #1 was his own Responsible Party and that she had given him a copy of "A Matter of Rights" booklet that speaks to letting the facility know of any plans for leaving. The Social Worker stated that she had informed Resident #1 that he would need to sign out at the station when he left the building. Interview with CNA #1 on 4/10/12 at 10:45 a.m. revealed that Resident #1 was in the restorative ambulation program and that she tried to ambulate him with the rolling walker at least 100 feet per day. CNA #1 stated that Resident #1 also ambulated some on his own. CNA #1 stated that Resident #1's gait was pretty steady right now. However, that it was not as steady when he first came in. CNA #1 stated that she was surprised that Resident #1 had walked away from the facility. Interview with RN #1, Charge Nurse, on 4/9/12 at 2:55 p.m. revealed that Resident #1 used the wheelchair and walker for mobility. RN #1 stated that she had not seen him use the walker without assistance from the staff. RN #1 stated that Resident #1 had always been alert and oriented when she had talked with him and had never shown any signs of leaving the facility before. RN #1 stated that Resident #1 sat out on the porch several times daily for 10-15 minutes and then come back inside. RN #1 stated that residents were identified at risk for elopement by what the family reports in the history on admit, if they wander without purpose, say something about leaving/going home, or attempts to leave without assistance. RN #1 stated that a care plan was usually done for the code alert bracelets and the Resident's tendency to wander. RN #1 stated that if a resident left the facility a search was conducted, and administration and security were notified. When they were returned to the facility the resident's mental and physical status would be assessed and reasons ascertained as to why they left. RN #1 stated that if a code alert bracelet was placed on the resident then, documentation every shift would be required on the treatment record that the bracelet was in place. Review of Resident #1's medical record with RN #1 confirmed that there was no documentation in the nurse's notes after 3/30/12 of a wander/elopement risk, or if Resident #1 had attempted to leave again. There was no care plan for the elopement or the risk of future elopements. RN #1 stated that the code alert bracelet was checked every shift for placement but not for function. RN #1 confirmed that there should have been a documented assessment of Resident #1's physical and mental status upon return to the facility on [DATE]. There should have been an assessment for the code alert bracelet and Resident #1's risk for elopement. RN #1 stated that she had not participated in elopement drills routinely. However, had participated in a "Code Adam" drill where a child was missing at the hospital. Interview with Resident #1's sister on 4/9/12 at 3:30 p.m. revealed that Resident #1 was confused at times due to his nutrition and the way that he'd been treated prior to coming to the facility. Resident #1's sister stated that Resident #1 had fallen several times in the past due to weakness and mini-strokes. The sister stated that Resident #1 was picked up by a nephew and his wife the night that he left the facility and that he had gotten close to the jewelry store. Interview with the DON on 4/9/12 at 4:35 p.m. revealed that she was notified of Resident #1 leaving the facility and came to the facility and talked with Resident #1 after his return. The DON stated that Resident #1 had no signs of injury and had no complaint of falling. The DON stated that she asked Resident #1 where he was going and he reported that he was going to get his things. The DON stated that she informed Resident #1 that he needed to let staff know if he wanted to leave and go somewhere. The DON stated that in-services were not started that night (3/30/12) but that she did talk with staff and get a timeline of the events. The DON stated that the Administrator did an in-service beginning 4/4/12 about the policy/procedure on elopement/missing persons. The DON stated that there was no documented physical assessment of Resident #1 in the nurse's note after his return. The DON stated that there should have been documentation. The DON stated that she was not aware that Resident #1 could get around that well. The DON stated that no one was checking the function of the code alert bracelets, only the placement; and that LPN #3 checked code alert door function when she was here Monday through Friday. The DON stated that there was no visual monitoring of a where a resident was located documented for residents at risk for wandering/elopement. The DON stated that there were no elopement drills conducted specific to elopements at the facility. Interview with Resident #1's ex-wife on 4/10/12 at 7:30 a.m. revealed that Resident #1 told her that he left the facility to go find his stuff that his daughter had taken. Resident #1's ex-wife stated that she was told that Resident #1 didn't get quite to the jewelry store the evening that he left the facility. The ex-wife stated that Resident #1 had his good days and bad days. The ex-wife stated that Resident #1 could tell you who he is and where he is, but, that he might get his times and dates mixed up. Attempts were made to contact Resident #1's family member/friend that picked him up on 3/30/12 were unsuccessful. Attempts were made on 4/9/12 at 4:05 p.m., 4/10/12 at 3:00 p.m., and on 4/11/12 at 10:55 a.m. Interview with the Administrator on 4/9/12 at 2:45 p.m. revealed that both a physical assessment and care plan should have been initiated on Resident #1 upon his return to the facility after the elopement. The Administrator stated that there had not been a formal QA (Quality Assurance) meeting about Resident #1's elopement from the facility. The Administrator stated that no formal elopement drills were being conducted in the facility. The Administrator stated that there had been disaster drills, with the last one being about an earthquake, within the past two (2) weeks. Resident #2 Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's "Admission Data Collection Tool" dated 11/4/11 revealed that her Psychosocial/Emotional assessment indicated that she was angry, anxious, combative and confused. There was no documentation related to a history of wandering. Resident had documentation of being alert and oriented to person, place and time on the Assessment Tool. Review of a "Social History and Initial Assessment" dated 11/4/11 revealed that the reason for Resident #2's admission to the facility was due to mental status changes and no longer able to live alone. Review of Resident #2's most recent MDS with an ARD of 1/30/12 revealed that she was cognitively intact with a BIMS score of "13", a score of 13-15 indicates intact cognition, and only required cuing at times. Resident #2 was coded with inattention and disorganized thinking and had socially disruptive behaviors. Resident #2 was also coded for wandering one (1) to three (3) days out of the previous seven (7) days. Resident #2 required one (1) person to assist with supervised ambulation. Review of Resident #2's Treatment Record for April 2012 revealed that there was documentation q (every) shift for fall precautions and for a code alert bracelet to the wrist/ankle. There was no documentation that Resident #2's code alert bracelet was checked for proper functioning. There was no documented evidence that Resident #2 had a documented assessment or care plan for the risk of wandering/elopement, or an assessment with the date/time that the decision was made to place a code alert bracelet on the resident. Resident #2's care plan dated 11/4/11 for socially disruptive behavior included "code alert bracelet on admit" was added, with no implementation date documented. Review of Resident #2's ADL record for April 2012 revealed documentation of hydration q (every) two (2) hours. There was no documented evidence that Resident #2 was visually monitored for her wander/elopement risk. Review of a "CNA Info List" and a "Nursing End of Shift Report" revealed documentation of a code alert bracelet for Resident #2 Behavior Notes for Resident #2 dated 3/8/12 on the 7-3 shift revealed that Resident #2 became very agitated and was trying to leave. Haldol 1 mg by mouth was given. Behavior Notes for Resident #2 dated 3/15/12 at 8:00 a.m. revealed that Resident #2 was confused and was making statements that she needed to go to work. Resident #2 was reassured and redirected. Behavior Notes for Resident #2 on 4/4/12 on the 7:00 a.m. to 3:00 p.m. shift revealed that Resident #2 was outside with staff and was agitated and trying to leave the facility area. Resident #2 was redirected back into the building with staff. (Was never out of staff site). Observation of Resident #2 on 4/9/12 at 5:10 p.m. revealed that she was sitting in her room with a visitor present. Resident #2 was alert and oriented to person and place. Resident #2 knew that it was 2012, but was not sure of the month or date. A code alert bracelet was attached to her left wrist. Further observation and interview with Resident #2 and the Activity Director (AD) on 4/10/12 at 9:40 a.m. revealed that Resident #2 was ambulating in the hallway with assistance from the AD. Resident #2 continued to be alert and oriented to person and place. The AD stated that Resident #2 had made attempts to go outside several times and talked about going home or to work. Interview with the DON on 4/10/12 at

CI MS # Based on observation, interview, record review and policy review the facilty failed to ensure that unannounced elopement drills were performed routinely on all three (3) shifts by nursing home staff. The facility had identified four (4) of 40 residents at risk for elopement, Resident #1, Resident #2, Resident #3, and Resident #4. The failure to ensure that elopement drills were performed on a routine basis on all three (3) shifts to ensure adequate procedures were in place for missing residents was deemed an Immediate Jeopardy (IJ) on 4/10/12 at 8:30 a.m. The IJ began on 3/30/12 when Resident #1 left the building without staff supervision.There was no documentation of an elopement drill prior to the incident. The Administrator was notified of the IJ on 4/10/12 at 8:30 a.m. The facility provided a Credible Allegation of Compliance (AoC) on 4/11/12. Based on the facility's implementation of corrective actions and an acceptable AoC, the IJ was removed as of 4/11/12 and lowered to a "D" level which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor and evaluate interventions for effectiveness. Findings include: Cross refer to F323 for the facility's failure to perform unannounced elopement drills on all three (3) shifts to ensure that staff had adequate knowlege and functioned appropriately to find missing residents. The facility had no documentation that elopement drills were conducted before the incident. Staff interview revealed that they had not participated in an elopement drill at the Nursing Home. The facility provided a Credible Allegation of Compliance (Aoc) on 4/11/12: "Resident #1 was admitted on [DATE] with diagnosis' which include Nausea/Vomiting with dehydration, dizziness, Hypertension (HTN) with [MEDICAL CONDITION], Urinary Tract Infection, recent [MEDICAL CONDITION], history of [MEDICAL CONDITION], Coronary Artery Bypass Graft, and Caregiver neglect . He is alert and oriented to person, place, and time, but the Brief Interview for Mental Status by Social Worker dated 3-16-2012 indicated some moderate cognitive impairment. Resident #1 uses wheelchair and walker for mobility. Resident #1 is his own Responsible Party. At 7:45PM on 3-30-12, LPN#1 went to resident's room to give medications and discovered that Resident #1 was missing. A search of the facility was initiated by Licensed Practical Nurse (LPN) #1 at 7:46 PM. Certified Nurse Assistant (CNA) #3 informed LPN #1 that Resident #1 had stated earlier at 4:30 PM that he needed to go to Stone ' s Jewelry Store. This had not been reported to the nurses prior. On 3-30-2012 at approximately 7:50 PM LPN #1 drove to Stone's Jewelry (which is approximately .2 miles from the facility). LPN #1 did not find Resident #1. On 3-30-2012 at 8:02 PM, LPN #1 instructed LPN #2 to notify DON and NHA. Resident #1 was last seen on 3-30-2012 between 5:30 and 6:00 PM by LPN #1, LPN #2, and CN A#3 when he went back to his room and then came back to the dining area requesting his shower. CNA#3 informed Resident #1 that she could not give him a shower until the supper trays were picked up. CNA#3 reports this made Resident #1 agitated. LPN #1 and LPN #2 reported they visualized Resident #1 going to the front porch and to his room several times after 5:30PM, but did not know an exact time. On 3-30-12 at 8:02 PM, LPN#2 notified Director of Nursing (DON) about Resident #1 missing from the facility. The DON notified Nursing Home Administrator (NHA). On 3-30-2012 at 8:10 PM Resident #1's cousin called the Nursing Home to report Resident #1 was at her apartment. Resident #1 ' s cousin reported she had picked him up beside Highway 15 and (Name of Jewelry store). On 3-30-2012 at approximately 8:11 PM, LPN#2 notified (Name of Police Department) to meet LPN #1 at Resident #1's cousin's apartment. LPN #1 returned to the Nursing Home with Resident #1 on 3-30-2012 at approximately 8:18 PM. He came back willing and in good spirits, with no apparent injury. When LPN #1 asked Resident #1 why he had left, he said, "I got pissed off about the shower." Resident #1 also told LPN #1 that he was trying to get to the house where he was living, prior to nursing home admission, to get his things. He said that his daughter was "stealing everything that he had." After arrival back to Nursing Home, on 3-30-12, CNA #3 gave Resident #1 a shower and LPN #1 placed Code Alert Bracelet on Resident #1. There was no physical assessment documented and care plan was not updated at that time to include Resident #1's elopement. There was no apparent injury. On 3-30-2012, Resident #1's physician was notified at 9:30 PM by LPN #1 of Resident #1's elopement. Orders received for [MEDICATION NAME] 20 milligrams by mouth daily for depression and [MEDICATION NAME] 1 milligram by mouth daily for anxiety. Resident #1 is his own Responsible Party. On 4-2-2012 at 09:18 AM and 09:24 AM NHA reported 03-30-2012 elopement event to Mississippi State Licensure and Certification Bureau and Mississippi's Attorney General's Office. On 4-4-2012 In-services were initiated by NHA, DON, and LPN #3 to the CNAs, LPNs, RNs, Activities Director, and Social Worker regarding facility ' s current policies on Missing Resident, Wandering Resident, Documentation and Follow-up of Eloping/Wandering Resident Incident, and Resident Missing from Designated area of Facility. In-service completed on 4-9-2012. Also on 4-4-2012, NHA contacted Resident #1's sister regarding Resident #1's elopement and trying to locate his belongings. Resident #1's sister informed NHA that Resident #1's belongings had either been sold or destroyed by Resident #1's daughter. NHA notified Resident #1 of findings and verbalized understanding. On 4-9-2012 at 5:00 PM, LPN #3 reviewed and updated elopement care plans for the four (4) residents who had been deemed an elopement risk to include: 1. risk for elopement, 2. check placement of Code Alert bracelet every shift, 3. check functioning of Code Alert Bracelet every shift, 4. staff to accompany resident when going outside unless with family and signed Leave of Absence Book, and 5. monitor resident 's anxiety that could lead to leaving the facility and chart in Behavior Book. On 4-9-2012 LPN #3 and NHA reviewed and revised or created the following policies: 1. Elopement/Wandering Resident policy (revised by NHA): Elopement monitoring for all residents determined to be at risk for elopement, definition of elopement/wandering and hazards that could occur, procedure to use the Risk Assessment Elopement Decision Tree Tool, Code Alert Resident Book process-residents deemed to be at risk for elopement will have a full length and face photo placed in the Code Alert Resident Book, along with a face sheet and a brief description of the resident, elopement care plans to include wandering behavior, risk factors, and the appropriate interventions in place to minimize wandering; documentation of wandering behavior, involvement of Interdisciplinary team to identify factors that precipitate wandering and interventions to prevent or minimize elopement, documentation in weekly nurse's notes regarding wandering behavior, two (2) to three (3) outdoor activities per week when weather permits; if resident missing or wandered from safe area initiate missing resident policy, Code Alert bracelets are used to discreetly identify residents at risk for elopement; Training on elopement policies for new hires and annual training; monitoring elopement incidents through the QA/PI Committee; Forms to be utilized including the Risk Assessment Elopement Decision Tree, Code Alert monitoring Forms, Elopement Care Plans (which include checking placement code alert bracelets every shift, ensure code alert is working every shift, observing resident behavior). 2. Code Alert Monitoring Forms policy (created by LPN #3): Residents at risk for elopement are checked every hour checks to see where resident and what resident is doing and document on Code Alert monitoring form to be used, alternating hours between LPN's (documentation will be on the Treatment Record) and CNA's (documentation will be on the ADL Record). 3. Elopement Drill Policy (created by NHA): Guidelines for Elopement Drill and procedure during Elopement Drill. Elopement Drills were conducted on 4-10-2012 7/3 at 11:15 AM, 3/11 at 3:30 PM, and 11/7 at 11:55 PM. Elopement Drills will continue to conducted quarterly on every shift, a signature sheet and evaluation will be maintained by the facility, results of the elopement drill will be reviewed at Quality Assurance meetings. On 4-9-2012 at 3:15 PM, LPN #3 and NHA in-serviced Nursing Home staff, RN's, LPN's, CNA's, Activities Director, and Social Worker and implemented the Code Alert Monitoring Forms and Code Alert Wandering Resident Policy. The staff will check on residents deemed at risk for elopement hourly. The CNA staff will check on even hours and the LPN staff will check on odd hours. Documentation will be noted on the Activities of Daily Living (ADL) Forms for the CNA's and on the Treatment Record for LPN's. On 4-10-2012 LPN #3 and NHA reviewed and revised or created the following policies: 1. Missing Resident Policy (revised by NHA): process in the event of a missing resident, quarterly drills, procedure for observation of resident leaving premises, procedure when resident is returned to the facility, procedure if resident not found within 20 minutes; calling "Code Adam, Nursing Home" and calling "Code Adam Nursing Home All Clear." Guidelines to follow when resident returns back to the facility to include examine resident for injuries, obtain vital signs and implement 24 hour observation charting to include vital signs every shift; notify physician and responsible party of incident, complete QCC report, document the event, assessment and any follow-up in the resident ' s medical record, complete investigation report including statements from staff and residents; if resident not found within 20 minutes, page "Code Adam Nursing Home" three times with a brief description of the resident, what the resident was wearing, and where the resident was last seen, notify law enforcement, NHA, DON, and emergency medical services; staff will provide search teams and law enforcement with resident's picture and identification information; call "Code Adam Nursing Home All Clear" when resident is found. 2. Risk Assessment Elopement Decision Tree Tool policy (created by LPN #3): process to use the Risk Assessment Elopement Decision Tree Tool to determine if resident is at risk for elopement or not, and time frames are prior to or upon admission, quarterly, and as needed by any licensed nurse. Complete the tool, and if resident is at risk for elopement complete elopement care plan, educate staff of residents risk of elopement, place code alert bracelet in resident, re-evaluate all interventions quarterly. 3. Elopement Care Plan policy (created by LPN #3): Process to use and update Elopement Care Plan policy to include goals for the resident to remain safe within the facility and Code Alert bracelet applied. After the Risk Assessment Decision Tree is completed and the resident is deemed at risk for elopement the elopement care plan will be initiated, the elopement care plan will be updated with any changes by any licensed nurse, the elopement care plan will be reviewed quarterly by the interdisciplinary team. 4. Code Alert Resident Book (created by Activities Director and DON): A book that has resident pictures including a full length and face photograph with a brief description of the resident and a copy of the face sheet. 5. Code Alert Wandering Resident policy (revised by NHA): All residents are assessed for elopement risk prior to or upon admission, if resident is at risk for elopement a code alert bracelet placed on resident, hourly checks by LPNs and CNAs and documentation per the Code Alert Monitoring Form policy.; the medication nurse will check the Code Alert bracelet every shift while awake to ensure the Code Alert Bracelet is working properly; if a resident appears to be no longer at risk for elopement the Risk Assessment Elopement Decision Tree will be completed and if the resident is not at risk the code alert bracelet will be removed, only the Charge Nurse, DON, or NHA can remove the code alert bracelet, Elopement Care Plan will be updated by any licensed staff. 6. Care Plans for Elopement/Wandering Policy (created by LPN #3): goals are for resident to remain safe within the facility and use Code alert bracelet if applicable, the elopement plan of care represents evidence of implementation of processes and interventions to protect the at risk for elopement resident, after the Risk Assessment Decision Tree is completed and the resident is deemed at risk, the licensed nurse will complete the elopement care plan, the elopement care plan will be updated when changes are made, and will be reviewed by the interdisciplinary team quarterly. 7. Code Alert System Check Policy (Created by LPN #3): to ensure Code Alert System is working properly, the Code Alert System doors are checked daily at all three doors by LPN #3 or Charge Nurse, documentation for Code Alert System Checks will be maintained in the Code Alert Resident book, if a door fails to alarm maintenance will be notified ASAP, Code Alert bracelets will be checked every shift for placement by the medication nurse and documented on the treatment record, if Code Alert alarm fails to work another bracelet will be used to check the Code Alert alarm, if it is the fault of the door maintenance will be notified, if the Code Alert bracelet is not working, another bracelet will be checked to ensure it is working properly and placed on resident. On 4-10-2012, in-services were initiated at 11:00 AM by LPN #3 and NHA. Licensed Nurses, CNA's were in-serviced on Elopement/Wandering Resident policy, Elopement Drills, Elopement Drills policy, Code Alert Monitoring Forms policy, Code Alert Wandering Resident policy, Missing Resident Policy, Risk Assessment Elopement Tool, Code Alert Resident Book, and Code Alert Care plans. LPN #4 and NHA initiated the in-services. In-services were also provided to Environmental Services, Dietary, and Therapy Departments. No employee will be allowed to work until in-serviced on the revised and new policies. On 4-10-2012, an Elopement Drill was conducted by LPN #3 with assistance of NHA on 7/3 at 11:15 AM, 3/11 at 3:30 PM, and 11/7 at 11:55 PM. Each shift responded to the drill appropriately. The designated "resident" was found within five minutes. The staff involved and responding to the elopement drill were Nurses, CNA's, Social Worker, Activities Director, Environmental Services, Maintenance, Materials Management, Dietary Staff, and Security Staff. On 4-10-2012 at 11:30 AM, RN #1 assessed all 40 residents for elopement risk using the Risk Assessment Elopement Decision Tree tool. Four (4) residents, Resident #1, Resident #2, Resident #3, and Resident #4 had previously been identified as elopement risk. No further residents were identified as at risk for elopement. On 4-10-2012 at 1:30 PM, a Quality Assurance Meeting was held to discuss elopement policy revisions, recommendations, elopement drills, code alert monitoring, and in-services that were done. Those who attended included: Medical Director, DON, NHA, LPN #3, Compliance Officer, Resident #1's attending physician, Social Worker, Activities Director, MDS Nurse, RN #1, and CEO. There were no further recommendations from the QA Committee. " Verification of the AoC: "Random interviews with licensed nurses and Certified Nursing Assistants (CNAs) on 4/11/12 confirmed that they had been in-serviced on the new policies and procedures for elopement and wandering residents, code alert monitoring, and elopement drills and all were able to verbalize the procedures of searching for a missing resident, visual observation of a resident at risk every hour, monitoring and documentation of the code alert bracelet and reporting any signs and symptoms of residents who might be at risk for elopement. Licensed Nurses also verbalized training and understanding of the policies for assessment and care plan of residents at risk for elopement and procedures for code alert door checks daily. Observation on 4/11/12 revealed the "Code Alert Resident Book" with resident photos and identification was at the nurse's station and staff were aware. Observation on 4/11/12 revealed that Residents were taken to the door to verify function of the code alert bracelets which were functional. It was verified through random interviews and observation of the Treatment Record and Activity of Daily Living Records that visual checks had been documented hourly by Nurses and/or CNAs for those residents at risk for elopement. Documentation of shift checks for placement and function of the code alert bracelets was also verified. Random review of medical records revealed that Risk Assessment Elopement Decision Tree assessment forms had been completed. Observation on 4/10/12 at 11:15 a.m. and 3:30 p.m. revealed that elopement drills were performed and staff present in the facility responded appropriately. Review of the documentation verified that an elopement drill was also performed on 4/10/12 at 11:55 p.m. Review of a sign in sheet dated 4/10/12 confirmed that the Quality Assurance (QA) meeting had been held. Interview with the Medical Director on 4/10/12 confirmed that he had attended the QA meeting with no further recommendations at that time. Based on verification of the facility's corrective actions that was validated by staff interviews, observation and in-service reviews, the IJ was removed and the scope and severity was lowered to a "D" level which constitutes no actual harm with the potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's QA Committee.

Based on observation, record review, and staff interview, the facility failed to ensure that effective measures were implemented for one (1) of six (6) resident's reviewed to prevent skin tears. This is for Resident #9, who sustained repeated skin tears with no new interventions. There were 28 incidents of skin tears from 5/1/10 until 6/24/11, and no effective preventative implementations. Findings include: Record review revealed that Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/20/11, revealed that Resident #9 required total dependence of two (2) persons to physically assist with bed mobility and transfers. Resident #9 was identified as being severely impaired in cognitive skills for daily decision making. Observation on 6/23/11 at 2:05 p.m., revealed that Resident #9 was seated in a reclining geri chair. A dressing was observed to the right arm and steri strips to the left lower leg. Review of the incident log and occurrence reports for Resident #9 revealed that on 11/15/10, Resident #9 was in the dining room seated in a geri chair eating supper. Certified Nursing Assistant (CNA), noticed the resident's right leg had fallen off of the pillow on the footrest. "Assisted resident leg back on pillow noted 6 cm (centimeter) skin tear to right leg. Leg cleansed with normal saline and steri strips applied." On "1/29/11, skin tear left lower leg while in geri chair leg slid off of geri chair three (3) inch skin tear." On "1/17/11, skin tear to right lower leg right leg slid off geri chair." On "6/9/11, skin tear left lower leg appeared leg bumped side of geri chair causing skin tear." On "5/1/11, resident in dining room in geri chair when left leg slipped and hit corner of geri chair which caused a large skin tear to lower leg." There were 28 incidents from 5/1/10 until 6/24/11. Review of the care plan with a problem onset date of 12/29/10, revealed: "Skin problems present AEB (as evidenced by) fragile skin (r) leg." "Skin tear to (l) lower leg on 1/29/11." Approaches listed stated: "1. Skin audit daily; 3. Use caution when doing care; 4. Use gentle motion when bathing resident, rinse and dry thoroughly. 7. Use buddy system when doing care; and on 6/23/11 (during the survey process) "11. Arm and leg protectors on as needed" was added to the care plan. Review of the care plan with a date of 5/12/10, and last updated 3/23/11, revealed a problem stating: "Total ADL's". Approaches listed stated: "(10) Keep right arm elevated on 2 pillows; and (11) Float right leg and heel on pillow while in bed." Review of the May 2011 physician's orders [REDACTED]." "Microfiber dressing to left lower leg skin tear every 3 days and call MD on 5th day to report progress. " "Air mattress to bed." Record review revealed, on 5/27/11 there was a physician's orders [REDACTED]." On 6/17/11, there was an order stating: "Cleanse skin tear to (l) lower leg with N.S. (normal saline). Apply Benzoin to skin edges, then steri strip. Cover ster- strips with dry bandage daily x 7 days." An interview on 6/23/11 at 3:45 p.m., with RN #1 revealed, "We didn't do anything different. There's no way to keep her legs from falling off the pillows." In an interview on 6/23/11 at 4:15 p.m., RN #4 stated, "I'll just be honest, I told the aide to put the sleeves on her arms and legs because I checked and she didn't have them on. I'll be honest, we weren't putting them on every day. She has them for her arms and legs. I know that we were not putting them on all the time." Observation on 6/23/11 at 4:00 p.m. with RN #1 present, revealed that Resident #9 was seated in a reclining geri chair. Resident #9 had protective sleeves on both upper and lower extremities. RN #1 stated, "The CNA put the sleeves on today when she came in. I didn't know she had them."