Every finding on record at Tupelo Community Care Center

Based on observation, staff and resident interviews, record review and facility policy review, the facility failed to ensure a call light was maintained within reach for a resident who was dependent for assistance for 3 (three) of 6 (six) residents reviewed. Resident #1, Resident #2 and Resident #5. Findings Include: Review of the facility policy Call Light/Call Pager Systems with effective date of 09/09/22 revealed, .The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room . An observation and interview on 06/10/26 at 9:55 AM revealed Resident #1 lying in bed in his room. He revealed that he had been having trouble with his call light, but he now had a clip attached to the call light cord and he kept it clipped to his clothes. He revealed that prior to having the clip, he had to call his family three or four different times because his call light was on the floor or in the trash can and he couldn't reach it. He revealed that he was not able to get up without help and if he could not reach his call light, he had no way of calling for help. Resident #1 revealed that when he called his family, they called the facility and the staff came in and found it for him. A phone interview on 06/10/26 at 11:00 AM with Complainant, revealed that she visited frequently, and, on several occasions, she had observed his call light not within reach and once noticed it in the trash can. She revealed that Resident #1 had called her three or four times saying that he could not reach his call light, she called the facility and a staff member went down and got it for him. Complainant revealed that Resident #1 was not the easiest person to take care of and could be hateful at times, but he deserved to be taken care of. She further revealed that he was the type of person to get up by himself if he couldn't get someone to help him and she was concerned for his safety. Observations on 06/10/26 at 9:20 AM and at 10:05 AM revealed Resident #2 lying in his bed in his room. His call light was underneath his bed on the floor. Resident #2 revealed that he had a problem with finding his call light often, but mostly in the morning when he wakes up. He revealed that when he can't find his call light, he whistles loudly and hopes they hear him. Resident #2 revealed that he had two strokes back-to-back, and his left side was out and clarified that he could not use his left side. He revealed that he required significant help and depended on the staff to provide it. He also revealed that if no one heard him when he whistled for them, he used his cell phone to call the front desk. He revealed that he can't get up by himself, the staff used a lift to get him up and he needed his call light within reach to be able to call for help when needed. During an interview and observation on 06/10/26 at 10:10 AM with Licensed Practical Nurse (LPN) #1, she confirmed that Resident #2's call light was on the floor underneath his bed and was not within his reach. She revealed that this could prevent him from getting the help that he needed timely. She also revealed that not having the call light within reach could cause a safety issue if he tried to get up and get the call light off the floor himself. LPN #1 confirmed that Resident #2 depended on staff to take care of his needs and that he should have access to the call light at all times. She revealed that all staff were expected to ensure call lights were within reach of the residents after providing care and during rounding. An interview with Director of Nursing (DON), revealed that she wasn't aware of the call light issues with Resident #1. She revealed that she expected all staff to ensure call lights were within reach so residents could remain safe and receive the help they needed timely. She also confirmed that Resident #2 came into the facility following a stroke and that he could not use his left side and that he depended on staff for assistance. DON revealed that Resident #2's call light should not have been under his bed on the floor and that staff should have noticed it and placed it within his reach. An interview on 06/10/26 at 12:00 PM revealed Resident #5 lying in her bed. She revealed that she had concerns with her call light not being within reach sometimes after staff helped her transfer into her chair. She revealed that when she gets out of bed, she sits in a chair near the right side of her bed and staff placed her call light on the left side of her bed out of her reach. Resident #5 revealed that this had happened several times and she's had to yell for someone to help her or get her roommate to use her call light to get help. She revealed that she depended on the staff and she needed to be able to call for help when she needed something. Record review of Resident #1's admission Record revealed an admission date of 06/07/24 and that he had diagnoses that included Hemiplegia and Hemiparesis Following Cerebral Infarction. Record review of Resident #1's Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/05/26 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 09 which indicated that he had moderate cognitive impairment. Record review of Resident #2's admission Record revealed an admission date of 05/27/26 and that he had diagnoses that included Cerebral Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction, and Acquired Absence of Right Leg Above Knee. Record review of Resident #2's MDS with ARD of 06/03/26 under Section C revealed a BIMS score of 15 which indicated that he had no cognitive deficits. Record review of Resident #5's admission Record revealed an admission date of 03/28/26 and that she had diagnoses that included Polyneuropathy and Chronic Obstructive Pulmonary Disease. Record review of Resident #5's Quarterly MDS with ARD of 05/20/26 under Section C revealed a BIMS score of 15 which indicated that she had no cognitive deficits.

Based on observation, resident and staff interviews, and record review, the facility failed to ensure adequate accident prevention for one (1) of five (5) residents reviewed for accident hazards (Resident #3). The facility failed to ensure the resident's ordered three-quarter length side rail was maintained in the raised position while the resident was in bed, resulting in the resident rolling out of bed and sustaining a fracture. Findings Include:Review of a statement on facility letterhead revealed that Proper Name Care Center did not have a specific policy pertaining to accident prevention.An observation conducted on 12/10/25 at 8:30 AM revealed Resident #3 in bed with three-quarter length side rails raised on both sides of the bed.Review of the Medication Review Report dated 1/13/25 revealed an order for three-quarter length side rails to be used as enablers to assist with turning and repositioning while in bed, with instructions to release and reposition every two hours and as needed.Review of an accident report dated 10/29/25 at 01:00 AM revealed that staff heard yelling from down the hall. Upon entering the room, staff observed Resident #3 lying under the bedside table beside the bed. The resident's right leg was wrapped in a blanket, skin tears were noted to both elbows, and the resident complained of right hip pain. The resident stated, Yeah, I think it's broke, and further stated he rolled out of bed during sleep.Review of Emergency Department records dated 10/29/25 revealed Resident #3 was diagnosed with a closed comminuted intertrochanteric fracture of the proximal end of the right femur.An interview with Resident #3 on 12/10/25 at 9:00 AM revealed he confirmed experiencing a fall in October when he rolled out of bed during the night because his side rail was not raised. He stated he uses the side rails to assist with turning and repositioning while in bed because he is an amputee. When asked why the side rail was not raised, he stated he did not know who had lowered it, but when he rolled over, it would have prevented him from falling in the floor if it had been up.A phone interview with Certified Nurse Assistant (CNA) #1 on 12/10/25 at 10:10 AM revealed she responded to the fall after hearing the resident yelling. She stated that upon entering the room, Resident #3 was lying on the floor on the left side of the bed, and the left side rail was not raised.An interview with the Director of Nursing on 12/10/25 at 9:11 AM revealed that, upon investigation of Resident #3's fall on 10/29/25, it was her understanding that the side rail was not in the raised position at the time of the fall. She stated the resident's bed was equipped with three-quarter length side rails on both sides, which were utilized to assist with turning and repositioning while in bed and should have been raised to prevent him from rolling out of the bed. She further confirmed that the side rail not being raised contributed to the resident's fall resulting in injury and fracture.An observation conducted on 12/10/25 at 2:37 PM with CNA #2 revealed the lever used to lower the left side rail was located at the end of the side rail near the foot of the bed. CNA #2 stated Resident #3 would not be physically able to reach the lever to lower the side rail. She further stated the resident does not attempt to get up without assistance and uses the side rails to assist with turning and repositioning since he is an amputee.Record review of the admission Record revealed Resident #3 was admitted on [DATE] with diagnoses including acquired absence of the left leg above the knee and other reduced mobility.Record review of the Brief Interview for Mental Status (BIMS) dated 11/8/25 revealed a score of 9, indicating the resident was moderately cognitively impaired.

Based on observation, resident and staff interviews, record review and facility policy review, the facility failed to implement a fall care plan for Resident # 3 and failed to implement a fluid restriction care plan for Resident #87 for two (2) of 23 care plans reviewed. Findings Include: Review of a facility policy titled, Goals and Objectives, Care Plans, last revised September 2013, revealed the policy statement indicated that care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. An observation conducted on 12/10/25 at 8:30 AM revealed Resident #3 in bed with three-quarter length side rails raised on both sides of the bed. Record review of a care plan titled, I am at high risk for falls related to impaired mobility and unawareness of safety precautions, initiated 9/5/24 and last revised 2/28/25, revealed interventions included use of three-quarter length side rails as enablers to assist with turning and repositioning while in bed, with instructions to release and reposition every two hours and as needed. Record review of an accident report dated 10/29/25 revealed staff heard yelling from down the hall. Upon entering the room, staff observed Resident #3 lying under the bedside table beside the bed. The resident's right leg was wrapped in a blanket, skin tears were noted to both elbows, and the resident complained of right hip pain. The resident stated, Yeah, I think it's broke, and further stated he rolled out of bed during sleep. Record review of Emergency Department records dated 10/29/25 revealed Resident #3 was diagnosed with a closed comminuted intertrochanteric fracture of the proximal end of the right femur. On 12/10/25 at 9:00 AM an interview with Resident #3 revealed he confirmed experiencing a fall in October when he rolled out of bed during the night because his side rail was not raised. On 12/10/25 at 10:10 AM a phone interview with Certified Nurse Assistant (CNA) #1 revealed she confirmed the left side rail was not raised when she entered Resident #3's room following the fall in October 2025. On 12/10/25 at 9:11 AM an interview with the Director of Nursing revealed that, upon investigation of Resident #3's fall from bed on 10/29/25, it was her understanding that the resident's side rail was not in the raised position at the time of the fall and it should have been. Review of the fall care plan with the Clinical Minimum Data Set (MDS) Nurse on 12/10/25 at 11:00 AM revealed she confirmed the fall care plan was not implemented when Resident #3's side rail was not raised at the time of the fall. She further stated the resident was to have three-quarter length side rails bilaterally to assist with turning and repositioning while in bed. Record review of the admission Record revealed Resident #3 was admitted on [DATE] with diagnoses including acquired absence of the left leg above the knee and other reduced mobility. Record review of the Brief Interview for Mental Status (BIMS) score dated 11/8/25 revealed a score of 9, indicating the resident was moderately cognitively impaired. Resident #87 Review of Resident #87's Care Plan Report revealed under, Focus: I am at risk for complications d/t (due/to) renal dialysis with fluid restrictions r/t (related to) renal failure. Further revealed under, Interventions/Task: 900 CC (cubic centimeter) fluid restriction- breakfast-200 lunch -200 dinner- 200 medications – 200 snacks -100. Record review of Resident #87's December 2025 Medication Administration Record (MAR) revealed an order dated 7/16/25, Record fluid intake in 24 hours. 900 cc (cubic centimeter) fluid restriction – Breakfast 200, Lunch 200, Dinner 200, Medications 200, Snacks 100. Review revealed there was no documentation of fluid intake amounts recorded, and the MAR was only initialed by the nurse. Record review of Resident #87's December 2025 Flowsheet revealed there was no evidence that fluid intake was monitored or documented. On 12/10/25 at 11:32 AM, an interview with the Director of Nursing (DON) revealed fluid restrictions were to be tracked on the MAR and totaled at the end of each shift and the DON confirmed this was not done for Resident #87. An interview with the Minimum Data Set (MDS) Nurse on 12/11/25 at 8:15 AM revealed the purpose of the care plan was so that staff knew what care to provide. She confirmed the care plan was not followed for Resident #87 since staff were not tracking and documenting fluid intake. Record review of the admission Record revealed the facility admitted Resident #87 on 2/01/22 with medical diagnoses including End Stage Renal Disease and Dependence on Renal Dialysis. Record review of the MDS with an ARD of 11/02/25 revealed under Section C, a BIMS summary score of 15, indicating Resident #87 was cognitively intact.

Based on observations, staff interview, record review, and facility policy review, the facility failed to clean and disinfect a multi-use glucometer according to the manufacturer's instructions and the required wet contact time for one (1) of two (2) glucometers observed. Resident #16Findings Include: Review of the facility policy titled Assure Prism Multi Blood Glucose Monitor System: Use, Cleaning and Controls Policy undated, revealed under, Cleaning and Disinfecting the Assure Prism Multi Blood Glucose Monitoring System: 1. Follow standard precautions and the manufacture's disinfection procedures to clean and disinfect the meter. On 12/10/25 at 8:15 AM, an observation of Licensed Practical Nurse (LPN) #3 revealed she completed a blood glucose check for Resident #16 and then cleaned the glucometer using Sani-cloth germicidal wipes by swiping over the front and back of the machine three times for a total of 30 seconds. LPN #3 explained this was how she had been trained to clean the glucometer and stated this was the method their facility policy instructed them to use. LPN #3 was not aware of the wet contact time required on the back of the Sani-cloth container. She acknowledged that if the machine was not cleaned appropriately, it could spread germs to other residents because the glucometer was used on multiple residents. Record review of the manufacturer's instructions Arkway Technical Brief Cleaning and Disinfecting the Assure Prism multi-Blood Glucose Monitoring System (BGMS) revealed Super Sani-Cloth(R) Germicidal Disposable Wipe was listed for use in cleaning and disinfecting the meter. Further instruction revealed, Meter surfaces must remain wet according to contact times listed in the wipe manufacturer's instructions. Record review of the Super Sani-cloth Germicidal Disposable Wipes revealed, unfold wipe and thoroughly wet surface. Allow surface to remain wet for two (2) minutes. An interview with the Director of Nursing (DON) on 12/10/25 at 10:48 AM revealed the staff recently attended training and were taught to swipe over the glucometer with Sani-cloth wipes three times on the front and back. The DON explained she was aware of the required wet contact time on the Sani-cloth wipes and confirmed that improper glucometer cleaning practices could spread infection throughout the building. Record review revealed the facility admitted Resident #16 on 6/07/24 with medical diagnoses including Unspecified Sequalae of Cerebral Infarction and Encounter for Attention to Gastrostomy. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/05/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 12, indicating Resident #16 was moderately cognitively impaired.

Based on observation, resident and staff interview, and record review, the facility failed to ensure meals were served in accordance with a resident's physician-ordered nutritional requirements for one (1) of four (4) residents reviewed for dining. Resident #87Findings Include:The facility provided a statement on letterhead that read, (Proper name of the facility) does not have a specific policy on therapeutic diet.During an observation on 12/09/25 at 8:06 AM, Resident #87 was observed sitting up in her wheelchair in her room with her breakfast tray in front of her untouched. The resident had 2 pieces of bacon, scrambled eggs, toast, water, and apple juice. Review of the meal ticket dated 12/09/25 revealed, Supplements: Nepro - 1 carton and under Notes; Add Nepro to all trays. The Nepro supplement was not on the meal tray. Resident #87 stated she only received it sometimes.An observation and interview with Licensed Practical Nurse (LPN) #1 on 12/09/25 at 8:12 AM confirmed Resident #87 did not receive the Nepro supplement as ordered on the meal ticket. LPN #1 stated the meal provided should match the meal ticket and acknowledged the resident would not receive the necessary nutrients if supplements were omitted.An interview with the Dietary Manager (DM) on 12/09/25 at 3:26 PM revealed she was made aware that Resident #87 did not receive Nepro with her breakfast meal. She stated it was the dietary drink aide's responsibility to read the meal cards and provide the necessary supplements on the meal tray. She described the incident as a human mistake and acknowledged Resident #87 would not get the necessary nutrients.Record review of the admission Record revealed the facility admitted Resident #87 on 2/01/22 with medical diagnoses including End Stage Renal Disease and Dependence on Renal Dialysis.Record review of the Minimum Data Set with an Assessment Reference Date (ARD) of 11/02/25 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #87 was cognitively intact.

Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure fluid intake was managed, tracked, and documented in accordance with a physician ordered fluid restriction for a resident receiving dialysis for one (1) of six (6) resident reviewed for fluid restrictions. Resident #87Findings Include:Review of the facility policy titled Encouraging and Restricting Fluids revised 10/10 revealed under, Purpose: The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. The policy further revealed under, Steps in the Procedure: . 5. Record the amount of fluid consumed on the intake side of the intake and output record. Record fluid in MLs (milliliters).Record review of Resident #87's December 2025 Medication Administration Record (MAR) revealed an order dated 7/16/25, Record fluid intake in 24 hours. 900 cc (cubic centimeter) fluid restriction - Breakfast 200, Lunch 200, Dinner 200, Medications 200, Snacks 100. Review revealed there was no documentation of fluid intake amounts recorded, and the MAR was only initialed by the nurse.Record review of Resident #87's December 2025 Flowsheet revealed there was no evidence that fluid intake was monitored or documented.Record review of Resident #87's December 2025 MAR revealed an order dated 8/03/24, Nepro/Carb Steady Oral Liquid (Nutritional Supplement) give 8 ounces by mouth two times a day for End Stage Renal Disease (ESRD).Record review of Resident #87's breakfast meal tray ticket dated 12/09/25 revealed under, Notes: Add Nepro to all trays. The tray ticket further revealed under, Beverages: Fluid Restriction: 4 ounces (OZ) Apple juice - 1 cup, Water - 1 cup.An observation on 12/09/25 at 8:06 AM revealed Resident #87 received her breakfast meal in her room which included two pieces of bacon, scrambled eggs, toast, 240 milliliters (ML) of water, and 120 ML of apple juice, totaling 360 ML of fluid at one meal, excluding the Nepro supplement.An interview with the Director of Nursing (DON) on 12/10/25 at 11:32 AM revealed fluid restrictions were to be tracked on the MAR and totaled at the end of each shift. The DON confirmed this had not been done for Resident #87 and stated the resident could be receiving too much fluid, which could contribute to fluid volume overload. She further confirmed there was inconsistency with the Nepro supplement and stated this would place the resident over her fluid restriction and should have been clarified.An interview with the Registered Dietitian (RD) on 12/10/25 at 11:52 AM revealed Resident #87 was receiving Nepro twice daily; however, she spoke with the dialysis RD in September, who suggested increasing the Nepro to three times daily. The RD confirmed she had not calculated the Nepro into the resident's daily fluid allowance. She further confirmed she was aware the resident's fluid intake was not being documented or totaled at the end of the shift but did not report this to the nursing department. She acknowledged this failure could cause the resident to develop fluid volume overload.Record review of the admission Record revealed the facility admitted Resident #87 on 2/01/22 with medical diagnoses including End Stage Renal Disease and Dependence on Renal Dialysis.Record review of the Minimum Data Set with an Assessment Reference Date (ARD) of 11/02/25 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #87 was cognitively intact.

Based on record review, staff interview, and facility policy review, the facility failed to accurately complete section K of the Minimum Data Set (MDS) for one (1) of 23 minimum data sets reviewed. Resident #100.Findings Include: Review of the facility policy titled Certifying Accuracy of the Resident Assessment undated, revealed under, Policy Statement: All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. Record review of the Weights and Vitals Summary for Resident #100 revealed the following documented weights: 10/08/25 252 pounds10/28/25 252 pounds11/03/25 249.6 pounds11/13/25 230.8 pounds11/18/25 230.7 pounds Record review revealed Resident #100 has a significant weight loss of 21 pounds and -8.3% (percent) in 1 month. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/25 revealed under section K0300, Resident #100 did not have a weight loss of 5 % (percent) or more in the last month, which was inaccurate. An interview with the MDS Nurse on 12/11/25 at 7:58 AM revealed she was responsible for completing section K of the MDS. She confirmed she made an error on Resident #100's MDS and stated weight loss should have been coded. Record review of the Transfer/Discharge Report revealed the facility admitted Resident #100 on 7/12/21 with medical diagnosis that included Chronic Combined Systolic and Diastolic Heart Failure. Record review of the Progress Notes for Resident #100 dated 11/20/25, revealed a Brief Interview for Mental Status (BIMS) Evaluation was not conducted due to resident is rarely/never understood.Record review of the admission Record revealed the facility admitted Resident #100 on 7/12/21 with diagnoses including chronic combined systolic (congestive) and diastolic (congestive) heart failure.

Based on resident and staff interview, record review, and facility policy review, each resident had the right to determine their end-of-life care and the facility failed to ensure the desired code status of the resident was reflected in the documentation for one (1) of 23 sample residents reviewed. Resident #10Findings include: Record review of the facility policy titled, Advance Directives, undated, revealed, It is the policy of the facility to respect the resident's right of self-directed care including the right to issue Advance Directives on health care, to refuse or accept treatment, to make informed decisions, and/or appoint a health care agent to make decision on the behalf of the resident when the resident lacks the capacity to do so. 1. Each competent adult has the right to control his or her own health care decisions. Record review of facility policy titled, Resident Rights dated [DATE], revealed, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . self-determination. Record review of Resident #10's Consent for Cardiopulmonary Resuscitation, undated, revealed, I understand that CPR (Cardiopulmonary Resuscitation) constitutes an extraordinary measure and SHOULD NOT be done on this resident. This was signed by the resident's representative. Record review of Resident #10's Do Not Resuscitate consent revealed the document was undated and signed by the resident's representative and the physician and indicated Resuscitation would be medically futile. Record review of Resident #10's electronic Order Listing Report revealed an order dated [DATE] for a full code. Record review of Resident #10's Physician Telephone Order dated [DATE] revealed, Patient is a full code. During an interview on [DATE] at 1:40 PM, the Director of Nursing (DON) revealed each resident had the right to choose their end-of-life care and this choice was required to be properly documented to ensure the resident's desired end-of-life care would be honored. She acknowledged the physician's orders indicated a full code status. She acknowledged the Consent for Cardiopulmonary Resuscitation (CPR) signed by the resident's representative indicated that CPR should not be done and the Do Not Resuscitate form was undated and signed by the resident's representative and the physician revealed Resuscitation would be medically futile. She acknowledged the documentation should reflect the resident's wishes for their end-of-life care and inaccurate documentation could lead to the resident's desires not being honored. She confirmed the facility failed to ensure the resident signed the consent for end-of-life care and failed to ensure the accuracy of the documentation for Resident #10's end-of-life care, which had the potential for the resident's desire to not be honored. An interview with Resident #10 on [DATE] at 3:05 PM, revealed she desired a full code status and was capable of signing her documents for this. An interview with the Administrator on [DATE] at 2:00 PM revealed each resident had the right to choose their end-of-life care and the documentation should be accurate and reflect the resident's wishes. She acknowledged the undated Consent for Cardiopulmonary Resuscitation signed by the resident's representative indicated CPR should not be done on this resident and the Do Not Resuscitate (DNR) consent, undated and signed by the resident's representative and the physician indicated a DNR status. She acknowledged the written order dated [DATE] and the electronic order dated [DATE] both indicated a full code status. She confirmed the facility failed to accurately document the resident's desire for end-of-life care which could have led to the resident's wishes not being honored. Record review of Resident #10's admission Record revealed the facility admitted resident originally on [DATE] with the most recent admission date of [DATE]. Diagnoses included Type 1 Diabetes Mellitus. Record review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure resident privacy was maintained during medication administration for a resident with a gastrostomy tube for one (1) of six (6) care opportunities observed. Resident #16Findings Include: Review of the facility policy titled Dignity with a revision date of 2/21 revealed under, Policy Interpretation and Implementation: . 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. An observation during medication pass on 12/10/2025 at 8:15 AM with Licensed Practical Nurse (LPN) #3 revealed she administered medications to Resident #16 via a gastrostomy tube while the room blind was half open, allowing the resident to be visible from the back parking lot and compromising the resident's bodily privacy. An interview with LPN #3 on 12/10/25 at 8:32 AM confirmed the window blind was left open while administering medications to Resident #16 and revealed this was a privacy concern for the resident as his stomach and tube were visible to the people outside the window. An interview with the Director of Nursing (DON) on 12/10/25 at 10:48 AM revealed that residents were expected to be provided privacy during care and confirmed this was a dignity concern. Record review revealed the facility admitted Resident #16 on 6/07/24 with medical diagnoses including Unspecified Sequalae of Cerebral Infarction and Encounter for Attention to Gastrostomy. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/05/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 12, indicating Resident #16 was moderately cognitively impaired.

Based on record reviews, resident and staff interviews, facility policy review, the facility failed to ensure a resident's right to be free from abuse and reprisal by staff. Resident #1 was verbally abused and confronted by Licensed Practical Nurse (LPN #1) for reporting that she had not received pain medications in a time when Resident #1 asked for them. Resident #1 was one (1) of three (3) residents reviewed for abuse and neglect. Findings include: The facility undated policy titled Abuse Prevention revealed, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff . a) Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a care taker of goods or services are necessary to attain or maintain physical, mental and psychosocial well-being. b) Verbal abuse: The use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability . Interview on 02/18/25 at 12:25 PM with the facility Administrator (ADM)/ Executive Director (ED) revealed that the facility had conducted a full investigation of the alleged verbal abuse reported by Resident #1 and the facility did not substantiate any abuse, but they did substantiate poor customer service. The facility found that Licensed Practical Nurse (LPN) #1 delivered poor customer service when Resident #1 asked for her pain medications. The facility suspended the nurse from work while the investigation was conducted. The facility issued a written class one reprimand to LPN #1 for poor customer service. The ADM presented supporting investigation materials and written statements that the facility had gathered during their facility investigation dated 01/03/2025 and signed by the ADM/ED and the Director of Nursing (DON). Interview on 02/18/25 at 12:45 PM with the Director of Nursing (DON) revealed that she and the ADM had investigated the incident and that they had suspended LPN #1 until the investigation was completed. The facility issued written discipline to LPN #1 for poor customer service. The facility also pulled LPN #1 from working the rehabilitation unit and she was not allowed to work on that unit any longer. DON stated that Resident #1 was a short-term rehab resident and was admitted to the facility for rehab from a tibia fracture. DON stated that Resident #1 was cognitive and was a good historian and had a Brief Interview of Mental Status (BIMS) score of 15 which indicated that she was intact cognitively. Record review of the facility investigation dated 1/03/25 revealed: Conclusion: After a thorough investigation, (name of facility) was unable to substantiate abuse or neglect. This was based on interviews with residents and staff members. It was determined that the nurse exhibited poor customer service in explaining how the medications are given and asking her about anything that was reported. Record review of the Admission Record of Resident #1 revealed that she had admitted s of 2/01/24 and a second admitted [DATE] with diagnoses of Unspecified fracture of upper end of left tibia, subsequent encounter for closed fracture with routine healing; Type 2 Diabetes; Chronic Obstructive Pulmonary Disease; and Repeated Falls. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date of 12/31/24 revealed a BIMS score of 15, indicating that Resident #1 was cognitively intact. Interview on 02/18/25 at 1:20 PM with the Director of the Rehabilitation (DOR) Department revealed that she had two (2) rehab therapy staff members that had reported to her that LPN #1 had spoken harshly and in a demeaning tone to Resident #1. The DOR stated that she stood behind her staff and supported them, and she had full confidence in the statements that the rehab therapy staff had made in the incident involving Resident #1 and LPN #1 and she believed the statements were true and accurate. She stated that the Speech Therapist (ST) had been a witness to the harsh tone and confrontational manner in which LPN #1 had used toward Resident #1. She also stated that the Physical Therapy Assistant (PTA) had gone in to assist Resident #1 when he found her crying and upset due to the confronting manner of LPN #1 towards her. The DOR stated that both staff had provided the facility with written statements about their account of the incident. The DOR confirmed that the rehab department had a policy that they would not deliver services to residents complaining of pain and that they would request pain medications prior to rehab services with residents. She stated that the ST had delivered the message to LPN #1 that Resident #1 was requesting pain medications prior to the physical therapy sessions and that LPN #1 denied that the ST had made the pain medication request. Interview on 2/18/25 at 4:00 PM with the ST revealed that she was in Resident #1's room with her on 12/31/24 at approximately 7:30 AM and LPN #1 came in and began to yell at the resident. ST stated that LPN #1 loudly told Resident #1 that she should never have called the front desk to complain on her and that she had not asked for her the pain medications. ST stated that she interrupted and told LPN #1 that she herself had come to her on the day before and had requested pain medications for the resident prior to therapy and LPN #1 told her, No you never told me she requested medications. LPN #1 continued to tell Resident #1 that she had to request the medications and that she had not requested them and that she should not have called the front desk and complained about her. ST stated that she was trying to defuse the situation and asked to move on because LPN #1 was very rude and hostile toward Resident #1 and she was not going to argue with LPN in front of the resident, because she could tell it was upsetting the resident already how LPN #1 was acting towards her. ST stated that Resident #1 began to cry and shake after LPN #1 confronted her. ST stated that she gave the facility a written statement of the accounts of the incident that she witnessed. The interview on 2/18/25 at 2:45 PM with the PTA revealed that on 12/31/24 he had gone into Resident #1's room and found her crying and upset. When he asked her what was wrong and why she was upset and crying she stated that LPN #1 had blessed her out. Resident #1 stated that she felt unsafe around LPN #1, and she never wanted her to come into her room again. PTA stated that he gave a written statement to the facility as to what Resident #1 had told him and that she had requested that LPN #1 never come into her room again. Resident #1 had her face in her hands crying and she voiced that she was bothered and upset by the manner in which LPN #1 had talked to her. Resident #1 was a cognitive resident, and she presented as a resident that was truthful. I trusted that what she was telling me was what had happened. Interview on 2/18/25 at 4:15 PM with LPN #1 revealed that she had been sent home on 12/31/24 for the facility to conduct an investigation after Resident #1 had told the facility that she was not getting her medications timely. LPN #1 stated that her supervisor, LPN #2, had come to her and told her that Resident #1 had called the front desk and issued complaints that she was not getting her pain medications. LPN #1 stated that the resident had to request the medications, and she had not made a request for pain medications to her. LPN #1 stated that she told Resident #1 that she would need to turn on her call light and ask her for her pain medications because they were not scheduled, they were as needed (PRN) medications. LPN stated that she returned to work after her suspension, and she received in-services regarding customer service skills. Interview on 2/18/25 at 1:45 PM with the LPN #2 Supervisor confirmed that she was the supervisor for all the LPN's and that LPN #1 was one of the LPN's that she supervised. LPN #2 stated that she remembered Resident #1 well and that she was a cognitive resident that was admitted to the short-term unit for rehab. LPN #2 denied knowledge of Resident #1's complaints against LPN #1 and stated that she has no knowledge that Resident #1 had called the front desk issuing complaints against LPN #1 on 12/31/24. LPN #2 stated that she had been in-serviced numerous times on the facility Abuse Prevention Policy, and stated that verbal abuse did include tone of your voice and body language. She stated that confronting a resident about issuing complaints was abuse and could also be considered bullying. LPN #2 stated that LPN #1 should never have confronted Resident #1 and asked her about calling the front desk to complain about her. LPN #2 stated Resident #1 was not the type of individual to be untruthful, and that she was unaware that LPN #1 had given a written statement to the facility that she had told LPN #1 that Resident #1 was complaining to the front desk that LPN #1 was not giving her pain medications. LPN #2 stated that LPN #1's written statement to the facility was not true because she had not told her that the resident had complained about her, because she did not know at that time. An interview on 2/18/25 at 2:50 PM with Resident #1 revealed that she had been a resident of the facility on two (2) different occasions. She stated that she had problems with LPN #1 on more than one occasion for not getting her pain medications in a timely manner. Resident #1 stated that she had been a City Police Officer for over [AGE] years and had to retire early due to a fall and some health issues. She stated that in all her [AGE] years with the police department she had never had anyone talk so badly to her like LPN #1 had talked to her. She stated that she got tired of sending someone up to ask for her pain medications, so she called the front desk and complained about her not giving her pain medications every six hours after she had asked for them. Resident #1 stated that the CNA's answered the call lights, and she would tell them to please go and ask the nurse for her pain medications. Resident stated that she was admitted to the facility after a fall and fracture for rehab and was a short-term rehab resident. She stated that she needed her pain medications prior to physical therapy and that LPN #1 was well aware of this yet she continued to delay giving the medications. Resident stated that ST was in her room on one occasion and had witnessed the demeaning loud tone and degrading manner that LPN #1 spoke to her. LPN #1 would come to my room and ball me out. LPN #1 Told me that she was doing the best that she could and that I was a damn liar. I felt mentally and emotionally unsafe and she had me shook. I was not physically afraid of her, but I was emotionally harmed by her. She told me that I had no business calling the front desk and telling the front office about her. Resident #1 stated that she had all her marbles and if LPN #1 talked to her in such a hostile manner how did she talk to those that had fewer mental abilities. Resident #1 stated that on 12/31/24 she requested that LPN #1 not be allowed in her room ever again. Resident #1 stated that she was discharged from the facility on 1/15/25 and LPN #1 was never in her room again after that day. An interview on 2/18/25 at 3:15 PM, with a Licensed Social Worker (LSW) confirmed that she believed the events outlined by Resident #1 happened and she was traumatized and harmed mentally and emotionally from the incident. LSW confirmed that she had completed a Trauma assessment dated [DATE] related to the incident that occurred on 12/31/24. LSW confirmed that the resident marked Yes that she was shaken and nervous after the encounter, that she had upset thoughts and was jumpy after the incident with LPN #1. The LSW confirmed that she and the ADM/ED did interview Resident #1, and she did express being upset by LPN #1, and the LSW confirmed that she conducted two (2) trauma assessments for Resident #1 and placed them in the medical record. The interview on 2/18/25 at 3:40 PM with CNA #1 revealed that she worked from 7:00 AM until 3:00 PM on the A-hall, where Resident #1 resided. She stated that on several occasions she would answer the call light of Resident #1 when she was requesting pain medications and she confirmed that she would go tell LPN #1 that the resident was requesting pain medications, and she would tell me she was busy and would be there in a little while. CNA #1 stated that on 12/31/24, Resident #1 was crying in her room upset that LPN #1 had talked mean to her after asking for pain medications. CNA #1 stated that Resident #1 was an intelligent free spirited person and she was well aware of her surroundings and events. CNA #1 confirmed that after LPN #1 confronted Resident #1 that day she saw her upset and crying alone in her room. Interview on 2/18/25 at 4:10 PM with CNA #2 revealed that on 12/31/24 she saw Resident #1 crying and upset after LPN #1 had left her room. Resident #1 was a cognitive and well-behaved resident and CNA #2 stated that she believed what Resident #1 had told her. Resident #1 told CNA #2 that she didn't want LPN #1 to come back in her room and that she had been loud and rude to her and had called her a liar. CNA #2 stated that she believed what Resident #1 had told her because she was visibly upset and crying. Record review of the facility's written documentation contained in the personnel record of LPN #1 revealed: Category One Violation Employee Corrective Counseling Memorandum contained the name and position of (LPN #1) read: Category One Warning: If a further incident of this nature occurs, your employment will be terminated. Violation 1.13 conduct widely regarded as immoral, improper, fraudulent, or otherwise inappropriate in the workplace. The nurse was accused of being confrontational with a resident regarding her PRN medications and the times that it can be given. Returned to work 1/4/25 Employees are to address the residents in a respectful manner at all times. The violation was signed by the ADM and the DON and dated 12/31/24. The violation was signed by LPN #1 and dated 1/4/25. Record review of the handwritten statement of PTA dated 12/31/24 revealed: Pt (patient) requested medicine from CNA prior to therapy. CNA states nursing said she was busy. Pt. states she was not within her 6-hour window prior to therapy. Pt. requested for me to close her door. Pt reports several incidents have occurred with current nurse where the nurse has been loud, rude, and confrontational with pt in regard to her medicine. Around 15 minutes upon leaving the room I went in to check on pt and she was in tears, when asked what happened, she states that the nurse has just left and was yelling directly at her that she knows she should have already asked for her medicine. Pt reports she feels unsafe and requests that the nurse does not come in her room again. Record review of the handwritten statement of ST dated 12/31/24 revealed, ST walked in approx. 730 (am) to pt's room. The nurse on A-Hall was talking to patient in a confrontational manner stating 'I never refused to give you pain meds. You should have never called up here and told them that. Your pain meds are PRN (as needed), so you have to request them.' ST stepped in due to observing pt's (patients) anxiousness asked, 'are you talking about yesterday because after I got done with therapy I came and told you she wanted her pain meds while you were on med pass' The nurse stated I never asked her that. The nurse continued to state that she needs to request her meds either before shift change or after. Record review revealed that there were two (2) Trauma Screening Assessments completed on Resident #1 dated 12/25/24 and dated 1/2/25 that were completed by the LSW. The 12/25/24 Trauma Screening Assessment (prior to the incident with LPN #1 on 12/31/24) did not contain information that was conducive to trauma experienced by Resident #1. The Trauma Screening Assessment conducted on 01/2/25 (after the incident with LPN #1 on 12/31/24) completed by the LSW, revealed that Resident #1 had experienced excessive trauma. The second Trauma Assessment for Resident #1 dated 1/2/25 was positive for trauma and confirmed that the resident had Upset thoughts; feeling upset by reminders of events; jumpy; and heightened awareness.

Based on staff interview and record review, the facility failed to ensure that staff were trained on dementia care prior to caring for residents with dementia for one (1) of three (3) survey days. Findings Include: Record review of a typed statement on facility letterhead, dated September 11, 2024 and signed by the Executive Director revealed (Proper name of facility) do not have a policy on training staff or competency of staff. Record review of a typed statement on facility letterhead, dated September 11, 2024 and signed by the Executive Director revealed (Proper name of facility) have not implemented training on Dementia Care. An interview on 09/10/24 at 11:05 AM, with Certified Nurse Assistant (CNA) #1 and CNA #2 revealed they had been working at the facility for about 4 months and had not been trained on dementia care. CNA #1 stated that she did not know any special considerations regarding dealing with residents that have dementia and that she did not have any residents on her assigned B hall that had dementia. An interview on 09/10/24 at 11:48 AM, with the Staff Development Nurse confirmed that dementia care training is not included in the new hire orientation. She stated she has a video that she could let them watch, but she does not. An interview on 09/10/24 at 11:58 AM, with the Administrator confirmed that staff should be receiving dementia care training prior to caring for residents because we have a lot of residents with dementia. She stated that was a staff competency issue and they need to know how to deal and approach residents with dementia. Record review revealed the last two dementia care in-services were on 8/25/23 and 10/06/23. An interview on 09/10/24 at 12:42 PM with the Staff Development Nurse confirmed that CNA #1 and CNA #2 had not received any training on dementia care prior to starting work. She stated she had been doing staff development for about 5 years and it had never been included in the new hire orientation and training. She stated she understands now that it should have been included so that staff would know how to react and deal with residents and be able to recognize the signs. She confirmed that the last dementia care in-service was on 10/6/23. Record review of the New Hire Program revealed dementia care was not included. Record review of the Facility Assessment Tool dated July 22, 2024 revealed New Hire Training Topics-All Staff did not include dementia care listed as a required topic. Record review of the facility Resident Matrix revealed there were 16 current residents with a diagnosis of Dementia and/or Alzheimer's Disease and 2 resided on the B Hall.

Based on observations, staff and resident interviews, record review and facility policy review, the facilities Quality Assessment Performance Improvement (QAPI)/ Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee put into place. This failure resulted in four recited deficiencies that was originally cited on the 5/18/23 recertification survey. The recited deficiencies were in the areas of failing to implement an Activities of Daily Living (ADL) care plan, assist residents with ADL's, monitor for side effects of psychotropic medications and place an infectious resident in contact isolation. The continued failures during 2 recertification's shows a pattern of the facilities inability to sustain an effective Quality Assurance Program. Findings Include: This tag is cross referenced to: F656, F677, F758 and F880. Review of the facility policy titled, Quality Improvement Program with a revision date of 10/2022 revealed under the Policy .The Quality Improvement Committee will assess and monitor the quality of services provided to the residents in the facility in order to identify potential problems and/or opportunities for improvement. The committee will implement and systemically evaluate programs and processes to identify problems in order to proactively improve health care delivery. During the recertification survey on 5/18/23 the facility was cited for F656, F677, F758, and F880. During the recertification and complaint survey on 9/9/24, the facility was cited for deficiencies that included repeat deficiencies of F656, for failure to implement a care plan regarding ADL's. F677 for failure to bath, shave and provide nail care for a total of 6 out of 7 residents investigated for ADL's. F758 for failing to monitor for side effects of psychotropic medications and F880 for failing to place a resident with an infectious disease in contact isolation. An interview on 9/11/24 at 11:10 AM, with the Director of Nurses (DON) revealed that she relies on the charge nurses and Unit Managers to direct their staff and follow up to make sure the work is done. She admitted that does not always happen. She revealed she knows there have been issues, but does not know the answer. She stated staff in healthcare is just different now, they are worried more about the money than the job. An interview and record review on 09/11/24 at 11:53 AM, with the Administrator revealed the facility has a QAPI/QAA meeting with the medical director and other interdisciplinary team members monthly. She stated they have not addressed staffing concerns, ADL care or care plans during the meetings. An interview on 09/11/24 at 12:52 PM, with the Administrator and the DON confirmed there is an issue, but they are not sure if it is a breakdown in communication or follow up. The Administrator revealed they have been working on Survey Readiness since their last survey in 5/2023 and part of that was putting quality measures such as care under a Performance Improvement Plan (PIP). She stated that has included their administrative nurses and Unit Managers being assigned certain rooms and making rounds on those residents. She revealed that during those rounds they are supposed to be looking for issues such as needed care, dirty wheelchairs, facial hair, etc. She admitted there had been no real issues found and admits that its impossible for things to be perfect. The Administrator stated that there had been no changes to their polices or procedures based on the results of the rounds. They both admitted that when they do find something that needs to be fixed then they fix it, but do not get to the root cause. The Administrator added that she has seen residents in the same clothes for days or have food on their clothes and has told the administrative staff and Unit Managers that if she sees these things she knows they do. The DON added that the administrative staff have to document their round results and turn them in, but the Unit Managers do not. She stated they verbally report if there are any issues. The DON admitted she thinks the problem is there is no accountability. They both agreed that they are accountable and should follow up as oversight to make sure the rounds are correct and being done.

Based on observation, staff interview and facility letterhead review, the facility failed to ensure the handrails on the resident's halls were permanently affixed to the wall for four (4) of 4 hallways. Findings Include: Record review of a typed statement on facility letterhead, dated September 11, 2024, and signed by the Executive Director revealed the (Proper name of facility) do not have a policy on facility repairs. An observation on 09/09/24 at 11:49 AM, of all resident halls revealed multiple loose hand rails with the ends of the hand rails not being permanently affixed to the walls on all four halls of the facility. An interview and observation on 9/9/24 at 12:00 PM with the Administrator confirmed that the hand rails on the resident halls had been loose for a while. She admitted that they had been talking about replacing them, but she wanted to get the floor replaced first. She stated that the handrails were PVC (polyvinyl chloride) pipes, and they had put them up. She stated she knew one of the residents on the B Hall pulled on them a lot but had not had an accident. She revealed that she had talked with a company about getting it fixed, but that was back in May, and she had not got that approved from corporate yet. She admitted that the lose handrails could be a safety issue for the residents. Record review revealed that there was communication from (proper name of business) in 5/10/2024 regarding options for fixing the broken handrails in the facility.

Based on staff interview and record review, the facility failed to ensure that new hire staff were trained on dementia care prior to caring for residents with dementia for one (1) of three (3) survey days. Findings Include: This tag is cross referenced to F 726, Competent Staff Record review of a typed statement on facility letterhead, dated September 11, 2024 and signed by the Executive Director revealed (Proper name of facility) do not have a policy on training staff or competency of staff. An interview on 09/10/24 at 11:05 AM, with Certified Nurse Assistant (CNA) #1 and CNA #2 revealed they both had been working at the facility for about 4 months and had not been trained on dementia care. CNA #1 stated that she did not know any special considerations regarding dealing with residents that have dementia and that she did not have any residents on her assigned B hall that had a diagnosis of dementia. An interview on 09/10/24 at 11:48 AM, with the Staff Development Nurse confirmed that dementia care training is not included in new hire orientation. She stated she has a video that she could let them watch, but she does not. An interview on 09/10/24 at 11:58 AM, with the Administrator confirmed that staff should be receiving dementia care training prior to caring for residents because we have a lot of residents with dementia. She stated that was a staff competency issue and they need to know how to deal and approach residents with dementia. An interview on 09/10/24 at 12:42 PM, with the Staff Development Nurse confirmed that she had been doing staff development for about 5 years and it had never been included in the new hire orientation and training. She stated she understands now that it should have been included so that staff would know how to react and deal with residents and be able to recognize the signs. Record review of the New Hire Program revealed dementia care was not include. Record review of the Facility Assessment Tool dated July 22, 2024 revealed New Hire Training Topics-All Staff did not include dementia care listed as a required topic. Record review of the facility Resident Matrix revealed there were 16 current residents with a diagnosis of Dementia and/or Alzheimer's Disease and 2 were on the B Hall.

Based on observations, staff and resident interviews and record reviews, the facility failed to be administered in a way that allows it to use its resources effectively to ensure the wellbeing of its residents for three (3) of three (3) days of survey. Findings Include: This tag is cross referenced to F561, F584, F677, F725, F726, F758, F908, F924 & F947. Record review of a typed statement on facility letterhead dated September 11, 2024, and signed by the Executive Director revealed (Proper name of facility) do not have a policy on Administration or Administrative Staff. We have a job description for each employee position. Record review of the facilities Job Description with an effective date of 8/01/12 revealed Job Title: Executive Director . General Description .The Executive Director leads and directs the overall operation of the Facility in accordance with resident needs .so as to maintain quality care for the residents .Essential Duties 1. Works with the Facility management staff in planning all aspects of Facility's operations, including setting priorities and job assignments. Monitors each department's activities, communicates policies, evaluates performance, provides feedback and assists, coaches, and disciplines as needed . Record review of the facility Job Description: Job Title: Director of Nurses with an effective date of 01/2017 revealed General Description .Responsible for the overall management of resident care 24 hours a day, seven days per week .In the absence of the Executive Director, assumes responsibility for the Facility . Record review of the facility Job Description: Assistant Director of Nurses with an effective date of 01/2017 revealed General Description .Responsible for performing a variety of duties to provide quality nursing care to residents . F 561 An interview on 09/10/24 at 11:00 AM, with the Dietary Manager revealed that the facility's coffee maker that was used to make the coffee for the residents had been broken for about two months. She stated that they had been boiling water on top of the stove and using a filter to make some coffee, but there was a delay in getting the coffee to the residents because it was a slow process. She confirmed she had complaints about the coffee machine being broken and understands the residents' frustration. She stated that the Administrator had known about it, and they tried to get someone to repair it, but they never came. She stated someone finally came yesterday and brought a coffee pot as a replacement and this one was working fine. During an interview on 09/10/24 at 11:24 AM, the Administrator confirmed that the coffee pot for the residents had been broken for a while, but she was thinking it had only been a month. She stated she thought someone had already been out to look at the coffee pot before yesterday. She stated that they had a back-up method for making coffee for the residents, but did not realize there was a delay in getting it out to the residents. F 584 An observation of room D5 B on 9/9/24 at 10:20 AM, revealed a light gray fall protection floor mat that was a length of 72 inches by width of 24 inches on the left side of the bed covered in black and brown dried stains. A quarter size clump of a brown leaf tobacco product was observed on the floor next to the floor mat, with a dried brown ring around the tobacco. In an interview with the Director of Nursing (DON) on 9/9/24 at 3:10 PM, revealed the floor mats should be cleaned daily to prevent the spread of infections when staff step on the dirty fall mat. In an interview with the Assistant Director of Nursing/Infection Control Nurse on 9/10/24 at 10:44 AM, she revealed that the resident's fall mat should be cleaned and sanitized every day along with the room to reduce the risk for spread of infection. F 677 Resident #43 During an interview and observation in Resident #43's room on 9/10/24 at 12:05 PM, the resident informed the Director of Nursing (DON) that she wanted her facial hair shaved, but staff had not done this. The resident informed the DON she had a shower yesterday afternoon, but shaving was not done. The DON confirmed the resident, who required assistance with care, had facial hair present and did not receive the Activity of Daily Living (ADL) care for shaving, which was part of the grooming process, especially for a female resident. During an observation and interview with the Director of Nursing (DON) and Resident #151 on 9/10/24 at 4:15 PM, the resident revealed she wanted her nails to be trimmed. The DON confirmed the nails were long with a brown substance under each nail and nails were to be trimmed and cleaned to ensure skin was not scratched and to prevent infections and the facility failed to do this. Resident #59 An observation and interview on 9/9/2024 at 12:18 PM, with Resident #59 who stated, I'm not going to lie on them or for them. I have not had a bath of any type since last Tuesday. They will wash my face, but that's it. He revealed he would love to be really cleaned up. An interview on 9/10/2024 at 12:10 PM, with Licensed Practical Nurse (LPN) #1 confirmed that Resident #59 had complained to her about not receiving a bath on 8/31/24, but she did not report it to anyone. Record review of documented baths for Resident #59 confirmed that the resident did not receive a bath on 8/31/2024. This documentation revealed the resident received a bed bath on 8/29/2024 with the next bath on 9/3/2024. Resident #68 An interview with the Director of Nursing (DON) on 9/10/2024 at 8:50 AM, revealed she was aware of both incidents that happened over the weekend with Resident #68 regarding not answering the call light and providing incontinent care timely. She revealed the aide who cared for the resident on Saturday (9/7/24) had been terminated. The DON revealed she spoke with the aide, and the aide stated that she changed the resident after breakfast and that every time she went back into the resident's room, the resident was asleep. The aide reported that she did not wake the resident to check her or provide incontinent care. The DON revealed that she terminated the aide because this was her second occurrence of not making rounds and leaving the residents soiled. She explained that the resident had a different aide on Sunday (9/8/24). The DON revealed that she met with that aide, and the aide stated that she answered the call light, cut it off, and told the resident she would be back, but never went back. She revealed The DON confirmed her expectations were for the aides to make rounds on the residents every 2 hours and as required, and render the necessary care needed. An interview with the Director of Nursing (DON) on 9/10/2024 at 1:21 PM, confirmed staff did not provide the necessary care for Resident #68. She revealed her expectations were for staff to answer the call lights and render the care that the resident needs in a timely manner. She explained that the aides were to make rounds every 2 hours and as needed to ensure the residents were clean and dry and to prevent skin breakdown. Resident #151 During an observation and interview with the DON and Resident #151 on 9/10/24 at 4:15 PM, the resident revealed she wanted her nails to be trimmed. The DON confirmed the nails were long with a brown substance under each nail and nails were to be trimmed and cleaned to ensure skin was not scratched and to prevent infections and the facility failed to do this. Resident #351 An interview with the DON on 9/10/2024 at 11:10 AM, revealed Resident #351 should be checked and changed every 2 hours and more if he needed it. She explained that he may be a heavy wetter and needed to be changed more frequently. The DON revealed if the resident was a heavy wetter, she could see that the resident could wet the bed. She revealed she was not aware of the family members' concerns regarding the resident's care, and stated those concerns were just brought to her attention yesterday. Resident #352 An interview with the Physical Therapy Assistant (PTA) on 9/10/2024 at 11:50 AM revealed, Resident #352 not being changed had been an issue since he had been working with him. He revealed he had only done about 4 sessions with the resident, and each time the resident would be dirty. The PTA revealed it took 2-3 hours before the resident got changed by the staff. He stated he usually goes down to the resident's room about 8-9 in the morning to start his session, but after the resident reports being soiled, he will push the resident's call light. He stated he also goes to hunt down someone to help change the resident, but nine times out of ten he cannot find anybody. The PTA stated like yesterday he pushed the call light, and nobody ever came, so he went to the nurse and told her. She then went to change the resident. He confirmed that this caused a delay in therapy session because time starts when he knocks on the door. An interview with the DON on 9/10/2024 at 2:52 PM, revealed,she was not aware Resident #352 was not being changed in a timely manner. She stated that therapy had not reported anything to her. She revealed when an issue was brought to her attention, she would address it. The DON confirmed that the aides should be rounding on the residents every 2 hours and the residents should be changed in a timely manner. F 725 An interview on 9/11/24 at 11:10 AM, with the DON revealed that she relies on the charge nurses and Unit Managers to direct their staff and follow-up to make sure the work is done. She admitted that does not always happen. She stated honestly sometimes you have to treat them like children, for instance the aides need to be told exactly what to do. She revealed she knows there have been issues but does not know the answer. She revealed that staff in healthcare today is just different now, they are worried more about the money than the job. She revealed they do not even think of it as health care, instead just health services. An interview with the Administrator (ADM) with the Director of Nursing (DON) in attendance, on 9/11/2024 at 11:16 AM, revealed she was not aware of any workload concerns from the staff or care concerns from the residents. She revealed we discuss this in resident council meetings and every morning in the stand-up meeting. She revealed the aides say they are short, but they are not. The ADM stated, We just have the wrong people in place. The ADM explained that they have a Registered Nurse (RN) Unit Manager for both units, and they also have an LPN which was a Charge Nurse on each hall. She confirmed they were supposed to be rounding on the residents to ensure the care was provided and the resident's needs are met. F 726 An interview on 09/10/24 at 11:48 AM, with the Staff Development Nurse confirmed that dementia care training is not included in new hire orientation. She stated she has a video that she could let them watch, but she does not. She stated that staff just get in-serviced on dementia care when it is time for an in-service. An interview on 09/10/24 at 11:58 AM, with the Administrator revealed she was unaware that new staff were not receiving dementia care training prior to working. She stated that staff should be receiving dementia care training prior to caring for residents because we have a lot of residents with dementia. She stated that was a staff competency issue and they need to know how to deal and approach residents with dementia. F 908 During an observation and interview with the Director of Nursing (DON) on 9/10/24 at 1:00 PM, she confirmed that Resident #84's wheelchair arms needed to be replaced to prevent skin injury. She revealed that they had a system in place for any needed repairs to be noted in so areas of concern could be corrected, but this was overlooked and not put into their system. She confirmed the facility failed to maintain Resident #84's wheelchair in safe and good repair, which could cause an injury to the resident's skin. F 924 An interview and observation on 9/9/24 at 12:00 PM with the Administrator confirmed that the hand rails on the resident halls had been loose for a while. She admitted that they had been talking about replacing them, but she wanted to get the floor replaced first. She stated that the hand rails were PVC pipes, and they had put them up. She stated she knew one of the residents on the B Hall pulled on them a lot but had not had an accident. She revealed that she had talked with a company about getting it fixed, but that was back in May, and she had not got that approved from corporate yet. She admitted that the lose handrails could be a safety issue for the residents. F 947 An interview and observation on 9/9/24 at 12:00 PM with the Administrator confirmed that the hand rails on the resident halls had been loose for a while. She admitted that they had been talking about replacing them, but she wanted to get the floor replaced first. She stated that the hand rails were PVC (Polyvinyl Chloride) pipes, and they had put them up. She stated she knew one of the residents on the B Hall pulled on them a lot but had not had an accident. She revealed that she had talked with a company about getting it fixed, but that was back in May, and she had not got that approved from corporate yet. She admitted that the lose handrails could be a safety issue for the residents. An interview on 09/11/24 at 12:52 PM, with the Administrator and the DON confirmed there is issues, but they are not sure if it is a breakdown in communication or follow up. The Administrator revealed they have been working on Survey Readiness since their last survey in 5/2023 and part of that was putting quality measures such as care under a Performance Improvement Plan (PIP). She stated that has included their administrative nurses and Unit Managers being assigned certain rooms and making rounds on those residents. She revealed that during those rounds they are supposed to be looking for issues such as needed care, dirty wheelchairs, facial hair, etc. She admitted there had been no real issues found and admits that is really impossible. The Administrator stated that there had been no changes to their polices or procedures based on the results of the rounds. They both admitted that when they do find something that needs to be fixed then they fix it, but never get to the root cause. The Administrator added that she has seen residents in the same clothes for days or have food on their clothes and has told the administrative staff and Unit Managers that if she sees these things she knows they do. The DON added that the administrative staff have to document their round results and turn them in, but the Unit Managers do not. She stated they verbally report if there are any issues. The DON admitted she thinks the problem is there is no accountability. They both agreed that they are accountable and should follow up as oversight to make sure the rounds are correct and being done and that care is being provided.

Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to ensure a developed care plan was implemented for shaving (Resident #43), bathing (Resident #59), incontinent care (Resident #68, 351, & 352), and nail care (Resident #151) for six (6) of 24 resident care plans reviewed. Findings include: Record review of facility policy titled, Shaving - Male and Female dated 1/15, revealed, Residents will be free of facial hairs - both male and female. If the resident is alert and oriented and requests not to be shaved, this will be noted in the Care Plan. Record review of facility policy titled, Comprehensive Person Centered Care Plans, revealed, Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Resident #43 Record review of Resident #43's Care Plan revealed, I require assistance with my ADL's with intervention listed as assist me with my shower/bath three times weekly and as needed. During an interview and observation on 9/9/24 at 10:50 AM, Resident #43 revealed her preference is to have her facial hair removed by shaving, and she had asked staff to assist her with this, but they had not helped her and facial hair was observed on the resident's face. An interview with the Director of Nursing (DON) on 9/10/24 at 2:30 PM, revealed the shower was documented as given yesterday and shaving was a part of the shower/bathing routine and the facility failed to do the shaving. She confirmed the care plan's purpose was to provide resident's preferences and care requirements and Resident #43's care plan for activities of daily living (ADL) was not followed. During an interview on 9/10/24 at 2:33 PM, the Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Assistant confirmed the resident had a care plan for assistance with her Activities of Daily Living (ADL) care which included showers/baths three times weekly. She stated shaving is included in that care and was not done. She confirmed the care plan allows the staff to know what care each resident requires and their preferences for care and she confirmed the facility failed to follow Resident #43's developed care plan for ADL assistance. Record review of Resident #43's Admission Record revealed the facility admitted the resident on 12/18/2020 with diagnoses that included Type 1 Diabetes Mellitus and Arthritis. Record review of Resident #43's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/26/24, revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had a mild cognitive impairment. Resident #151 Record review of Resident #151's Care Plan date initiated 9/2/24 revealed, The resident has an ADL self-care performance deficit. Interventions included, Check nail length and trim and clean on bath day and as necessary. An observation and interview with Resident #151 on 9/9/24 at 10:50 AM revealed fingernails were long (approximately one-half inch from nail bed) with a brown substance noted under nails. The resident stated she would love for her nails to be trimmed but no one had done it. During an observation and interview with the Director of Nursing (DON) and Resident #151 on 9/10/24 at 4:15 PM, the resident told the DON she wanted her nails to be trimmed. The DON confirmed the nails were long with a brown substance under each nail. She confirmed the care plan for assistance with activities of daily living (ADL) for nail care was not followed for this resident. An interview with the MDS Assistant on 9/11/24 at 9:10 AM, revealed Resident #151's comprehensive care plan for assistance with nail care and activities of daily living had been developed but it was not implemented. She stated purpose of care plan is to provide staff with care required and preferences and should be followed. She confirmed the facility failed to implement the care plan for Resident #151's nail care. Record review of Resident #151's Admission Record revealed the facility admitted the resident on 8/23/24. Diagnoses included Metabolic Encephalopathy, Type 2 Diabetes Mellitus, and Need for assistance with personal care. Record review of Resident #151's admission MDS with ARD of 8/30/24 revealed a BIMS score of 9 which indicated the resident was moderately impaired cognitively. Resident #59 Record review of Resident #59's Care Plan with a problem onset date of 11/29/23 revealed, I require assistance with ADL's (activities of daily living) r/t (related to) impaired mobility d/t (due to) BIL (bilateral) amputee .Approaches: Shower/Bath resident 3 X (times) weekly . An interview on 9/9/2024 at 12:18 PM, with Resident #59 who stated, I'm not going to lie on them or for them . I have not had a bath of any type since last Tuesday; They will wash my face, but that's it. He revealed he would love to be really cleaned up. Record review of documented baths for Resident #59 revealed the resident received a bed bath on 8/29/2024 with the next bath on 9/3/2024. An interview on 9/11/2024 at 7:45 AM, with CNA #7 revealed, if a resident was supposed to get a bath 3 times per week, and it was care planned, then the care plan was not implemented. An interview on 9/11/2024 at 7:50 AM, with the MDS Nurse revealed, she was one of the staff members responsible for developing the residents' care plans. She confirmed that if a resident had a care plan indicating a resident receives 3 baths a week and did not get them, then the care plan was not implemented. Record review of the Admission Record revealed the facility admitted Resident #59 on 11/14/2023 with a medical diagnosis of Need for Assistance with Personal Care. Record review of the Quarterly MDS with an ARD of 7/24/2024 revealed, under section C, a BIMS summary score of 13, which indicated Resident #59 was cognitively intact. Resident #68 Review of Resident #68's Care Plans date initiated 8/27/24, revealed under, Focus: The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) Hemiplegia, Limited Mobility, Stroke. Also revealed under, Interventions: . Personal hygiene: The resident requires partial assistance by 1 staff with personal hygiene . Toilet use: The resident is totally dependent on 2 staff for toilet use. An interview on 9/9/2024 at 10:20 AM, with Resident #68 revealed, that both Saturday (9/7) and Sunday (9/8) she rang her call light and told the CNA who came in that she was wet and needed to be changed. She revealed on both days the CNA turned the call light off, said she would be back, and left the room without ever coming back. She revealed, last night, her sister called the facility and spoke with the nurse to report that the aide never came back. The resident explained that the nurse and another aide later came to change her. She revealed, I sat in that urine for an hour. Record review of the Admission Record revealed the facility admitted Resident #68 on 8/19/2024 with a medical diagnosis of Chronic Combined Systolic and Diastolic Heart Failure. Record review of the Admission MDS with an ARD of 8/26/2024 revealed, under section C, a BIMS summary score of 13, which indicated Resident #68 was cognitively intact. Resident #351 Review of Resident #351's Care Plans date initiated 9/2/24, revealed, Focus: The resident has an ADL (activities of daily living) self-care deficit r/t (related to) Hemiplegia, Limited Mobility, Stroke. Also revealed under, Interventions/Tasks: Personal Hygiene . The resident is totally dependent on 1 staff for personal hygiene . Toilet Use: The resident is totally dependent on 2 staff for toilet use. An observation of Resident #351 on 9/9/2024 at 10:45 AM revealed, he was sitting in a reclining wheelchair in his room. His eyes were open, and he was non-verbal. The resident was wearing a gray pair of jogger pants that were saturated through the groin area and in between the legs with urine. An interview with a family member, while in the room, revealed he was brought back from therapy like this, and nobody had been there since to check on him. The family member revealed the resident's bed was always wet with urine. She revealed the bed was soaked out this morning and had to be changed after they got him up. She stated, They say they are changing him every 2 hours, but they are not because I am here, and they do not enter the room. Record review of the Admission Record revealed the facility admitted Resident #351 on 8/23/2024 with diagnoses including Cerebral Infarction. Resident #352 Review of Resident #352's Baseline Care Plan dated 9/3/24 revealed under, Bowel and Bladder: . Incontinence care An observation and interview with Resident #352 on 9/9/2024 at 10:58 AM revealed, he was lying in bed and it was noted that a foul odor was around the resident. The resident revealed, after he ate breakfast and took his morning medicine, it was 2 hours before someone could come to clean him up and change him. He stated, They tell me they are working with somebody and will get to me when they can. He revealed the therapy man will even come to his room to take him to therapy, and he must tell him that he cannot go right now because he needs changing. The resident stated, He wouldn't want to sit like that, so he should understand. The resident stated he was still waiting to be changed today. An interview with the Physical Therapy Assistant (PTA) on 9/10/2024 at 11:50 AM revealed, Resident #352 not being changed had been an issue since he had been working with him. He revealed he had only done about 4 sessions with the resident, and each time the resident would be dirty. The PTA revealed it took 2-3 hours before the resident got changed by the staff. He stated he usually goes down to the resident's room about 8-9 in the morning to start his session, but after the resident reports being soiled, he will push the resident's call light. He stated he also goes to hunt down someone to help change the residents, but nine times out of ten he cannot find anybody. The PTA stated like yesterday he pushed the call light, and nobody ever came, so he went to the nurse and told her, and she went to change the resident. Record review of the Admission Record revealed the facility admitted Resident #352 on 9/3/2024 with medical diagnoses that included Osteomyelitis of vertebra, thoracic region. Record review of the Admission MDS with an ARD of 8/13/2024 revealed under section C, a BIMS score of 15, which indicated Resident #352 was cognitively intact. An interview with the MDS Nurse on 9/11/2024 at 7:50 AM revealed, she does MDS and the care plans. She revealed, if the ADL care was on the care plan, and it was not being done by the staff, then the care plan was not being followed. 44804 47874

Based on observation, resident/family/staff interviews, and record review, the facility failed to ensure nursing staff provided the necessary resident care for six (6) of seven (7) residents reviewed for Activities of Daily Living (ADL) during the survey. Resident #43, #59, #68, #151, #351, #352 Cross-Reference to F 677 Findings include: Record review of a statement on letterhead dated 9/11/2024 and signed by the Executive Director revealed, (Proper name of facility) do not have a policy on staffing. We staff according to resident acuity. Resident #43 During an interview and observation on 9/9/24 at 10:50 AM, Resident #43 revealed her preference was to have her facial hair removed by shaving, and she had asked staff to assist her with this, but they had not and facial hair was noted on resident's face. An interview and observation of Resident #43 on 9/10/24 at 11:50 AM, revealed facial hair on the chin and lower jaw area. She stated she had a shower yesterday afternoon, and she wanted her facial hair to be removed, but the staff did not do it. During an interview and observation in Resident #43's room on 9/10/24 at 12:05 PM, the resident informed the Director of Nursing (DON) that she wanted her facial hair shaved, but staff had not done this. The resident informed the DON she had a shower yesterday afternoon, but shaving was not done. Resident #59 An observation and interview on 9/9/2024 at 12:18 PM, with Resident #59 who stated, I'm not going to lie on them or for them. I have not had a bath of any type since last Tuesday. They will wash my face, but that's it. He revealed he would love to be really cleaned up. This observation revealed the resident was a double above the knee amputee and stated he needed assistance with his baths. An interview on 9/10/2024 at 10:17 AM, with Certified Nurse Assistant (CNA) #1 confirmed that she was assigned to Resident #59, and he had told her he only gets a bath when she was on duty. She stated she knew that the resident complained to Licensed Practical Nurse (LPN) #1 last week about it, but was not sure what happened. An interview on 9/10/2024 at 12:10 PM, with LPN #1 confirmed that Resident #59 had complained to her about not receiving a bath on 8/31/24, but she did not report it to anyone. She stated that she just discussed it with the resident. Record review of documented baths for Resident #59 confirmed that the resident did not receive a bath on 8/31/2024. This documentation revealed the resident received a bed bath on 8/29/2024 with the next bath on 9/3/2024. Resident #68 An observation and interview on 9/9/2024 at 10:20 AM, with Resident #68 revealed, she was sitting in her wheelchair in her room. The resident explained that both Saturday (9/7/24) and Sunday (9/8/24) she rang her call light and told the girl who came in that she was wet and needed to be changed. She revealed on both days the girl turned the call light off, said she would be back, and left the room without ever coming back. She revealed, last night, her sister called the facility and spoke with the nurse to report that the aide never came back. The resident explained that the nurse and another aide later came to change her. She revealed, I sat in that urine for an hour. An interview with the Director of Nursing (DON) on 9/10/2024 at 8:50 AM, revealed, she was aware of both incidents that happened over the weekend with Resident #68. She explained that she met with the resident and her son yesterday. She revealed the aide who cared for the resident on Saturday (9/7/24) had been terminated. The DON revealed she spoke with the aide, and the aide stated that she changed the resident after breakfast and that every time she went back into the resident's room, the resident was asleep. The aide reported that she did not wake the resident to check her or provide incontinent care. The DON revealed that she terminated the aide because this was her second occurrence of not making rounds and leaving the residents soiled. She explained that the resident had a different aide on Sunday (9/8/24). The DON revealed that she met with the aide, and the aide stated that she answered the call light, cut it off, and told the resident she would be back, but never went back. She revealed the resident called her sister, who then called the facility and reported the issue. The DON revealed that during that time the aide had gone to break, and the aide stated that she had changed the resident before supper. The DON revealed the aide was written up and counseled on answering the call lights and rendering the care when needed, as this was her first offense. The DON confirmed her expectations were for the aides to make rounds on the residents every 2 hours and as required and render the necessary care needed. An interview with Resident #68 on 9/10/2024 at 9:25 AM, revealed the aide assigned to her on Sunday (9/8/24) did not toilet or change her before supper. She explained that she waited until after supper and the trays were all picked up and pushed her call light to be changed. She stated the aide came in, turned the light off and said she would be back. The resident explained that after the aide did not return, she called her sister around 7:30 PM, who called the facility. She stated, They don't come check on me every 2 hours. They say they do, but they don't. She stated, They can't be lying on me because I have my mind. An interview with Certified Nurse Aide (CNA) #4 on 9/10/2024 at 3:20 PM, revealed she had been employed at the facility for 8 months and worked 3-11 shift. She revealed on Sunday (9/8/24) she was assigned to Resident #68. She revealed they were short-staffed that day, and she had the split section, which included her working the top section of A and B hall. CNA #4 revealed she was in the middle of cleaning up another resident on another hall at the time Resident #68's light went off. She explained that she had stepped out of the other resident's room to get some clean linen when she answered Resident #68's light, turned it off, and told the resident she would be back. She stated she forgot to go back. CNA #4 revealed they work short-staffed a lot and stated that staffing was a big concern because things do not get done. She revealed the aides were responsible for vitals, showers, making rounds every 2 hours, toileting, passing out supper trays, assisting the residents who need help with eating, picking the trays back up, answering the call lights, passing out ice, and charting. She stated, It's a lot. I'm just one person and I do all I can do. Resident #151 An observation and interview with Resident #151 on 9/9/24 at 10:50 AM, revealed fingernails were long (approximately one-half inch from nail bed) with a brown substance noted under the nails. The resident stated she would love for her nails to be trimmed, but no one had done it. During an observation and interview with the Director of Nursing (DON) and Resident #151 on 9/10/24 at 4:15 PM, the resident stated she wanted her nails to be trimmed. The DON confirmed Resident #151's nails were long with a brown substance under each nail. She stated nails were to be trimmed and cleaned to ensure the skin was not scratched and to prevent infections, and the facility failed to do this. Resident #351 An observation on 9/9/2024 at 10:45 AM, revealed Resident #351 was sitting in a reclining wheelchair in his room. His eyes were open, and he was non-verbal. The resident was wearing a gray pair of jogger pants that were saturated through the groin area and in between the legs with urine. An interview with a family member, while in the room, revealed he was brought back from therapy like this, and nobody had been there since to check on him. The family member revealed the resident's bed was always wet with urine. She revealed the bed was soaked out this morning and had to be changed after they got him up. She stated, They say they are changing him every 2 hours, but they are not because I am here, and they do not enter the room. She explained that the resident was wetting out his clothes and the bed with urine through a brief. The family member revealed when he was in bed, she positioned a pillow under his stroke affected arm, and it even got soaked with urine. She reiterated, They are not changing him like they should be. She revealed she had been waiting on the resident's nurse to come back since 10:15 AM because she had some questions regarding the resident's fluid medication, but she had yet to come back. An interview with CNA #5 on 9/9/2024 at 10:51 AM,revealed she got Resident #351 up this morning, but she was unsure what time. She stated the resident had been to therapy and she did not realize he was back. She revealed therapy did not come and let her know he was back or that he was wet. CNA #5 confirmed the resident's bed linen had to be changed because it was wet this morning. Resident #352 An observation and interview with Resident #352 on 9/9/2024 at 10:58 AM, revealed he was lying in bed with a foul odor noted around the resident. The resident revealed, after he ate breakfast and took his morning medicine, it was 2 hours before someone could come to clean him up and change him. He stated, They tell me they are working with somebody and will get to me when they can. He revealed the therapy man will even come to his room to take him to therapy, and he must tell him that he cannot go right now because he needs changing. The resident stated, He (the therapy man) wouldn't want to sit like that, so he should understand. The resident stated he was still waiting to be changed today. An interview on 9/10/24 at 11:05 AM, with CNA #1 and #2 revealed they had been working at the facility for about 4 months and stated they work shorthanded a lot and usually just get one day a week off. An interview with the Physical Therapy Assistant (PTA) on 9/10/2024 at 11:50 AM, revealed Resident #352 not being changed had been an issue since he had been working with him. He revealed he had only done about 4 sessions with the resident, and each time the resident would be dirty. The PTA revealed it took 2-3 hours before the resident got changed by the staff. He stated he usually goes down to the resident's room about 8-9 in the morning to start his session, but after the resident reports being soiled, he will push the resident's call light. He stated he also goes to hunt down someone to help change the resident, but nine times out of ten he cannot find anybody. The PTA stated like yesterday he pushed the call light, and nobody ever came, so he went to the nurse and told her. The nurse then went to change the resident. An interview with the Director of Nursing (DON) on 9/10/2024 at 3:12 PM, revealed they base their facility staffing needs on the acuity of the residents. Record review of a list provided by the facility revealed there were 18 residents who required assistance with meals. Record review of a list provided by the facility revealed there were 19 residents that requires the use of a total lift x 2 staff members for transfer. Record review of a list provided by the facility revealed there were 14 residents that requires the use of a sit-to-stand lift x 2 staff for transfers. Record review of a list provided by the facility revealed there were 16 residents that requires the assistance of 2 staff members for transfers. An interview with the Staff Development Nurse on 9/10/2024 at 3:40 PM, revealed the aides were responsible for ensuring the residents were clean and dry, answering call lights, making rounds, meals and providing showers which are split between 7-3 and 3-11 shifts. She revealed they do not have a shower team right now, but it was the goal. She revealed call ins were the main concern with staffing and explained that call ins were called to her or the DON. She revealed she then tries to get someone to fill the position but sometimes they are not able to get anyone. The Staff Development Nurse explained that sometimes the aides do not show up for a shift and do not call and then try to say they tried calling the facility,which leaves them in a bind. Furthermore, she explained they do have a high acuity of residents and stated any of the residents that use a lift of any kind must have 2 staff present for transfers. An interview with the Staff Development Nurse on 9/11/2024 at 9:30 AM, revealed On a good day, the aides are responsible for caring for 14-15 residents a piece. She explained that they work with 2 aides to each hall for all shifts, and sometimes extra when they can get someone. She revealed they are actively hiring for 4 nurse positions and 3 aides. She confirmed call ins were the biggest concern. She stated that she had to work as a med cart nurse on 3 PM-11 PM last night due to a call in, and revealed they were short-staffed. She explained that the 7 AM-3 PM shift was her most challenging shift to staff. She stated that the staff was just different now versus how they used to be and stated, They are more concerned about how much they are going to get paid. She explained that she tried to encourage the charge nurses on each hall to take charge of their hall and their CNA's, but that does not always happen. She stated, unfortunately, you sometimes must treat them like children and give them direction. An interview with CNA #7 on 9/11/2024 at 10:02 AM, revealed she has worked at the facility for 1 year and worked night shift but was working over today to fill an open position. She explained that on day shift they usually have about 7 showers to do, which did pull them away from the floor. She revealed they split them between the 2 aides on the hall and tried to cover each other's lights during that time. An interview on 9/11/24 at 11:10 AM, the DON revealed that she relies on the Charge Nurses and Unit Managers to direct their staff and follow-up to make sure the work is done. She admitted that does not always happen. She stated honestly sometimes you have to treat them like children, for instance the aides need to be told exactly what to do. She revealed she knows there have been issues but does not know the answer. She stated staff in healthcare is just different now, they are worried more about the money than the job. She revealed they do not even think of it as health care, instead just health services. An interview with the Administrator (ADM) with the DON in attendance, on 9/11/2024 at 11:16 AM, revealed she was not aware of any workload concerns from the staff or care concerns from the residents. She revealed we discuss this in resident council meetings and every morning in the stand-up meeting. She revealed the aides say they are short, but we are not. The ADM stated, We just have the wrong people in place. The ADM explained that they have a Registered Nurse (RN) Unit Manager for both units, and they also have a LPN which was a Charge Nurse on each hall. She confirmed they were supposed to be rounding on the residents to ensure the care was provided, and the resident's needs were met.

Based on staff interview, record review, and facility policy review, the facility failed to ensure residents were free from unnecessary drug use as evidenced by no side effect monitoring for the use of psychotropic medications for three (3) of 64 residents receiving psychotropic medications. (Resident #44, #54 and #87) Findings include: Record review of the facility policy Behavior Management and Psycho-pharmacological Medication Monitoring Protocol, (K.1) with a History date of 3/18 revealed Policy: Residents will be reviewed routinely for effectiveness and monitored for side effects of these medications . Record review of Resident #44's Order Summary Report with active orders as of 9/10/24 revealed orders dated 11/29/23 for Duloxetine 30 milligrams (mg) - give one capsule by mouth in the afternoon related to major depressive disorder (give along with the 60 mg to equal a 90 mg dose, Duloxetine 60 mg - give one tablet by mouth in the afternoon related to major depressive disorder (take along with the 30 mg to equal 90 mg dose). Quetiapine Fumarate tablet 25 mg - give 0.5 tablet by mouth at bedtime related to generalized anxiety disorder. Lorazepam 0.5 mg tablet - Give 0.5 tablet by mouth two times a day related to Generalized anxiety disorder. Divalproex Sodium Cap Delayed Release Sprinkle 125 mg - Give 2 capsules by mouth three times a day related to Generalized anxiety disorder. Record review of Resident #44's Admission Record revealed the facility admitted the resident on 11/29/23 with diagnoses that included Major depressive disorder, Generalized anxiety disorder, Primary insomnia and Restlessness and agitation. Record review of Resident #44's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/20/24, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. Resident #54 During the record review of Resident #54's Order Summary Report with active orders as of 9/10/24 revealed orders dated 5/3/24 for Quetiapine Fumarate 100 milligrams (mg) tablet - give 1.5 tablet at bedtime related to Psychotic disorder with delusions, Memantine tablet 10 mg - Give one tablet every morning and at bedtime related to Unspecified dementia with psychotic disturbance, Divalproex Sodium delayed release 125 mg - Give one capsule orally two times a day related to Psychotic disorder with delusions, Donepezil Hydrochloride (HCl) 5 mg - Give one tablet orally at bedtime related to Unspecified dementia with psychotic disturbance, Mirtazapine 30 mg - Give one tablet at bedtime related to Major depressive disorder, Venlafaxine HCl tablet 75 mg (base equivalent) - Give 1.5 tablet one time a day related to Major depressive disorder (one and one half tablet to equal 112.5 mg), Buspirone HCl oral tablet 5 mg - give one tablet every morning and at bedtime related to Psychotic disorder with delusions due to known physiological condition. Record review of Resident #54's Admission Record revealed the facility admitted the resident on 7/20/23. Diagnoses included Dementia with psychotic disturbance, Alzheimer's disease, Psychotic disorder with delusions due to known physiological condition and Major depressive disorder. Record review of Resident #54's MDS with an ARD of 8/2/24 revealed a BIMS score of 3 which indicated severe cognitive impairment. Resident#87 Record review of the Medication Review Report on or after date of 9/1/24 revealed an order dated 3/1/23 for Buspirone 10 MG: Give one tablet orally three times a day related to Generalized anxiety disorder, an order dated 3/1/23 for Fluoxetine 40 MG: Give one capsule orally one time a day related to Depressive episodes, an order dated 2/9/24 for Trazodone 100 MG tablet: Give one tablet orally at bedtime related to Insomnia, and an order dated 3/15/24 for Quetiapine Fumarate 25 MG: Give one tablet orally at bedtime related to Generalized anxiety. A continued review of the medical record for Resident # 87 revealed no monitoring for side effects of the use of psychotropic medications. Review of the Admission Record revealed the facility admitted Resident # 87 on 3/01/23 with diagnoses that included Generalized anxiety disorder, Major depressive disorder, Other specified depressive episodes, and Insomnia. An interview with Registered Nurse (RN) #1 on 9/10/24 at 1:10 PM, revealed she did not routinely monitor or document side effects of psychotropic medication use. She stated if she noted any abnormal movement or other concern in her routine assessment or medication administration, she would document in progress note and notify the provider, but this was not done or documented routinely. During an interview on 9/10/24 at 1:40 PM, the Director of Nursing (DON) confirmed the facility did not monitor for side effects of psychotropic medication use. She acknowledged that monitoring for psychotropic medication side effects was important to ensure any adverse effect was noted quickly and responded to for appropriate care of the resident. In an interview with the Pharmacy Consultant on 9/10/24 at 3:05 PM, he revealed all residents on psychotropic medications should be monitored for side effects like over sedation and other adverse reactions that could indicate a resident may require a change in medication. 47157

Based on observation, resident and staff interview, record review, and facility review the facility failed to help prevent the transmission of infections when a resident returned from the hospital with a treatment for Clostridium Difficile Colitis (C-Diff) infection was not placed on contact isolation precautions for one (1) of 14 residents being treated for an infection. Resident #83 Findings include: A review of Centers for Disease Control (CDC) document revealed Contact Precautions: Contact precautions are intended to prevent transmission of infectious agents, which are spread by direct or indirect contact with the patient or the patient's environment.(Example: C. Difficile) . C-diff is a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon).Key Points: Most cases of C. Diff occur when you have been taking antibiotics or not long after you have finished . A review of the facility policy titled, Contact Precautions, revealed Policy: Contact precautions are a transmission-based precaution that will be utilized to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. In an interview with Resident # 83 on 9/9/24 at 10:00 AM, he revealed he had just returned from the hospital the day before with bad diarrhea. He stated the diarrhea was C-Diff. Observation of the resident's room revealed there were no isolation barrels in the room. There was no signage on the resident's door alerting the staff that the resident was on contact precautions. A review of the diagnosis information on the Admission Record for Resident #83 revealed on 8/30/24 he received a diagnosis of long-term use of antibiotics. A review of the Order Details revealed a physician's order for Resident # 83 dated 9/8/24 Fidaxomicin Oral Table 200 MG(milligram) Give 1( one) tablet by mouth every morning and at bedtime for C-Diff until 9/13/24. Review of hospital lab values for Resident #83 dated 9/3/24 revealed C. Difficile results was positive. In an interview with Licensed Practical Nurse (LPN) #2 on 9/9/24 at 1:20 PM, she revealed Resident #83 was not on contact precautions for C-Diff. She stated she asked the night nurse if the resident was supposed to be on isolation because he was on medication for C-diff, and the nurse told her no because he was treated in the hospital. LPN #2 stated she should have questioned this further. In an interview with the Director of Nursing on 9/9/24 at 1:50 PM, she revealed that Resident #83 did come back from the hospital with orders to treat C-Diff and confirmed staff should have placed him on contact isolation to reduce the risk of infection transmission. In an interview with Assistant Director of Nursing/Infection Control nurse on 9/10/24 at 11:38 AM, she confirmed Resident #83 should have been placed on contact isolation when he returned from the hospital the evening of 9/8/24 to reduce the spread of the infection. Review of the Admission Record revealed the facility admitted Resident #83 on 6/09/23 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/9/24 revealed a Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact

Based on observation, staff and resident interview, record review and facility policy review the facility failed to provide assistance with Activities of Daily Living (ADL's) for residents that were dependent on staff, as evidenced by not being shaved (Resident #43), missed bath (Resident #59), not performing timely incontinent care (Resident # 68, 351 & 352) and long dirty nails (Resident #151) for six (6) of seven (7) residents reviewed for ADL's. Resident #43, 59, 68, 151, 351 and 352. Cross Reference F725 Findings include: Record review of facility policy titled, Shaving - Male and Female dated 1/15, revealed, Residents will be free of facial hairs - both male and female. If the resident is alert and oriented and requests not to be shaved, this will be noted in the Care Plan. Review of the facility policy titled Bath/Shower-Dependent with a revision date of 8/11 revealed, Policy: A bath (shower/tub) for cleanliness and comfort is scheduled at least weekly for each resident. Also revealed under, Responsibility: Nursing Assistants or Licensed Nurses monitored by Charge Nurse. Review of the facility policy titled Incontinent Care with a review date of 1/15 revealed, Policy: To provide routine, preventative skin, perineal care to residents after an incontinent episode. Also revealed under, Responsibility: All Nursing Personnel. Record review of facility policy titled, Fingernails/Toenails Care, dated 1/15, revealed, The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Resident #43 On 9/9/24 at 10:50 AM, during an interview and observation , Resident #43 revealed her preference was to have her facial hair removed by shaving, and she had asked staff to assist her with this, but they had not. Facial hair was noted on resident's face. An interview and observation of Resident #43 on 9/10/24 at 11:50 AM, revealed facial hair on chin and lower jaw area. She stated she had a shower yesterday afternoon and she wanted her facial hair to be removed, but the staff did not do it. During an interview and observation in Resident #43's room on 9/10/24 at 12:05 PM, the resident informed the Director of Nursing (DON) that she wanted her facial hair shaved, but staff had not done this. The resident informed the DON she had a shower yesterday afternoon, but shaving was not done. The DON confirmed the resident, who required assistance with care, had facial hair present and did not receive the Activity of Daily Living (ADL) care for shaving, which was part of the grooming process, especially for a female resident. Record review of Task Record revealed Resident #43 had a bath on 9/9/24 at 8 PM. Record review of Resident #43's Admission Record revealed the facility admitted the resident on 12/18/2020. Diagnoses included Type 1 diabetes mellitus and arthritis. Record review of Resident #43's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/26/24, revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had a mild cognitive impairment. Resident #151 On 9/9/24 at 10:50 AM, an observation and interview with Resident #151 revealed fingernails were long (approximately one-half inch from nail bed) with a brown substance noted under nails. The resident stated she would love for her nails to be trimmed but no one had done it. On 9/10/24 at 4:15 PM, during an observation and interview with the DON and Resident #151 , the resident stated she wanted her nails to be trimmed. The DON confirmed the nails were long with a brown substance under each nail and nails were to be trimmed and cleaned to ensure skin was not scratched and to prevent infections and the facility failed to do this. Record review of Resident #151's Admission Record revealed the facility admitted the resident on 8/23/24. Diagnoses included Metabolic Encephalopathy, Type 2 Diabetes Mellitus, and Need for assistance with personal care. Record review of Resident #151's admission MDS with ARD of 8/30/24 revealed a BIMS score of 9 which indicated the resident was moderately impaired cognitively. Resident #59 An observation and interview on 9/9/2024 at 12:18 PM, with Resident #59 who stated, I'm not going to lie on them or for them . I have not had a bath of any type since last Tuesday; They will wash my face, but that's it. He revealed he would love to be really cleaned up. This observation revealed the resident was a double above the knee amputee and stated he needed assistance with his baths. An interview on 9/10/2024 at 10:17 AM, with Certified Nurse Assistant (CNA) #1 confirmed that she was assigned to Resident #59, and he had told her he only gets a bath when she was on duty. She stated she knew that the resident complained to Licensed Practical Nurse (LPN) #1 last week about it, but was not sure what happened. In an interview on 9/10/2024 at 12:10 PM, with LPN #1, confirmed that Resident #59 had complained to her about not receiving a bath on 8/31/24, but she did not report it to anyone, that she just discussed it with the resident. Record review of documented baths for Resident #59 confirmed that the resident did not receive a bath on 8/31/2024. This documentation revealed the resident received a bed bath on 8/29/2024 with the next bath on 9/3/2024. Record review of the Admission Record revealed the facility admitted Resident #59 on 11/14/2023 with a medical diagnosis of chronic venous insufficiency. Record review of the Quarterly MDS with an ARD of 7/24/2024 revealed, under section C, a BIMS summary score of 13, which indicated Resident #59 was cognitively intact and in Section GG that the resident needs assistance with Activities of Daily Living (ADL's). Resident #68 An observation and interview on 9/9/2024 at 10:20 AM, with Resident #68 revealed, she was sitting in her wheelchair in her room. The resident explained that both Saturday (9/7) and Sunday (9/8) she rang her call light and told the aide who came in that she was wet and needed to be changed. She revealed on both days the aide turned the call light off, said she would be back, and left the room without ever coming back. She revealed, last night, her sister called the facility and spoke with the nurse to report that the aide never came back. The resident explained that the nurse and another aide later came to change her. She revealed, I sat in that urine for an hour. On 9/10/2024 at 8:50 AM, in an interview with the DON revealed she was aware of both incidents that happened over the weekend with Resident #68. She explained that she met with the resident and her son yesterday. She revealed the aide who cared for the resident on Saturday (9/7) had been terminated. The DON revealed she spoke with the aide, and the aide stated that she changed the resident after breakfast and that every time she went back into the resident's room, the resident was asleep. The aide reported that she did not wake the resident to check her or provide incontinent care. The DON revealed that she terminated the aide because this was her second occurrence of not making rounds and leaving the residents soiled. She explained that the resident had a different aide on Sunday (9/8). The DON revealed that she met with the aide, and the aide stated that she answered the call light, cut it off, and told the resident she would be back, but never went back. She revealed the resident called her sister, who then called the facility and reported the issue. The DON revealed that during that time the aide had gone to break, and the aide stated that she had changed the resident before supper. The DON revealed the aide was written up and counseled on answering the call lights and rendering the care when needed, as this was her first offense. The DON confirmed her expectations were for the aides to make rounds on the residents every two (2) hours and as required, and render the necessary care needed. An interview with Resident #68 on 9/10/2024 at 9:25 AM, revealed the aide assigned to her on Sunday (9/8) did not toilet or change her before supper. She explained that she waited until after supper and the trays were all picked up and pushed her call light to be changed. She stated the aide came in, turned the light off and said she would be back. The resident explained that after the aide did not return, she called her sister around 7:30 PM, who called the facility. She stated, They don't come check on me every 2 hours; They say they do, but they don't. She stated, They can't be lying on me because I have my mind. An interview with the DON on 9/10/2024 at 1:21 PM, confirmed staff did not provide the necessary care for Resident #68. She revealed her expectations were for staff to answer the call lights and render the care that the resident needs in a timely manner. She explained that the aides were to make rounds every 2 hours and as needed to ensure the residents were clean and dry and to prevent skin breakdown. An interview with Certified Nurse Aide (CNA) #4 on 9/10/2024 at 3:20 PM, revealed she had been employed at the facility for eight (8) months and worked 3-11 shift. She revealed on Sunday (9/8) she was assigned to Resident #68. She revealed she had the split section which included her working the top section of A and B hall. CNA #4 revealed she was in the middle of cleaning up another resident on another hall at the time Resident #68's light went off. She explained that she had stepped out of the other resident's room to get some clean linen when she answered Resident #68's light, turned it off, and told the resident she would be back. She stated she forgot to go back. Record review of the Admission Record revealed the facility admitted Resident #68 on 8/19/2024 with a medical diagnosis of Chronic Combined Systolic and Diastolic Heart Failure. Record review of the Admission MDS with an ARD of 8/26/2024 revealed, under section C, a BIMS score of 13, which indicated Resident #68 was cognitively intact. Resident #351 On 9/9/2024 at 10:45 AM, observation of Resident #351 and interview with a family member revealed, he was sitting in a reclining wheelchair in his room. His eyes were open, and he was non-verbal. The resident was wearing a gray pair of jogger pants that were saturated through the groin area and in between the legs with urine. The family member revealed he was brought back from therapy like this, and nobody had been there since to check on him. The family member revealed the resident's bed was always wet with urine. She revealed the bed was soaked out this morning and had to be changed after they got him up. She stated, They say they are changing him every 2 hours, but they are not because I am here, and they do not enter the room. She explained that the resident was wetting out his clothes and the bed with urine through a brief. The family member revealed when he was in bed, she positioned a pillow under his stroke affected arm, and it even got soaked with urine. She reiterated, They are not changing him like they should be. She revealed she had been waiting on the resident's nurse to come back since 10:15 AM because she had some questions regarding the resident's fluid medication, but she had yet to come back. On 9/9/2024 at 10:51 AM, an interview with CNA #5 revealed she got Resident #351 up this morning, but she was unsure what time. She stated the resident had been to therapy, and she did not realize he was back. She revealed therapy did not come and let her know he was back or that he was wet. CNA #5 revealed she makes rounds every 2 hours to see if the residents need changing. She confirmed the resident's bed linen had to be changed because it was wet this morning. An interview with the DON on 9/10/2024 at 11:10 AM revealed, Resident #351 should be checked and changed every 2 hours and more if he needed it. She explained that he may be a heavy wetter and needed to be changed more frequently. The DON revealed if the resident was a heavy wetter, she could see that the resident could wet the bed. She revealed she was not aware of the family members' concerns regarding the resident's care, and stated those concerns were just brought to her attention yesterday. Record review of the Admission Record revealed the facility admitted Resident #351 on 8/23/2024 with diagnoses including cerebral infarction. Resident #352 On 9/9/2024 at 10:58 AM an observation and interview with Resident #352 revealed, he was lying in bed. There was a foul odor around the resident. The resident revealed, after he ate breakfast and took his morning medicine, it was 2 hours before someone could come to clean him up and change him. He stated, They tell me they are working with somebody and will get to me when they can. He revealed the therapy man will even come to his room to take him to therapy, and he must tell him that he cannot go right now because he needs changing. The resident stated, He (the therapy man) wouldn't want to sit like that, so he should understand. The resident stated he was still waiting to be changed today. On 9/10/2024 at 11:50 AM, interview with the Physical Therapy Assistant (PTA) revealed, Resident #352 not being changed had been an issue since he had been working with him. He revealed he had only done about 4 sessions with the resident, and each time the resident would be dirty. The PTA revealed it took 2-3 hours before the resident got changed by the staff. He stated he usually goes down to the resident's room about 8:00-9:00 in the morning to start his session, but after the resident reports being soiled, he will push the resident's call light. He stated he also goes to hunt down someone to help change the resident, but nine times out of ten he cannot find anybody. The PTA stated yesterday he pushed the call light, and nobody ever came, so he went to the nurse and told her, and she went to change the resident. An interview with the DON on 9/10/2024 at 2:52 PM, revealed she was not aware Resident #352 was not being changed in a timely manner. She stated that therapy had not reported anything to her. She revealed when an issue was brought to her attention, she would address it. The DON confirmed that the aides should be rounding on the residents every 2 hours and the residents should be changed in a timely manner. Record review of the Admission Record revealed the facility admitted Resident #352 on 9/3/2024 with diagnoses that included Osteomyelitis of vertebra, thoracic region. Record review of the Admission MDS with an ARD of 8/13/2024 revealed under section C, a BIMS score of 15, which indicated Resident #352 was cognitively intact. 44804 47874

Based on staff interviews, record reviews, and facility policy review, the facility failed to implement the baseline plan of care for Res #1 who was a high risk for elopement, and had displayed exit seeking behaviors. Res #1 was one (1) of five (5) residents reviewed. The facility failed to provide supervision as outlined in the baseline care plan for hourly visual checks to prevent an elopement for Res #1, who was diagnosed with Dementia. Res #1 was allowed to leave the facility, unnoticed and unsupervised until the local Law Enforcement found the resident 4.2 miles away from the facility. During the investigation the State Agency (SA) identified an Immediate Jeopardy (IJ). The IJ had existed on 08/02/23 when Res #1 eloped from the facility unsupervised. The SA notified the facility's Administrator of the IJ on 08/08/23 at 10:10 AM and provide the IJ Template. The elopement placed Res #1 and other residents at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or death. Based on the facility's implementation of corrective actions on 08/04/23, the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on 08/05/23, prior to the SA's entrance on 08/07/23. Findings include: The facility policy titled, Comprehensive Person-Centered Care Plans, revised dated 3/18 stated, Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. The facility policy undated and titled, Elopement Guidelines, stated, The Elopement Risk Evaluation is to be done upon admission and quarterly & as needed with exit seeking behaviors. High risk residents are to be addressed on care plan and Pocket Care Guide. At the beginning and end of each shift the charge nurse is to make visual rounds on each high-risk resident to ensure that they can be in the facility. When exit seeking activity occurs consider 1:1 supervision or 15-minute checks. Record review of the facility investigation revealed that Res #1 was allowed to exit the facility on 08/02/23 at approximately 12:45 PM. At 2:40 PM on 08/02/23 the facility Medical Director (MD) discovered that Res #1 was not in the facility when he began looking for Res #1 to complete the admission assessment. Res #1 had been newly admitted to the facility on [DATE] at approximately 3:00 PM and eloped from the facility on 08/02/23 at approximately 12:45 PM. The MD notified the facility Administrator (ADM) and the Director of Nursing (DON) and they called Dr. Wander and the facility staff began to search for Res #1. When Res #1 was not located within the building or on the immediate facility grounds, the DON, the Maintenance Director, and several other staff members, got in their vehicles and began searching the community for Res #1. 911 was notified and the local law enforcement agencies began the search for Res #1. The facility had no identifying photographs of Res #1 therefore, the description of his appearance was given for the search. At approximately 3:00 PM the local law enforcement agency called the facility and stated that they had Res #1 in their vehicle and would bring him back to the facility. Res #1 was found by the local law enforcement in another nearby community approximately 4.2 miles away from the facility. The MD assessed Res #1 and sent him out to the local emergency room (ER) for further evaluation. Res #1's family came and picked up Res #1 from the ER to live with them and the family discharged Res #1 from the facility. Record review of the Baseline Care Plan, dated 08/01/23, revealed .Depression, anxiety, wandering, confusion Wander guard with visual checks, elopement risk. Check wander guard Q (every) shift, visual checks Q hour . Record review of Risk Elopement Evaluation, dated 08/01/23 stated, Past history of leaving facility/previous residence. Record review of the eFlowsheet, dated 08/23, indicated that hourly visual checks were documented by the licensed nursing staff and were checked and initialed for the hours of 9 AM, 10 AM, 11 AM, 12 PM, and 1 PM for the date of 08/02/23 and indicated an N for the 2 PM and 3 PM hourly visual checks, indicating Not Administered. Interview on 08/07/23 at 11:00 AM, with the Director of Nursing (DON) stated that Res #1 had a baseline care plan and that he had been placed on hourly checks along with the placement of a wander guard bracelet on 08/01/23 on admission because the resident was a high elopement risk. The DON confirmed that based on the resident's history of prior elopement from his residence that they probably should have watched him more frequently than hourly. Interview on 08/08/23 at 2:15 PM, with RN#2 revealed that she had assessed Res #1 upon his admission on 08/01/23 and that she placed the wander guard bracelet on Res #1 and placed him on hourly observation checks. RN#2 stated that prior to Res #1's admission to the facility she had read his history and physical and admitting information and she knew that he was at risk for elopement because his paperwork had documented that he had left his sister's house where he was living and had walked to his former home that he had once owned with his wife and broke in to the house and refused to leave when the new owners got home. Res #1 was confused at that time and thought that his dead wife and he were still living in their former home that had been sold to new owners. RN#2 stated that Res #1 had a history of confusion and elopement and that due to Res #1's history he was placed on close observation checks hourly and a wander guard was placed on his right leg. RN #2 stated that she and LPN#1 were together assessing Res #1 on 08/01/23 and that a baseline care plan for Res #1 was devised on 08/01/23 by her and LPN#1 and placed on Res #1's chart. Record review of the Face Sheet of Res #1 revealed that he was admitted to the facility on [DATE] at 1:36 PM and was discharged on [DATE] at 4:00 PM. Res #1 was admitted to the facility with diagnoses of Unspecified Dementia with Psychotic Disturbance; Generalized Anxiety; and Insomnia, among other diagnoses. Record review of Res #1 contained a Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 08/02/23 provided a Brief Interview for Mental Status (BIMS) score of 6 which indicated that he had severe cognitive impairment. The facility implemented the following Corrective Action Plan prior to the State Agency's (SA) entrance on 08/07/23: On August 2, 2023, at 2:20 PM the facility was notified by Medical Director that Resident #1 was not in his room for physical assessment. The nursing staff discovered the resident was not in last seen area or therapy department. At approximately 2:25 PM. a Dr. Wander was initiated by Business Office Manager in the facility and surrounding area. At 2:40 PM Business Office Assistant contacted Tupelo Police Department regarding missing elderly resident from the facility with description. At 3:15 PM Director of Nursing, called and notified facility that [NAME] County Sheriff had located Resident #1 approximated 4.2 miles from the facility toward (city proper name). At 3:18 PM Resident #1 was returned to the facility by [NAME] County Sheriff and escorted by Director of Nursing. An announcement of Dr. Wander all clear was initiated by Social Service Director. It was determined that Resident # 1 was last seen by facility staff at 12:45 PM and returned to facility at 3:18 PM. On August 8, 2023, at 10:00 AM the facility was verbally notified that IJ's were identified for Federal tag 656 Care Plans and Federal tag 689 Failure to Prevent Accidents and Hazards and the IJ templates were given to the facility. Immediate Actions: On 8/2/2023 at 3:03 PM Executive Director notified Resident # 1 Responsible Representative of possible elopement from facility. On 8/2/23 at 3:18 PM the Mississippi State Department of Health was notified of missing resident by Executive Director. On 8/2/2023 facility completed a 100% head count of all other Residents to ensure they were accounted for. On 8/2/2023 at 3:18 PM upon return to facility Resident # 1 was assessed by physician. On 8/2/2023 at 4:15 PM Resident #1 was sent to emergency room for further evaluation. On 8/2/2023 at 3:30 PM Executive Director and Director of Nursing begin official investigation of Resident #1 Elopement. On 8/2/2023 at 3:30 PM all facility exit doors were checked for proper functioning by Maintenance Director. On 8/2/2023 at 3:30 PM an educational in-service was initiated by Staff Development Coordinator to include all staff on Elopement Protocol, Abuse and Neglect, and Residents exhibiting exit seeking behaviors to be completed by August 7, 2023 with no staff allowed to work until in-service completed. On 8/2/2023 at 3:30 PM Assistant Director of Nursing checked all residents at risk for elopement wander-guard bracelet for placement and function. On 8/2/23 at 4:10 PM Emergency AD HOC QA (Quality Assurance) committee and Medical Director (via phone) met and completed a root cause analysis related to the elopement, and implemented new interventions as a result of the findings. New Interventions: 1) Facility initiated new protocol to immediately place any resident actively exit seeking on 1 on 1 staff monitoring of resident until calm and no longer attempting to exit building, then to immediately notify the Executive Director and or Director of Nursing. All licensed nurses educated on this new protocol by 8/4/23. Any nurse who has not completed in-service education by 8/4/23 will be required to complete education prior to starting a shift 2) Signage was posted on the front door cautioning visitors not to allow anyone to exit with them that they do not know. 3) Photographs of elopement risk residents posted at the receptionist desk for quick reference to identify anyone at risk. 4) Also, the topic of new elopement risk residents was added to the daily stand-up meeting (department head meeting) format to ensure communication of risk to key personnel. On 8/2/2023 After investigating and interviewing All facility employees, the elopement for Resident #1 from facility was substantiated. On 8/2/23 at 4:30 PM all residents with risk of elopements were reevaluated, the pocket care guide and care plans were updated by Director of Nursing, Social Service and Unit Managers to ensure all residents for risk for elopement had appropriate interventions in place. This was completed on 8/2/23. On 8/3/23 at 6:32 AM Executive Director followed up with Resident #1 Responsible Representative regarding resident's condition. Executive Director was informed that resident was home with Representative. On 8/3/2023 at 8:00 AM Business Office Manager officially discharged resident from facility effective 8/2/2023 On 8/3/2023 at 10:00 AM the facility security cameras were serviced for malfunctioning by an outside contractor. On 8/3/2023 at 11:00 AM the Maintenance Director installed new security camera system in the facility. On 8/3/23, Social Service initiated an Elopement Alarm Drill with the 3pm-11pm shift employees. On 8/4/2023 Social Service initiated an Elopement Alarm Drill with the 7a-3p and 11p-7a shift employees. Mandatory Elopement Alarm Drills will be conducted by the Social Service Director weekly times one month on each shift and thereafter, monthly on each shift. On 8/3/23 a picture of all residents at risk for elopement was placed on a secure wall at the Receptionist area for immediate viewing. The facility removed the IJ on August 5, 2023, at 8:00 AM and alleges compliance. VALIDATION OF THE CORRECTIVE ACTION PLAN: The State Agency (SA) validated the facility's Past Non-Compliance (PNC) Removal Plan /Corrective Action on 08/09/23: The SA validated through interviews and record review that on 8/2/2023 at 3:03 PM Executive Director notified Resident # 1 Responsible Representative of possible elopement from facility. The SA validated through interview and record reviews that on 8/2/23 at 3:18 PM the Mississippi State Department of health was notified of missing resident by Executive Director. The SA Validated through interviews and record reviews that on 8/2/2023 facility completed a 100% head count of all other Residents to ensure they were accounted for. The SA validated through interviews and record reviews that on 8/2/2023 at 3:18 PM upon return to facility Resident # 1 was assessed by physician. SA validated through interviews and record reviews that on 8/2/2023 at 4:15 PM Resident #1 was sent to emergency room for further evaluation. SA validated that on 8/2/2023 at 3:30 PM Executive Director and Director of Nursing begin official investigation of Resident #1 Elopement. SA validated that through interviews and record review that on 8/2/2023 at 3:30 PM all facility exit doors were checked for proper functioning by Maintenance Director. The SA validated through interviews and record reviews that on 8/2/2023 at 3:30 PM an educational in-service was initiated by Staff Development Coordinator to include all staff on Elopement Protocol, Abuse and Neglect, and Residents exhibiting exit seeking behaviors to be completed by August 7, 2023 with no staff allowed to work until in-service completed. The SA validated through interviews and record reviews that on 8/2/2023 at 3:30 PM Assistant. Director of Nursing checked all residents at risk for elopement wander-guard bracelet for placement and function. The SA validated through record review and interviews that on 8/2/23 at 4:10 PM Emergency AD HOC QA committee and Medical Director (via phone) met and completed a root cause analysis related to the elopement and implemented new interventions as a result of the findings. New Interventions: 1) Facility initiated new protocol to immediately place any resident actively exit seeking on 1 on 1 staff monitoring of resident until calm and no longer attempting to exit building, then to immediately notify the Executive Director and or Director of Nursing. All licensed nurses educated on this new protocol by 8/4/23. Any nurse who has not completed in-service education by 8/4/23 will be required to complete education prior to starting a shift. 2) Signage was posted on the front door cautioning visitors not to allow anyone to exit with them that they do not know. 3) Photographs of elopement risk residents posted at the receptionist desk for quick reference to identify anyone at risk. 4) Also, the topic of new elopement risk residents was added to the daily stand-up meeting (department head meeting) format to ensure communication of risk to key personnel. All the above new interventions were validated by the (SA) through interviews, observations, and record reviews from 08/07/23-08/09/23 that the facility had implemented and educated the staff on the new Interventions. The SA validated through record reviews and interviews that on 8/2/2023 After investigating and interviewing All facility employees, the elopement for Resident #1 from facility was substantiated. The SA validated through interview and record review that on 8/2/23 at 4:30 PM all residents with risk of elopements were reevaluated, the pocket care guide and care plans were updated by Director of Nursing, Social Service and Unit Managers to ensure all residents for risk for elopement had appropriate interventions in place. This was completed on 8/2/23. The SA validated through record review and interviews that on 8/3/23 at 6:32 AM Executive Director followed up with Resident #1 Responsible Representative regarding resident's condition. Executive Director was informed that resident was home with Representative. SA validated through interviews and record reviews that on 8/3/2023 at 8:00 AM Business Office Manager officially discharged resident from facility effective 8/2/2023. SA validated through observations, interviews, and record reviews that on 8/3/2023 at 10:00 AM the facility security cameras were serviced for malfunctioning by an outside contractor. SA validated through observations, record reviews, and interviews that on 8/3/2023 at 11:00 AM the Maintenance Director installed new security camera system in the facility. SA validated through record review and interview that on 8/3/23, Social Service initiated an Elopement Alarm Drill with the 3pm-11pm shift employees. On 8/4/2023 Social Service initiated an Elopement Alarm Drill with the 7a-3p and 11p-7a shift employees. The SA validated through interview with the facility Social Worker that Mandatory Elopement Alarm Drills will be conducted by the Social Service Director weekly times one month on each shift and thereafter, monthly on each shift. The SA validated through observations, interviews, and record reviews that on 8/3/23 a picture of all residents at risk for elopement was placed on a secure wall at the Receptionist area for immediate viewing. The SA validated through policy reviews, observations, and record reviews that the facility removed the IJ on August 5, 2023, at 8:00 AM and alleges compliance.

Based on staff interviews, record review and facility policy review the facility failed to provide supervision to prevent a resident from leaving the facility unsupervised for one (1) of five (5) residents reviewed, Resident #1. The facility failed to provide supervision to prevent the elopement of Res #1 who was an elopement risk and had an order for visual checks every hour. Resident #1 was diagnosed with Dementia with Psychotic Disturbance. He was last seen by staff at approximately 12:20 PM on 08/02/23. He was allowed to leave the facility, unnoticed and unsupervised. Res #1 walked approximately 4.2 miles away from the facility in 94 degree weather along a busy highway before he was found by the local law enforcement at approximately 3:00 PM. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that existed on 08/02/23 when Res #1 eloped from the facility unsupervised. The SA notified the facility's Administrator (ADM) on 08/08/23 at 10:15 AM and provided the IJ template. The facility's failure to provide adequate staff supervision for Resident #1, with a history of elopement risk, placed this resident and other residents who exhibit wandering behavior in a situation that was likely to cause serious harm, injury, impairment or death. Based on the facility's implementation of corrective actions on 08/04/23, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 08/05/23, prior to the SA's entrance on 08/07/23. Findings include: Record review of the facility policy titled Accident & Incident Documentation & Investigation Resident Incident with a history dated 7/18 revealed . Policy .An incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident . Record review of the facility policy titled Missing Resident / Elopement reviewed 1/15 revealed, . Procedure: It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as practical . Record review of the investigation revealed Res #1 was allowed to exit the facility on 08/02/23 at approximately 12:45 PM. At 2:40 PM on 08/02/23 the facility Medical Director (MD) discovered that Res #1 was not in the facility when he began looking for Res #1 to complete the admission assessment. Res #1 had been newly admitted to the facility on [DATE] at approximately 1:36 PM and eloped from the facility on 08/02/23 at approximately 12:45 PM. The MD notified the facility Administrator (ADM) and the Director of Nursing (DON) and they called Dr. Wander and the facility staff began to search for Res #1. When Res #1 was not located within the building or on the immediate facility grounds, the DON, the Maintenance Director, and several other staff members, got in their vehicles and began searching the community for Res #1. 911 was notified and the local law enforcement agencies began the search for Res #1. The facility had no identifying photographs of Res #1 therefore, the description of his appearance was given for the search. At approximately 3:00 PM the local law enforcement agency called the facility and stated that they had Res #1 in their vehicle and would bring him back to the facility. Res #1 was found by the local law enforcement in another nearby community approximately 4.2 miles away from the facility. The MD assessed Res #1 and sent him out to the local emergency room (ER) for further evaluation. Res #1's family came and picked up Res #1 from the ER to live with them and the family discharged Res #1 from the facility. Record review of the Admission/Readmission Evaluation' dated 8/1/23 revealed, .Elopement Evaluation: 1 Intermittent confusion .Exhibited wandering behaviors/Dementia .2. History of wandering . Yes If YES, when? Prior to admission .3. Mobility .Ambulates independently .If yes, resident is at risk---Place appropriate intervention of Care Plan. Location Monitoring, (checked), Notify staff (checked), Personal Alarm (checked). Record review of the Risk Elopement Evaluation, dated 08/01/23 revealed, .Past history of leaving facility/previous residence . Record review of the eFlowsheet, dated 08/23, indicated that hourly visual checks were documented by the licensed nursing staff and were checked and initialed for the hours of 9 AM, 10 AM, 11 AM, 12 PM, and 1 PM for the date of 08/02/23 and indicated an N for the 2 PM and 3 PM hourly visual checks, indicating Not Administered. Record review of the Departmental Notes, dated 08/02/23 4:31 PM Addendum. Note based on conversation with res at approx.(approximately) 1230 pm. Resident stood at nurses' station and spoke with nurse about why he was here in the facility. Resident was showing some confusion. Departmental Notes, dated 08/02/23 4:36 PM Approx 220 pm this nurse and (Proper Name of Physician) went to resident's room. Resident was not in room, after walking through the facility for approx. 5 min (minutes) and not seeing resident a code Dr Wander was initiated . Interview on 08/07/23 at 8:00 AM, with the Ombudsman revealed that on 08/02/23 at approximately 2:40 PM she was in the conference room of the nursing home talking to the Director of Nursing (DON) and the facility Administrator (ADM) when the facility physician and Medical Director, (MD) came to the conference room and told the ADM that (Res #1) was missing from the facility. The MD, the DON, the ADM, along with many other staff members, and the Ombudsman, all searched the facility and the grounds for Res #1 and he was not found, so they all got in their separate vehicles and began searching for Res #1 in the community. The police department was notified of the missing resident. The facility had not made any pictures of Res #1 and had no photos to provide the law enforcement for their search. The staff determined that the last time they saw resident (Res #1) was at 12:20 PM wearing a camo shirt and a cap and that he was a white male approximately [AGE] years old that looked younger than his stated age. None of the facility staff or Ombudsman were able to locate Res #1. The Police department called the facility at approximately 3:00 PM and reported that they had found the resident walking along the side of a busy highway in a nearby community which was approximately 4.2 miles from the facility. The DON went to meet the police and found Res #1 sitting in the back seat of the police car. The resident was brought back to the facility at approximately 3:20 PM on 08/02/23. The facility physician assessed Res #1 at the facility and then sent Res #1 out to the local hospital (ER) for a second assessment. Record review of the weather in (proper name of city) on 08/02/23 documented that the temperature was 94 degrees Fahrenheit. In an interview on 08/07/23 at 11:00 AM, the ADM stated that Res #1 had on a wander guard ankle monitoring bracelet, but Res #1 had taken the wander guard monitoring bracelet off prior to leaving the facility and the ankle bracelet was never found in the facility. ADM stated that the facility MD had discovered that Res #1 was missing from the facility when he came to evaluate Res #1 on 08/02/23 after the lunch hour. The MD came to the conference room and told ADM that Res #1 was missing. The search for Res #1 began at approximately 2:40 PM on 08/02/23. The facility called 911 and reported that Res #1 was wearing blue jeans, a short sleeve camo print shirt and hat. The ADM confirmed that the facility had no identifying photographs of Res #1 because he was admitted to the facility on [DATE]. The ADM stated that the facility had put in place and had completed an action plan immediately after Res #1 eloped. Interview on 08/07/23 at 11:00 AM, with the Director of Nursing (DON) confirmed that the last time anyone saw the resident was around 12:20 PM when he was observed at the nurse's desk voicing his concerns as to why he was at the facility. The staff that she interviewed confirmed that they last saw him walking to the front lobby to sit down in a chair. DON confirmed that after they found the resident and he was sent to the ER that the QA (Quality Assurance) committee met and discussed supervision and elopement of all residents. The DON confirmed that based off the resident's history of elopement from his previous residence and his exit seeking behaviors that the resident probably should have been monitored more frequently than every hour. The DON stated that throughout the investigation the facility was never sure how the resident got out of the facility unnoticed unless he went out the door with a visitor. The DON confirmed that they were never really sure and that when the resident was returned that he did not have the wander guard on his leg, and he stated that he had removed it. The DON stated that they never found the wander guard in the facility. Interview on 08/07/23 at 2:00 PM, Licensed Practical Nurse (LPN#1) stated that she was the nurse on 08/02/23 for the unit where Res #1 resided. She stated that she had assisted with the admission of Res #1 on 08/01/23 and that he was well dressed and looked much younger than his stated age of 73. LPN#1 stated that she and another nurse, Registered Nurse (RN#2) obtained a wander guard bracelet from the Social Worker (SW) and tested it to make sure it was functioning properly, and they placed the wander guard on Res #1 on 08/01/23 at approximately 3:00 PM. LPN #1 confirmed that they did that because the resident had eloped from his residence and was found in a house that was previously his own but had been sold and he was confused and had some agitation and was not pleased about being admitted to the nursing home. She stated that Res #1 was at the nursing station on 08/02/23 at approximately 12:20 PM asking why he was admitted here and that he needed to go to his house and check things. Res #1 didn't appear agitated, and he was easily redirected and left the nursing station. LPN#1 stated that she talked to Res #1 for about 10 minutes, and he was confused and was not oriented to the situation. LPN#1 stated that she was with the MD on 08/02/23 when he discovered that Res #1 was missing from the building. Interview on 08/08/23 at 9:30 AM, with Medical Director (MD) revealed that he had talked to Res #1 on 08/01/23 via Face Time along with his Nurse Practitioner. MD stated that he was able to see Res #1 on Face Time and that was how he knew who to look for on 08/02/23 when he was unable to find Res #1 in the facility. MD stated that he went to the facility on [DATE] after the noon lunch hour to assess Res #1 as a new admission to the facility and upon searching for Res #1 and asking staff where he was they discovered he was gone from the facility, and they began the search and called 911. The MD stated that Res #1 was not injured when he was returned to the facility from his elopement but was confused and refusing the nursing home placement when he assessed him. The MD sent Res #1 out to the local ER for further assessment and for a psychological evaluation. Res #1 did not return to the facility from the ER. Interview on 08/08/23 at 2:15 PM, with Registered Nurse (RN#2) revealed that she had assessed Res #1 upon his admission to the nursing home on 08/01/23. She stated that she placed the wander guard bracelet on Res #1 and she placed him on hourly observation checks because she had read his history and physical and she knew that he was at risk for elopement because his paperwork had documented that he had left his sister's house where he was living and had walked to his former home. RN#2 stated that due to Res #1's history he was placed on hourly checks that was documented by the nurses and a wander guard was placed on his right leg. Interview on 08/09/23 at 9:20 AM, with the Maintenance Director revealed that on a regular basis and each week and on 08/02/23 he checked the doors of the facility on all halls, and all exits for functioning, locking, and proper movement. He found no issues with the doors, and he checked the functioning of the wander guard system and found no issues with functioning, and it was all in working order. Interview on 08/09/23 at 10:00 AM, with Certified Nursing Assistant (CNA#3) revealed that on 08/02/23 she was assigned as the CNA for Res #1 and at approximately 12:20 PM on 08/02/23 she last saw him at the nursing station talking to the nurse and asking why he was admitted to the nursing home. CNA #3 stated that at approximately 2:40 PM on 08/02/23 the MD stopped her in the hallway and asked if she had seen Res #1. CNA #3 began looking for Res #1 and was not able to find him. CNA #3 confirmed that she was not informed to make sure she had a visual check on the resident every hour, nor was she instructed to document any visual checks of the resident. Record review of the Face Sheet revealed that Res #1 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia with Psychotic Disturbance; Generalized Anxiety and Insomnia, among other diagnoses. Record review of Res #1 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/02/23 provided a Brief Interview for Mental Status (BIMS) score of six (6) which indicated that he had severe cognitive impairment. The facility implemented the following Corrective Action Plan prior to the State Agency's (SA) entrance on 08/07/23: On August 2, 2023, at 2:40 PM the facility was notified by Medical Director that Resident #1 was not in his room for physical assessment, a Dr. Wander was initiated by Business Office Manager in the facility and surrounding area. At 2:40 PM Business Office Assistant contacted Police Department regarding missing elderly resident from the facility with description. At 3:15 PM Director of Nursing, called and notified facility that County Sheriff had located Resident #1 approximated 4.2 miles from the facility. At 3:18 PM Resident #1 was returned to the facility by County Sheriff and escorted by Director of Nursing. An announcement of Dr. Wander all clear was initiated by Social Service Director. It was determined that Resident # 1 was last seen by facility staff at 12:45 PM and returned to facility at 3:18 PM. The facility was notified that IJ's were identified for Federal tag 656 Care Plans and Federal tag 689 Failure to Prevent Accidents and Hazards on 08/08/23 at 10:00 AM. Immediate Actions: On 8/2/2023 at 3:03 PM Executive Director notified Resident # 1 Responsible Representative of possible elopement from facility. On 8/2/23 at 3:18 PM the Mississippi State Department of Health was notified of missing resident by the Executive Director. On 8/2/2023 facility completed a 100% head count of all other Residents to ensure they were accounted for. On 8/2/2023 at 3:18 PM upon return to facility Resident # 1 was assessed by physician. On 8/2/2023 at 3:30 PM all facility exit doors were checked for proper functioning by Maintenance Director. On 8/2/2023 at 3:30 PM Executive Director and Director of Nursing begin official investigation of Resident #1 Elopement. On 8/2/2023 at 3:30 PM an educational in-service was initiated by Staff Development Coordinator to include all staff on Elopement Protocol, Abuse and Neglect, and Residents exhibiting exit seeking behaviors to be completed by August 7, 2023, with no staff allowed to work until in-service completed. On 8/2/2023 at 3:30 PM Assistant Director of Nursing checked all residents at risk for elopement wander-guard bracelet for placement and function. On 8/2/23 at 4:10 PM Emergency AD HOC QA committee and Medical Director (via phone) met and completed a root cause analysis related to the elopement and implemented new interventions as a result of the findings. On 8/2/2023 at 4:15 PM Resident #1 was sent to emergency room for further evaluation. New Interventions: 1) Facility initiated new protocol to immediately place any resident actively exit seeking on 1 on 1 staff monitoring of resident until calm and no longer attempting to exit building, then to immediately notify the Executive Director and or Director of Nursing. All licensed nurses educated on this new protocol by 8/4/23. Any nurse who has not completed in-service education by 8/4/23 will be required to complete education prior to starting a shift. 2) Signage was posted on the front door cautioning visitors not to allow anyone to exit with them that they do not know. 3) Photographs of elopement risk residents posted at the receptionist desk for quick reference to identify anyone at risk. 4) Also, the topic of new elopement risk residents was added to the daily stand-up meeting (department head meeting) format to ensure communication of risk to key personnel. On 8/2/2023 After investigating and interviewing All facility employees, the elopement for Resident #1 from facility was substantiated. On 8/2/23 at 4:30 PM all residents with risk of elopements were reevaluated, the pocket care guide and care plans were updated by Director of Nursing, Social Service and Unit Managers to ensure all residents for risk for elopement had appropriate interventions in place. This was completed on 8/2/23. On 8/3/23 at 6:32 AM Executive Director followed up with Resident #1 Responsible Representative regarding resident's condition. Executive Director was informed that resident was home with Representative. On 8/3/2023 at 8:00 AM Business Office Manager officially discharged resident from facility effective 8/2/2023 On 8/3/2023 at 10:00 AM the facility security cameras were serviced for malfunctioning by an outside contractor. On 8/3/2023 at 11:00 AM the Maintenance Director installed new security camera system in the facility. On 8/3/23, Social Service initiated an Elopement Alarm Drill with the 3pm-11pm shift employees. On 8/4/2023 Social Service initiated an Elopement Alarm Drill with the 7a-3p and 11p-7a shift employees. Mandatory Elopement Alarm Drills will be conducted by the Social Service Director weekly times one month on each shift and thereafter, monthly on each shift. On 8/3/23 a picture of all residents at risk for elopement was placed on a secure wall at the Receptionist area for immediate viewing. The facility removed the IJ on August 5, 2023, at 8:00 AM and alleges compliance. VALIDATION: The State Agency (SA) validated the facility's Past Non-Compliance (PNC) Removal Plan /Corrective Action on 08/09/23: The SA validated through interviews and record review that on 8/2/2023 at 3:03 PM Executive Director notified Resident # 1 Responsible Representative of possible elopement from facility. The SA validated through interview and record reviews that on 8/2/23 at 3:18 PM the Mississippi State Department of health was notified of missing resident by Executive Director. The SA Validated through interviews and record reviews that on 8/2/2023 facility completed a 100% head count of all other Residents to ensure they were accounted for. The SA validated through interviews and record reviews that on 8/2/2023 at 3:18 PM upon return to facility Resident # 1 was assessed by physician. SA validated through interviews and record reviews that on 8/2/2023 at 4:15 PM Resident #1 was sent to emergency room for further evaluation. SA validated that on 8/2/2023 at 3:30 PM Executive Director and Director of Nursing begin official investigation of Resident #1 Elopement. SA validated that through interviews and record review that on 8/2/2023 at 3:30 PM all facility exit doors were checked for proper functioning by Maintenance Director. The SA validated through interviews and record reviews that on 8/2/2023 at 3:30 PM an educational in-service was initiated by Staff Development Coordinator to include all staff on Elopement Protocol, Abuse and Neglect, and Residents exhibiting exit seeking behaviors to be completed by August 7, 2023, with no staff allowed to work until in-service completed. The SA validated through interviews and record reviews that on 8/2/2023 at 3:30 PM Asst. Director of Nursing checked all residents at risk for elopement wander-guard bracelet for placement and function. The SA validated through record review and interviews that on 8/2/23 at 4:10 PM Emergency AD HOC QA committee and Medical Director (via phone) met and completed a root cause analysis related to the elopement and implemented new interventions as a result of the findings. New Interventions: 1) Facility initiated new protocol to immediately place any resident actively exit seeking on 1 on 1 staff monitoring of resident until calm and no longer attempting to exit building, then to immediately notify the Executive Director and or Director of Nursing. All licensed nurses educated on this new protocol by 8/4/23. Any nurse who has not completed in-service education by 8/4/23 will be required to complete education prior to starting a shift. 2) Signage was posted on the front door cautioning visitors not to allow anyone to exit with them that they do not know. 3) Photographs of elopement risk residents posted at the receptionist desk for quick reference to identify anyone at risk. 4) Also, the topic of new elopement risk residents was added to the daily stand-up meeting (department head meeting) format to ensure communication of risk to key personnel. All the above new interventions were validated by the (SA) through interviews, observations, and record reviews from 08/07/23-08/09/23 that the facility had implemented and educated the staff on the new Interventions. The SA validated through record reviews and interviews that on 8/2/2023 after investigating and interviewing all facility employees, the elopement for Resident #1 from facility was substantiated. The SA validated through interview and record review that on 8/2/23 at 4:30 PM all residents with risk of elopements were reevaluated, the pocket care guide and care plans were updated by Director of Nursing, Social Service and Unit Managers to ensure all residents for risk for elopement had appropriate interventions in place. This was completed on 8/2/23. The SA validated through record review and interviews that on 8/3/23 at 6:32 AM Executive Director followed up with Resident #1 Responsible Representative regarding resident's condition. Executive Director was informed that resident was home with Representative. SA validated through interviews and record reviews that on 8/3/2023 at 8:00 AM Business Office Manager officially discharged resident from facility effective 8/2/2023. SA validated through observations, interviews, and record reviews that on 8/3/2023 at 10:00 AM the facility security cameras were serviced for malfunctioning by an outside contractor. SA validated through observations, record reviews, and interviews that on 8/3/2023 at 11:00 AM the Maintenance Director installed new security camera system in the facility. SA validated through record review and interview that on 8/3/23, Social Service initiated an Elopement Alarm Drill with the 3pm-11pm shift employees. The SA validated through interview with the Social Worker that on 8/4/2023 Social Service initiated an Elopement Alarm Drill with the 7a-3p and 11p-7a shift employees. The SA validated through interview with the facility Social Worker that Mandatory Elopement Alarm Drills will be conducted by the Social Service Director weekly times one month on each shift and thereafter, monthly on each shift. The SA validated through observations, interviews, and record reviews that on 8/3/23 a picture of all residents at risk for elopement was placed on a secure wall at the Receptionist area for immediate viewing. The SA validated through policy reviews, observations, and record reviews that the facility removed the IJ on August 5, 2023, at 8:00 AM and alleges compliance.

Based on staff interview, record review, and facility policy review, the facility failed to prevent a resident from leaving the facility unsupervised when facility staff neglected to complete one-hour visual checks as ordered by the physician for one (1) of five (5) residents reviewed, Resident #1. The facility neglected to provide supervision to prevent an elopement for Resident #1, who was a wandering risk and had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident left the facility through a window unnoticed and unsupervised until the resident was located in a community approximately 2.6 miles away from the facility. The resident was last seen in the facility at 12:04 AM on 6/10/2022. He was not discovered to be missing until 7:15 AM on 6/10/2022 and was later located by facility staff at 8:25 AM on 6/10/2022. The facility's failure to provide supervision to a resident who was a wandering risk and with physician orders for hourly visual checks placed this resident and other residents with wandering behaviors in a situation that has caused or is likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 6/10/2022 when Resident #1 left the facility through a window unnoticed and unsupervised until the resident was located in the community approximately 2.6 miles away from the facility. The facility Administrator was notified of the IJ on 6/22/2022 at 2:35 PM. The facility provided an acceptable Removal Plan on 6/23/22, in which the facility alleged all corrective actions were completed to remove the IJ on 6/22/2022, and the IJ removed on 6/23/2022. The State Agency (SA) validated the Removal Plan on 6/24/2022, and determined the IJ was removed on 6/23/2022, prior to exit. The scope and severity for F 600 was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility Policy titled Abuse Prevention dated 5/22 revealed, Policy: The facility is committed to protecting the resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing care to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors ,or any other individual .f) Neglect: A failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain .PROTECTION: .3. It is the responsibility of all staff to provide a safe environment for the residents . Record review of the facility policy titled Missing Resident/ Elopements dated May/22 revealed Policy: The unit charge nurse is responsible for knowing the location of their residents. Record review of the facility investigation Supervisor Investigation Summary Form revealed . Date of Event: 6-10-22, Time of Event: 7:52 AM, How and When was event discovered: On 6-10-22, staff went to resident's room to get him for breakfast and noticed that he was not in the room. Briefly describe event: On 6/10/2022 at approximately 7: 15 AM, staff went into the resident's room to get him for breakfast. Resident was noted to not be in his room. Staff then began to look about the facility for the resident and still could not find the resident. Staff then began to look outside of the facility for the resident. Social Service was notified. Dr. Wander was called, and all staff immediately begin looking for the resident. Executive Director was notified. Director of Nursing was notified. At approximately 8:00 AM, staff noticed that the resident's window in (Resident #1's room) was open and that the screen was pushed out. 911 was notified. Staff continued searching for resident outside of the building and began searching in the community. A staff member found the resident approximately 2.6 miles from facility at Veterans Square at 8:25 AM. Resident refused to get in the car with the staff member. Director of Nursing arrived and spoke with resident. The resident was in agreement to go with the Director of Nursing when the police arrived on the scene. The police officer then spoke to the resident and resident agreed to ride with the police officer. Resident keep saying that he needed to get to Alabama. He was outside approximately 2 to 3 hours, according to staff statements. It was approximately 71 degrees he was wearing blue jeans, dark colored pull over shirt with a vest on, tennis shoes and carrying a garbage bag with his belongings. He suffered no injuries .II. Investigation: (Formal Name of Resident #1) resident of Tupelo Nursing and Rehabilitation admitted on [DATE]. (Formal Name of Resident #1) had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident has not had exit seeking behavior since admission. He does state that he wants to leave go home to Alabama when he is in an anxiety state. (Formal Name of Resident #1) is alert can state date and time, person and place, current events. But he is paranoid and speaks about wanting to leave since admission to facility. He feels his family stole from him and becomes agitated at times with staff and other residents thinking someone will harm him, he is redirected easily. (Formal Name of Resident #1) was able to sign himself into facility and can make decisions. He sleeps fully dressed with shoes on. Gets up frequently at night, has history of pacing and wandering halls, sits in lobby frequently, but has never actually attempted to exit. On 6/10/22 he did state he was going to Alabama and his nurse was able to redirect him and he laid down in his bed as usual. (Formal Name of Certified Nursing Assistant (CNA) #4) states she was in the room between 5:00 am and 6:30 am to assist with the other 2 roommates, and he was not in his room, nor did she notice anything at window, employee states she did not go over to the window. (Formal Name of CNA#4) did not feel this was an unusual occurrence due to resident gets up and down frequently every night. Neither staff member felt there was anything unusual with this resident's behavior. (Formal Name of Resident #1) was taken to hospital after he was found at Veterans Square for examination. He was not injured but was sent to (Formal Name of Hospital) for evaluation and possible treatment .After a thorough investigation, Tupelo Nursing and Rehabilitation was able to substantiate that the resident did exit the premises by leaving out of his window Record review of the Physician Orders for Resident #1 revealed that on 12/15/2020 an order was written for visual checks every hour. The same day an order was written to check Wander Guard placement and function every shift. An interview with Licensed Practical Nurse (LPN) #1 on 6/20/2022 at 1:45 PM, revealed she worked the 11 PM to 7 AM shift on 6/9/2022 which ended on 6/10/2022. LPN #1 revealed that she last laid eyes on Resident #1 around midnight when he walked up to the desk fully dressed, with a hat on wanting to show her something in his room. She went to Resident #1's room where he showed her some pictures that he wanted her to keep for him as he was going to Alabama. She revealed that she talked to him, and he agreed to lay down and go to sleep. She left the room while he was laying on the bed. She revealed that she failed to go back and do follow up checks on Resident #1. LPN #1 revealed that Resident #1 had never tried to leave and that he did have a wander-guard on, he did have orders to be seen every one (1) hour and that she should have laid eyes on him again. She revealed she failed to complete the hourly checks on him. LPN #1 revealed that she had received a reprimand for her inaction and was allowed to continue to work her scheduled shifts. On 6/22/2022 at 11:30 AM an interview with the Administrator (ADM)/Executive Director revealed that on 6/10/2022 when they first knew of the elopement of Resident #1, she was unaware that the nurse had not seen him since midnight and that at first LPN #1 reported to her that she had seen him between 5 AM and 6 AM but on 6/14/2022 the nurse phoned the ADM admitting that she had not actually laid eyes on Resident #1 since around midnight. The ADM then scheduled a time the morning of 6/15/2022 to meet with LPN #1 for counseling conference and she was reprimanded. The ADM confirmed that LPN #1 was continuing to work her scheduled shifts and that the ADM had not reported LPN #1 to the Board of Nursing at this time. Record review of the facility electronic record titled Face Sheet for Resident #1 revealed that the resident was admitted to the facility on [DATE]. Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the elopement Care Plan for Resident #1 revealed, Problem Onset: 12/16/2020 Problem/Need: Risk for elopement .Approaches: Check placement and function of wander guard every shift . Visual Checks every hour . Record review of Resident #1's Section C of the Minimum Data Set (MDS) revealed that on 5/23/2022 the Brief Interview for Mental Status (BIMS) score was 99 due to the resident was unable to complete the interview. Record review of facility electronic record titled Departmental Notes revealed that on 6/10/2022 at 12:04 AM, a nurse's note was written by LPN #1 that revealed . Resident awake et (and) alert stated, I'm Going to Alabama for three days, Redirected per this nurse with success. Resident lying in bed resting at this time. Skin warm and dry. Resp. even/unlabored without SOB (shortness of breath) noted. No adverse reactions noted. 0 (no) acute distress noted, call light within reach Electronic record review titled E Flowsheet for Resident #1 revealed that it is documented by LPN #1 that his visual checks were completed on every hour from 12:00 AM to 6 AM on 6/10/2022. Record review of LPN #1's New Hire Orientation Acknowledgement of Receipt Form revealed that on 10/12/21 that LPN #1 signed the form that stated I have read and acknowledge receipt of the following facility, policies and procedures or have been provided training in the areas listed. I will comply with guidelines outlined in the policies and training and I understand that failure to do so may result in disciplinary or legal action. Abuse Prevention Policy and Video . Tupelo Nursing and Rehabilitation Center, LLC IJ Removal Plan The facility failed to provide supervision to prevent an elopement for Resident #1, who was a wandering risk and had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident left the facility through a window unnoticed and unsupervised until the resident was located in a community approximately 2.6 miles away from the facility. The Resident was last seen in the facility at 12:04 AM on 6/10/22 and was not discovered to be missing until 7:15 AM and was later located by staff at 8:25 AM on 6/10/22. Immediate Actions: On 6/10/2022 these actions were initiated and completed. On 6/10/ 2022 8:15 AM, the facility performed a 100% head count, to ascertain location of every resident this was completed by charge nurse on each unit. On 6/10/2022 8:22 AM, the Mississippi State Department of health notified of missing resident by Executive Director. On 6/10/2022 8:25 AM, the Director of Nursing and a Certified Nursing Assistant located resident in community approximately 2.6 miles away per private car. Resident was returned to facility by police car. Resident #1 appeared to have no injuries when returned to the facility. No body audit was completed by staff due to ambulance on site to transfer to local hospital for full evaluation, where resident was found to have no body injuries. Resident #1 was fully supervised by Director of Nursing until transferred to local hospital by Emergency Medical Teams (EMTs) at 8:40 AM. On 6/10/22 at 8:50 AM, the Maintenance Director and assistant placed screws in all windows to prevent opening greater than 4 inches. Facility Staff was in-serviced how to open windows with screwdriver by Maintenance Director, and screwdriver was placed on each med-cart. On 6/10/22 at 9:00 AM, an in-service was initiated on elopement protocol to include every one-hour checks on all residents assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/10/2022 at 9:00 AM, through 4 :00 PM All residents with risk of elopements were reevaluated, pocket care guides, and care plans were updated by Director of Nursing, Social Service, and unit manager to ensure all residents for risk for elopement had appropriate interventions in place. On 6/10/22 at 4:00 PM, emergency Quality Assurance (QA) meeting held related to elopement, and interventions put in place. No changes in policy and procedures made. Attendees for this meeting were Executive Director, Social Service, Director of Nursing and Medical Director per phone. On 6/10/22 Social service Director initiated Elopement Alarm Drill calling a Dr. Wander with the 7-3 shift at 7:52 AM, 3-11 shift at 3:24 AM. Then 6/11/22 11-7 shift at 6:36 AM. On 6/14/22 at 4:40 PM, Licensed Practical Nurse (LPN#1) called Executive Director and stated she was going to tell the truth, that she did not do visual checks on this resident as documentation indicated on Electronic Flow Sheet. On 6/15/22 at 6:40 AM, Disciplinary action for falsifying documentation was given to LPN #1 by Executive Director. On 6/22/2022 at 3:09 PM, the Executive Director filed a complaint with The Mississippi Board of Nursing concerning LPN #1 for false documentation on Resident #1 Electronic Flow Record. On 6/22/2022 at 3:30 PM, LPN # 1 was terminated by Executive Director for falsifying documentation. On 6/22/2022 at 3:40 PM, Emergency QA called with the following attendance: Executive Director, Director of Nurses, Social Services, Minimum Data Sets (MDS). Director, Maintenance Director, Medical Director and Vice President. No policy and procedure changes made, QA reviewed Immediate Jeopardy Removal Plans deficiencies and plans of corrections. On 6/22/2022 at 5:00 PM, Executive Director and Director of Nursing were In-serviced on Abuse and Neglect by Vice President to include instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. Facility alleges compliance and removal of immediate jeopardy as of 6/23/2022 State Agency (SA) Validation on 6/24/2022 The State Agency (SA) validated through record review and interview with the Executive Director that on 6/10/2022 at 8:15 AM, the facility performed a 100% head count, to ascertain location of every resident this was completed by charge nurse on each unit. The SA validated through record review and interview with the Executive Director (ADM) that on 6/10/2022 at 8:22 AM, the Mississippi State Department of health notified of missing resident by the Executive Director. The SA validated through interview with the Director of Nursing (DON) and record review that on 6/10/2022 at 8:25 AM the Director of Nursing and a Certified Nursing Assistant located resident in community approximately 2.6 miles away per private car. Resident was returned to facility by police car. Resident #1 appeared to have no injuries when returned to the facility. No body audit was completed by staff due to ambulance on site to transfer to local hospital for full evaluation, where resident was found to have no body injuries. Resident #1 was fully supervised by Director of Nursing until transferred to local hospital by the Emergency Medical Teams (EMTs) at 8:40 AM. The SA validated through interview with the Maintenance Director and record review that on 6/10/22 at 8:50 AM, the Maintenance Director and assistant placed screws in all windows to prevent opening greater than 4 inches. Facility Staff was in-serviced how to open windows with screwdriver by Maintenance Director, and screwdriver was placed on each med-cart. The SA validated through interviews with the ADM and DON, and record review that on 6/10/22 at 9:00 AM, an in-service was initiated on elopement protocol to include every one-hour checks on all residents assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The State Agency SA validated through interview with the DON and record review that on 6/10/2022 at 9:00 AM, through 4:00 PM, that all residents with the risk of elopements were reevaluated, pocket care guides, and care plans were updated by Director of Nursing, Social Service, and unit manager to ensure all residents for risk for elopement had appropriate interventions in place. The SA validated through interview with the ADM, DON, Social Services, and Medical Director and record review that on 6/10/22 at 4:00 PM, an emergency Quality Assurance (QA) meeting was held related to elopement, and interventions put in place. No changes in policy and procedures made. Attendees for this meeting was Executive Director, Social Service, Director of Nursing and Medical Director per phone. The SA validated through interview with the Social Services Director and record review that on 6/10/22 the Social Service Director initiated Elopement Alarm Drill calling a Dr. Wander with the 7-3 shift at 7:52 AM, 3-11 shift at 3:24 AM. Then on 6/11/22 11-7 shift at 6:36 AM. The SA validated through Interview with the ADM and record review that on 6/14/22 at 4:40 PM, Licensed Practical Nurse (LPN#1) called Executive Director and stated she was going to tell the truth, that she did not do visual checks on this resident as documentation indicated on Electronic Flow Sheet. The SA validated through interview with the ADM and record review that on 6/15/22 at 6:40 AM, Disciplinary action for falsifying documentation was given to LPN #1 by Executive Director. The SA validated through interview with the ADM and record review that on 6/22/2022 at 3:09 PM, the Executive Director filed a complaint with The Mississippi Board of Nursing concerning LPN #1 for false documentation on Resident #1 Electronic Flow Record. The SA validated through interview with the ADM and record review that on 6/22/2022 at 3:30 PM LPN #1 was terminated by Executive Director for falsifying documentation. The SA validated through interview with the ADM, DON, and Medical Director and record review that on 6/22/2022 at 3:40 PM, an emergency QA was called with the following attendance: Executive Director, Director of Nurses, Social Services, Minimum Data Sets (MDS). Director, Maintenance Director, Medical Director and Vice President. No policy and procedure changes made, QA reviewed Immediate Jeopardy Removal Plans deficiencies and plans of corrections. The State Agency (SA) validated through interview with the ADM and DON and record review that on 6/22/2022 at 5:00 PM, the Executive Director (ADM) and Director of Nursing were In-serviced on Abuse and Neglect by Vice President to include instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. The SA validated that all corrective actions to remove the IJ had been completed as of 6/22/2022, and the IJ was removed on 6/23/2022, prior to exit.

Based on observation, interview, record review, and facility policy review, the facility failed to report a nurse to the State Board of Nursing after failing to prevent a resident from leaving the facility unsupervised when facility staff failed to complete one-hour visual checks as ordered by the physician and falsified records for one (1) of five (5) residents reviewed, Resident #1. The facility failed to provide supervision to prevent an elopement for Resident #1, who was a wandering risk and had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident was last seen in the facility at 12:04 AM on 06/10/2022. He was not discovered to be missing until 7:15 AM on 06/10/2022 and was later located by facility staff at 8:25 AM on 06/10/2022. Eight (8) hours and 21 minutes elapsed between the last visualization in the facility and the resident being found. The facility's failure to provide supervision to a resident who was a wandering risk and had orders for hourly visual checks caused placed Resident #1 and other residents at risk for wandering/elopement, in a situation that has caused or is likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 6/10/2022 when Resident #1 left the facility through a window unnoticed and unsupervised until the resident was located in the community approximately 2.6 miles away from the facility. The facility Administrator was notified of the IJ on 6/22/2022 at 2:35 PM. The facility provided an acceptable Removal Plan on 6/23/22, in which the facility alleged all corrective actions were completed to remove the IJ on 6/22/2022, and the IJ removed on 6/23/2022. The State Agency(SA) determined the IJ was removed on 6/23/2022, prior to exit, and the scope and severity for F 610 was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility Policy titled Abuse Prevention dated 5/22 revealed Policy: The facility is committed to protecting the resident from abuse by anyone including, but not necessarily limited to: Facility staff, other residents, consultants, volunteers, staff from other agencies providing care to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors ,or any other individual .f) Neglect: A failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain . Protection: 1. Any allegation of abuse, neglect, misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the resident. 2. Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative, and as required by state guidelines . Record review of the facility policy titled; Missing Resident/ Elopements dated May/22 revealed Policy: The unit charge nurse is responsible for knowing the location of their residents. Record review of the facility investigation Supervisor Investigation Summary Form revealed . Date of Event: 6-10-22, Time of Event: 7:52 AM, How and When was event discovered: On 6-10-22, staff went to resident's room to get him for breakfast and noticed that he was not in the room. Briefly describe event: On 6/10/2022 at approximately 7: 15 AM, staff went into the resident's room to get him for breakfast. Resident was noted to not be in his room. Staff then began to look about the facility for the resident and still could not find the resident. Staff then began to look outside of the facility for the resident. Social Service was notified. Dr. Wander was called, and all staff immediately begin looking for the resident. Executive Director was notified. Director of Nursing was notified. At approximately 8:00 AM, staff noticed that the resident's window in (Resident #1's room) was open and that the screen was pushed out. 911 was notified. Staff continued searching for resident outside of the building and began searching in the community. A staff member found the resident approximately 2.6 miles from facility at Veterans Square at 8:25 AM. Resident refused to get in the car with the staff member. Director of Nursing arrived and spoke with resident. The resident was in agreement to go with the Director of Nursing when the police arrived on the scene. The police officer then spoke to the resident and resident agreed to ride with the police officer. Resident keep saying that he needed to get to Alabama. He was outside approximately 2 to 3 hours, according to staff statements. It was approximately 71 degrees he was wearing blue jeans, dark colored pull over shirt with a vest on, tennis shoes and carrying a garbage bag with his belongings. He suffered no injuries .II. Investigation: (Formal Name of Resident #1) resident of Tupelo Nursing and Rehabilitation admitted on [DATE]. (Formal Name of Resident #1) had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident has not had exit seeking behavior since admission. He does state that he wants to leave go home to Alabama when he is in an anxiety state. (Formal Name of Resident #1) is alert can state date and time, person and place, current events. But he is paranoid and speaks about wanting to leave since admission to facility. He feels his family stole from him and becomes agitated at times with staff and other residents thinking someone will harm him, he is redirected easily. (Formal Name of Resident #1) was able to sign himself into facility and can make decisions. He sleeps fully dressed with shoes on. Gets up frequently at night, has history of pacing and wandering halls, sits in lobby frequently, but has never actually attempted to exit. On 6/10/22 he did state he was going to Alabama and his nurse was able to redirect him and he laid down in his bed as usual. (Formal Name of Certified Nursing Assistant (CNA) #4) states she was in the room between 5:00 am and 6:30 am to assist with the other 2 roommates, and he was not in his room, nor did she notice anything at window, employee states she did not go over to the window. (Formal Name of CNA#4) did not feel this was an unusual occurrence due to resident gets up and down frequently every night. Neither staff member felt there was anything unusual with this resident's behavior. (Formal Name of Resident #1) was taken to hospital after he was found at Veterans Square for examination. He was not injured but was sent to (Formal Name of Hospital) for evaluation and possible treatment .After a thorough investigation, Tupelo Nursing and Rehabilitation was able to substantiate that the resident did exit the premises by leaving out of his window Record review of the Physician Orders for Resident #1 revealed that on 12/15/2020 an order was written for visual checks every hour. Electronic record review titled e Flowsheet for Resident #1 revealed that it is documented by Licensed Practical Nurse (LPN) #1 that his visual checks were completed on every hour from 12:00 AM to 6 AM on 06/10/2022. During an interview with Licensed Practical Nurse (LPN) #1 on 06/20/2022 at 1:45 PM, revealed that she worked the 11 to 7 shift on 6/9/2022 that ended on 6/10/2022. LPN #1 revealed that she last personally saw Resident #1 around midnight. He walked up to the desk fully dressed, with a hat on wanting to show her something in his room. LPN #1 stated she went to Resident #1's room where he showed her some pictures that he wanted her to keep for him as because he was going to Alabama. She revealed that she talked to Resident #1, and he agreed to lay down and go to sleep. She left the room while he was laying on his bed. She stated that she failed to go back and do follow up checks on Resident #1. LPN #1 revealed that Resident #1 had never tried to leave. He did have a wander-guard on. He had orders to be seen every 1 hour and that she should have laid eyes on him again. She revealed she failed to recheck on him and admitted that she had initialed in the electronic record titled e Flowsheet as if she had laid eyes on him hourly. LPN #1 revealed that she had received a reprimand for her inaction and was allowed to continue to work her scheduled shifts. During an interview with the Administrator (ADM)/Executive Director on 06/22/2022 at 11:30 AM, she revealed that on 06/10/2022 when they first knew of the elopement of Resident #1, she was unaware that the nurse had not seen him since midnight and that at first LPN #1 reported to her that she had seen him between 5 AM and 6 AM but on 6/14/2022 the nurse phoned the ADM admitting that she had not actually laid eyes on Resident #1 since around midnight. The ADM then scheduled a time the morning of 6/15/2022 to meet with LPN #1 for a counseling conference and she was reprimanded. The ADM confirmed that LPN #1 was continuing to work her scheduled shifts and that LPN #1 had not been reported to the Board of Nursing at this time. Record review of the Face Sheet for Resident #1 revealed that the resident was admitted on [DATE]. Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the elopement Care Plan for Resident #1 revealed, Problem Onset: 12/16/2020 Problem/Need: Risk for elopement .Approaches: Check placement and function of wander guard every shift . Visual Checks every hour . Record review of Resident #1's Section C of the Minimum Data Set (MDS) revealed that on 05/23/2022 the Brief Interview for Mental Status (BIMS) score was 99 due to the resident was unable to complete the interview. Record review Departmental Notes revealed that on 06/10/2022 at 12:04 AM, a nurse's note was written by LPN #1 that revealed . Resident awake et (and) alert stated, I'm Going to Alabama for three days, Redirected per this nurse with success. Resident lying in bed resting at this time. Skin warm and dry. Resp.(respirations) even/unlabored without SOB (shortness of breath) noted. No adverse reactions noted. 0 (no) acute distress noted, call light within reach Record review of LPN #1's New Hire Orientation Acknowledgement of Receipt Form revealed that on 10/12/21 that LPN #1 signed the form that stated I have read and acknowledge receipt of the following facility, policies and procedures or have been provided training in the areas listed. I will comply with guidelines outlined in the policies and training and I understand that failure to do so may result in disciplinary or legal action. Abuse Prevention Policy and Video . Tupelo Nursing and Rehabilitation Center, LLC IJ Removal Plan The facility failed to provide supervision to prevent an elopement for Resident #1, who was a wandering risk and had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident left the facility through a window unnoticed and unsupervised until the resident was located in a community approximately 2.6 miles away from the facility. The Resident was last seen in the facility at 12:04 AM on 06/10/22 and was not discovered to be missing until 7:15 AM and was later located by staff at 8:25 AM on 06/10/22. Immediate Actions: On 6/10/2022 these actions were initiated and completed. On 6/10/ 2022 8:15 AM, the facility performed a 100% head count, to ascertain location of every resident this was completed by charge nurse on each unit. On 6/10/2022 8:22 AM, the Mississippi State Department of health notified of missing resident by Executive Director. On 6/10/2022 8:25 AM, the Director of Nursing and a Certified Nursing Assistant located resident in community approximately 2.6 miles away per private car. Resident was returned to facility by police car. Resident #1 appeared to have no injuries when returned to the facility. No body audit was completed by staff due to ambulance on site to transfer to local hospital for full evaluation, where resident was found to have no body injuries. Resident #1 was fully supervised by Director of Nursing until transferred to local hospital by Emergency Medical Teams (EMTs) at 8:40 AM. On 6/10/22 at 8:50 AM, the Maintenance Director and assistant placed screws in all windows to prevent opening greater than 4 inches. Facility Staff was in-serviced how to open windows with screwdriver by Maintenance Director, and screwdriver was placed on each med-cart. On 6/10/22 at 9:00 AM, an in-service was initiated on elopement protocol to include every one-hour checks on all residents assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/10/2022 at 9:00 AM, through 4 :00 PM All residents with risk of elopements were reevaluated, pocket care guides, and care plans were updated by Director of Nursing, Social Service, and unit manager to ensure all residents for risk for elopement had appropriate interventions in place. On 6/10/22 at 4:00 PM, emergency Quality Assurance (QA) meeting held related to elopement, and interventions put in place. No changes in policy and procedures made. Attendees for this meeting were Executive Director, Social Service, Director of Nursing and Medical Director per phone. On 6/10/22 Social service Director initiated Elopement Alarm Drill calling a Dr. Wander with the 7-3 shift at 7:52 AM, 3-11 shift at 3:24 AM. Then 6/11/22 11-7 shift at 6:36 AM. On 6/14/22 at 4:40 PM, Licensed Practical Nurse (LPN#1) called Executive Director and stated she was going to tell the truth, that she did not do visual checks on this resident as documentation indicated on Electronic Flow Sheet. On 6/15/22 at 6:40 AM, Disciplinary action for falsifying documentation was given to LPN #1 by Executive Director. On 6/22/2022 at 3:09 PM, the Executive Director filed a complaint with The Mississippi Board of Nursing concerning LPN #1 for false documentation on Resident #1 Electronic Flow Record. On 6/22/2022 at 3:30 PM, LPN # 1 was terminated by Executive Director for falsifying documentation. On 6/22/2022 at 3:40 PM, Emergency QA called with the following attendance: Executive Director, Director of Nurses, Social Services, Minimum Data Sets (MDS). Director, Maintenance Director, Medical Director and Vice President. No policy and procedure changes made, QA reviewed Immediate Jeopardy Removal Plans deficiencies and plans of corrections. On 6/22/2022 at 5:00 PM, Executive Director and Director of Nursing were In-serviced on Abuse and Neglect by Vice President to include instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. Facility alleges compliance and removal of immediate jeopardy as of 6/23/2022 State Agency (SA) Validation on 06/24/2022 The SA validated through record review and interview with the Executive Director that on 6/10/2022 at 8:15 AM, the facility performed a 100% head count, to ascertain location of every resident this was completed by charge nurse on each unit. The SA validated through record review and interview with the Executive Director (ADM) that on 6/10/2022 at 8:22 AM, the Mississippi State Department of Health notified of missing resident by the Executive Director. The SA validated through interview with the Director of Nursing (DON) and record review that on 6/10/2022 at 8:25AM the Director of Nursing and a Certified Nursing Assistant located resident in community approximately 2.6 miles away per private car. Resident was returned to facility by police car. Resident #1 appeared to have no injuries when returned to the facility. No body audit was completed by staff due to ambulance on site to transfer to local hospital for full evaluation, where resident was found to have no body injuries. Resident #1 was fully supervised by Director of Nursing until transferred to local hospital by the Emergency Medical Teams (EMTs) at 8:40 AM. The SA validated through interview with the Maintenance Director and record review that on 6/10/22 at 8:50 AM, the Maintenance Director and assistant placed screws in all windows to prevent opening greater than 4 inches. Facility Staff was in-serviced how to open windows with screwdriver by Maintenance Director, and screwdriver was placed on each med-cart. The SA validated through interviews with the ADM and DON, and record review that on 6/10/22 at 9:00 AM, an in-service was initiated on elopement protocol to include every one-hour checks on all residents assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The SA validated through interview with the DON and record review that on 6/10/2022 at 9:00 AM, through 4:00 PM, that all residents with the risk of elopements were reevaluated, pocket care guides, and care plans were updated by Director of Nursing, Social Service, and unit manager to ensure all residents for risk for elopement had appropriate interventions in place. The SA validated through interview with the ADM, DON, Social Services, and Medical Director and record review that on 6/10/22 at 4:00 PM, an emergency Quality Assurance (QA) meeting was held related to elopement, and interventions put in place. No changes in policy and procedures made. Attendees for this meeting was Executive Director, Social Service, Director of Nursing and Medical Director per phone. The SA validated through interview with the Social Services Director and record review that on 6/10/22 the Social Service Director initiated Elopement Alarm Drill calling a Dr. Wander with the 7-3 shift at 7:52 AM, 3-11 shift at 3:24 AM. Then on 6/11/22 11-7 shift at 6:36 AM. The SA validated through Interview with the ADM and record review that on 6/14/22 at 4:40 PM, Licensed Practical Nurse (LPN#1) called Executive Director and stated she was going to tell the truth, that she did not do visual checks on this resident as documentation indicated on Electronic Flow Sheet. The SA validated through interview with the ADM and record review that on 6/15/22 at 6:40 AM, Disciplinary action for falsifying documentation was given to LPN #1 by Executive Director. The SA validated through interview with the ADM and record review that on 6/22/2022 at 3:09 PM, the Executive Director filed a complaint with The Mississippi Board of Nursing concerning LPN #1 for false documentation on Resident #1 Electronic Flow Record. The SA validated through interview with the ADM and record review that on 6/22/2022 at 3:30 PM LPN #1 was terminated by Executive Director for falsifying documentation. The SA validated through interview with the ADM, DON, and Medical Director and record review that on 6/22/2022 at 3:40 PM, an emergency QA was called with the following attendance: Executive Director, Director of Nurses, Social Services, Minimum Data Sets (MDS). Director, Maintenance Director, Medical Director and Vice President. No policy and procedure changes made, QA reviewed Immediate Jeopardy Removal Plans deficiencies and plans of corrections. The State Agency (SA) validated through interview with the ADM and DON and record review that on 6/22/2022 at 5:00 PM, the Executive Director (ADM) and Director of Nursing were In-serviced on Abuse and Neglect by Vice President to include instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. The SA validated that all corrective actions to remove the IJ had been completed as of 6/22/2022, and the IJ was removed on 6/23/2022, prior to exit.

Based on staff interview, record review, and facility policy review, the facility failed to prevent a resident from leaving the facility unsupervised when facility staff failed to follow the comprehensive care plan for one-hour visual checks for one (1) of five (5) residents reviewed, Resident #1. The facility failed to provide supervision to prevent an elopement for Resident #1, who was a wandering risk and had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident was last seen in the facility at 12:04 AM on 06/10/2022. He was not discovered to be missing until 7:15 AM on 06/10/2022 and was later located by facility staff at 8:25 AM on 06/10/2022. The facility's failure to follow the comprehensive care plan to provide supervision to a resident who was a wandering risk and had orders for hourly visual checks placed Resident #1 and all residents who were at risk for wandering in a situation that has caused or is likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 06/10/2022 when Resident #1 left the facility through a window unnoticed and unsupervised until the resident was located in the community approximately 2.6 miles away from the facility. The facility Administrator was notified of the IJ on 06/22/2022 at 2:35 PM. The facility provided an acceptable Removal Plan on 06/23/22, in which the facility alleged all corrective actions were completed to remove the IJ on 06/22/2022, and the IJ removed on 06/23/2022. The State Agency (SA) determined the IJ was removed on 06/23/2022, prior to exit, and the scope and severity for F 656 was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled SUBJECT: COMPREHENSIVE PERSON CENTERED CARE PLANS, history date 3/18, revealed POLICY: Each resident shall have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care .PROCEDURE: 6. Staff approaches are to be developed for each problem/strength/need .assigned disciplines will be identified to carry out the intervention . Record review of the facility investigation Supervisor Investigation Summary Form revealed . Date of Event: 6-10-22, Time of Event: 7:52 AM, How and When was event discovered: On 6-10-22, staff went to resident's room to get him for breakfast and noticed that he was not in the room. Briefly describe event: On 6/10/2022 at approximately 7: 15 AM, staff went into the resident's room to get him for breakfast. Resident was noted to not be in his room. Staff then began to look about the facility for the resident and still could not find the resident. Staff then began to look outside of the facility for the resident. Social Service was notified. Dr. Wander was called, and all staff immediately begin looking for the resident. Executive Director was notified. Director of Nursing was notified. At approximately 8:00 AM, staff noticed that the resident's window in (Resident #1's room) was open and that the screen was pushed out. 911 was notified. Staff continued searching for resident outside of the building and began searching in the community. A staff member found the resident approximately 2.6 miles from facility at Veterans Square at 8:25 AM. Resident refused to get in the car with the staff member. Director of Nursing arrived and spoke with resident. The resident was in agreement to go with the Director of Nursing when the police arrived on the scene. The police officer then spoke to the resident and resident agreed to ride with the police officer. Resident keep saying that he needed to get to Alabama. He was outside approximately 2 to 3 hours, according to staff statements. It was approximately 71 degrees he was wearing blue jeans, dark colored pull over shirt with a vest on, tennis shoes and carrying a garbage bag with his belongings. He suffered no injuries .II. Investigation: (Formal Name of Resident #1) resident of Tupelo Nursing and Rehabilitation admitted on [DATE]. (Formal Name of Resident #1) had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident has not had exit seeking behavior since admission. He does state that he wants to leave go home to Alabama when he is in an anxiety state. (Formal Name of Resident #1) is alert can state date and time, person and place, current events. But he is paranoid and speaks about wanting to leave since admission to facility. He feels his family stole from him and becomes agitated at times with staff and other residents thinking someone will harm him, he is redirected easily. (Formal Name of Resident #1) was able to sign himself into facility and can make decisions. He sleeps fully dressed with shoes on. Gets up frequently at night, has history of pacing and wandering halls, sits in lobby frequently, but has never actually attempted to exit. On 6/10/22 he did state he was going to Alabama and his nurse was able to redirect him and he laid down in his bed as usual. (Formal Name of Certified Nursing Assistant (CNA) #4) states she was in the room between 5:00 am and 6:30 am to assist with the other 2 roommates, and he was not in his room, nor did she notice anything at window, employee states she did not go over to the window. (Formal Name of CNA#4) did not feel this was an unusual occurrence due to resident gets up and down frequently every night. Neither staff member felt there was anything unusual with this resident's behavior. (Formal Name of Resident #1) was taken to hospital after he was found at Veterans Square for examination. He was not injured but was sent to (Formal Name of Hospital) for evaluation and possible treatment .After a thorough investigation, Tupelo Nursing and Rehabilitation was able to substantiate that the resident did exit the premises by leaving out of his window Record review of the Care Plan for Resident #1 revealed, Problem Onset: 12/16/2020 Problem/Need: Risk for elopement .Approaches: Check placement and function of wander guard every shift . Visual Checks every hour . Electronic record review titled e Flowsheet for Resident #1 revealed that it is documented by LPN #1 that visual checks were completed on every hour from 12:00 AM to 6 AM on 06/10/2022. Record review of the Physician Orders for Resident #1 revealed that on 12/15/2020 an order was written for visual checks every hour. At 1:45 PM on 6/20/2022, during an interview with Licensed Practical Nurse (LPN) #1 revealed that she worked the 11 to 7 shift on 6/9/2022 which ended on 6/10/2022. LPN #1 revealed that she last personally laid eyes on Resident #1 around midnight, he walked up to the desk fully dressed, with a hat on wanting to show her something in his room. LPN #1 went to Resident #1's room where he showed her some pictures that he wanted her to keep for him as he was going to Alabama. LPN #1 revealed that she talked to him, and he agreed to lay down and go to sleep. She left the room while he was laying on the bed. She revealed that she failed to go back and do follow up checks on Resident #1. LPN #1 revealed that Resident #1 had never tried to leave and that he did have a wander-guard on, he did have orders to be seen every 1 hour and that she should have laid eyes on him again. She revealed she failed to recheck on him and admitted that she had initialed in the electronic record titled e Flowsheet as if she had laid eyes on him hourly. LPN #1 revealed that she had received a reprimand for her inaction and was allowed to continue to work her scheduled shifts. On 6/22/2022 at 11:30 AM, an interview with the Administrator (ADM)/Executive Director revealed that on 6/10/2022 when they first knew of the elopement of Resident #1, she was unaware that the nurse had not seen him since midnight. At first LPN #1 reported to her that she had seen him between 5 AM and 6 AM but on 6/14/2022 the nurse phoned the ADM admitting that she had not actually laid eyes on Resident #1 since around Midnight. The ADM then scheduled a time the morning of 6/15/2022 to meet with LPN #1 for counseling conference and she was reprimanded. The ADM confirmed that LPN #1 was continuing to work her scheduled shifts and that the ADM had not reported LPN #1 to the Board of Nursing at this time. On 6/22/2022 at 1:00 PM, an interview with the DON confirmed that Resident #1 did have a plan of care related to risk for wandering/elopement and that by LPN #1 not following orders to make visual checks on the resident she did not follow the Care Plan. Record review of Employee Personnel file revealed that on 6/15/2022 LPN #1 received Corrective Counseling from the ADM related to the employee falsified inaccurate information on a resident's e-Tar (electronic Treatment Administration Record) who was not in the facility. Record review of the Face Sheet for Resident #1 revealed that the resident was admitted on [DATE]. Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Section C of the Minimum Data Set (MDS) revealed that on 05/23/2022 the Brief Interview for Mental Status (BIMS) score was 99 due to the resident was unable to complete the interview. Tupelo Nursing and Rehabilitation Center, LLC IJ Removal Plan The facility failed to provide supervision to prevent an elopement for Resident #1, who was a wandering risk and had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident left the facility through a window unnoticed and unsupervised until the resident was located in a community approximately 2.6 miles away from the facility. The Resident was last seen in the facility at 12:04 AM on 06/10/22 and was not discovered to be missing until 7:15 AM and was later located by staff at 8:25 AM on 06/10/22. Immediate Actions: On 6/10/2022 these actions were initiated and completed. On 6/10/ 2022 8:15 AM, the facility performed a 100% head count, to ascertain location of every resident this was completed by charge nurse on each unit. On 6/10/2022 8:22 AM, the Mississippi State Department of health notified of missing resident by Executive Director. On 6/10/2022 8:25 AM, the Director of Nursing and a Certified Nursing Assistant located resident in community approximately 2.6 miles away per private car. Resident was returned to facility by police car. Resident #1 appeared to have no injuries when returned to the facility. No body audit was completed by staff due to ambulance on site to transfer to local hospital for full evaluation, where resident was found to have no body injuries. Resident #1 was fully supervised by Director of Nursing until transferred to local hospital by Emergency Medical Teams (EMTs) at 8:40 AM. On 6/10/22 at 8:50 AM, the Maintenance Director and assistant placed screws in all windows to prevent opening greater than 4 inches. Facility Staff was in-serviced how to open windows with screwdriver by Maintenance Director, and screwdriver was placed on each med-cart. On 6/10/22 at 9:00 AM, an in-service was initiated on elopement protocol to include every one-hour checks on all residents assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/10/2022 at 9:00 AM, through 4 :00 PM All residents with risk of elopements were reevaluated, pocket care guides, and care plans were updated by Director of Nursing, Social Service, and unit manager to ensure all residents for risk for elopement had appropriate interventions in place. On 6/10/22 at 4:00 PM, emergency Quality Assurance (QA) meeting held related to elopement, and interventions put in place. No changes in policy and procedures made. Attendees for this meeting were Executive Director, Social Service, Director of Nursing and Medical Director per phone. On 6/10/22 Social service Director initiated Elopement Alarm Drill calling a Dr. Wander with the 7-3 shift at 7:52 AM, 3-11 shift at 3:24 AM. Then 6/11/22 11-7 shift at 6:36 AM. On 6/14/22 at 4:40 PM, Licensed Practical Nurse (LPN#1) called Executive Director and stated she was going to tell the truth, that she did not do visual checks on this resident as documentation indicated on Electronic Flow Sheet. On 6/15/22 at 6:40 AM, Disciplinary action for falsifying documentation was given to LPN #1 by Executive Director. On 6/22/2022 at 3:09 PM, the Executive Director filed a complaint with The Mississippi Board of Nursing concerning LPN #1 for false documentation on Resident #1 Electronic Flow Record. On 6/22/2022 at 3:30 PM, LPN # 1 was terminated by Executive Director for falsifying documentation. On 6/22/2022 at 3:40 PM, Emergency QA called with the following attendance: Executive Director, Director of Nurses, Social Services, Minimum Data Sets (MDS). Director, Maintenance Director, Medical Director and Vice President. No policy and procedure changes made, QA reviewed Immediate Jeopardy Removal Plans deficiencies and plans of corrections. On 6/22/2022 at 5:00 PM, Executive Director and Director of Nursing were In-serviced on Abuse and Neglect by Vice President to include instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. Facility alleges compliance and removal of immediate jeopardy as of 6/23/2022 State Agency (SA) Validation on 06/24/2022 The SA validated through record review and interview with the Executive Director that on 6/10/ 2022 at 8:15 AM, the facility performed a 100% head count, to ascertain location of every resident this was completed by charge nurse on each unit. The SA validated through record review and interview with the Executive Director (ADM) that on 6/10/2022 at 8:22 AM, the Mississippi State Department of health notified of missing resident by the Executive Director. The SA validated through interview with the Director of Nursing (DON) and record review that on 6/10/2022 at 8:25AM the Director of Nursing and a Certified Nursing Assistant located resident in community approximately 2.6 miles away per private car. Resident was returned to facility by police car. Resident #1 appeared to have no injuries when returned to the facility. No body audit was completed by staff due to ambulance on site to transfer to local hospital for full evaluation, where resident was found to have no body injuries. Resident #1 was fully supervised by Director of Nursing until transferred to local hospital by the Emergency Medical Teams (EMTs) at 8:40 AM. The SA validated through interview with the Maintenance Director and record review that on 6/10/22 at 8:50 AM, the Maintenance Director and assistant placed screws in all windows to prevent opening greater than 4 inches. Facility Staff was in-serviced how to open windows with screwdriver by Maintenance Director, and screwdriver was placed on each med-cart. The SA validated through interviews with the ADM and DON, and record review that on 6/10/22 at 9:00 AM, an in-service was initiated on elopement protocol to include every one-hour checks on all residents assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The State Agency SA validated through interview with the DON and record review that on 6/10/2022 at 9:00 AM, through 4 :00 PM, that all residents with the risk of elopements were reevaluated, pocket care guides, and care plans were updated by Director of Nursing, Social Service, and unit manager to ensure all residents for risk for elopement had appropriate interventions in place. The SA validated through interview with the ADM, DON, Social Services, and Medical Director and record review that on 6/10/22 at 4:00 PM, an emergency Quality Assurance (QA) meeting was held related to elopement, and interventions put in place. No changes in policy and procedures made. Attendees for this meeting was Executive Director, Social Service, Director of Nursing and Medical Director per phone. The SA validated through interview with the Social Services Director and record review that on 6/10/22 the Social Service Director initiated Elopement Alarm Drill calling a Dr. Wander with the 7-3 shift at 7:52 AM, 3-11 shift at 3:24 AM. Then on 6/11/22 11-7 shift at 6:36 AM. The SA validated through Interview with the ADM and record review that on 6/14/22 at 4:40 PM, Licensed Practical Nurse (LPN#1) called Executive Director and stated she was going to tell the truth, that she did not do visual checks on this resident as documentation indicated on Electronic Flow Sheet. The SA validated through interview with the ADM and record review that on 6/15/22 at 6:40 AM, Disciplinary action for falsifying documentation was given to LPN #1 by Executive Director. The SA validated through interview with the ADM and record review that on 6/22/2022 at 3:09 PM, the Executive Director filed a complaint with The Mississippi Board of Nursing concerning LPN #1 for false documentation on Resident #1 Electronic Flow Record. The SA validated through interview with the ADM and record review that on 6/22/2022 at 3:30 PM LPN #1 was terminated by Executive Director for falsifying documentation. The SA validated through interview with the ADM, DON, and Medical Director and record review that on 6/22/2022 at 3:40 PM, an emergency QA was called with the following attendance: Executive Director, Director of Nurses, Social Services, Minimum Data Sets (MDS). Director, Maintenance Director, Medical Director and Vice President. No policy and procedure changes made, QA reviewed Immediate Jeopardy Removal Plans deficiencies and plans of corrections. The State Agency (SA) validated through interview with the ADM and DON and record review that on 6/22/2022 at 5:00 PM, the Executive Director (ADM) and Director of Nursing were In-serviced on Abuse and Neglect by Vice President to include instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. The SA validated that all corrective actions to remove the IJ had been completed as of 6/22/2022, and the IJ was removed on 6/23/2022, prior to exit.

Based on observation, interview, record review, and facility policy review, the facility failed to provide supervision to prevent a resident from leaving the facility unsupervised for one (1) of five (5) residents reviewed, Resident #1. The facility failed to provide supervision to prevent an elopement for Resident #1, who was a wandering risk and had an order for visual checks every hour. Resident #1 was diagnosed with Anxiety Disorder and Major Depressive Disorder. The resident left the facility through a window unnoticed and unsupervised until the resident was located in a community approximately 2.6 miles away from the facility. The Resident was last seen in the facility at 12:04 AM on 6/10/2022. He was not discovered to be missing until 7:15 AM on 6/10/2022 and was later located by facility staff at 8:25 AM on 6/10/2022. Eight (8) hours and 21 minutes elapsed between the last visualization in the facility and the resident being found. The facility's failure to provide supervision to a resident who was a wandering risk and had orders for hourly visual checks caused Resident #1 and other residents at risk for elopement to be in a situation likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 6/10/2022 when Resident #1 left the facility through a window unnoticed and unsupervised until the resident was located in the community approximately 2.6 miles away from the facility. The facility Administrator was notified of the IJ on 6/22/2022 at 2:35 PM. The facility provided an acceptable Removal Plan on 6/23/22, in which the facility alleged all corrective actions were completed to remove the IJ on 6/22/2022, and the IJ removed on 6/23/2022. The State Agency (SA) determined the IJ was removed on 6/23/2022, prior to exit, and the scope and severity for F 689 was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled; Missing Resident/ Elopements dated May/22 revealed Policy: The unit charge nurse is responsible for knowing the location of their residents. Record review of the facility investigation Supervisor Investigation Summary Form revealed . Date of Event: 6-10-22, Time of Event: 7:52 AM, How and When was event discovered: On 6-10-22, staff went to resident's room to get him for breakfast and noticed that he was not in the room. Briefly describe event: On 6/10/2022 at approximately 7: 15 AM, staff went into the resident's room to get him for breakfast. Resident was noted to not be in his room. Staff then began to look about the facility for the resident and still could not find the resident. Staff then began to look outside of the facility for the resident. Social Service was notified. Dr. Wander was called, and all staff immediately begin looking for the resident. Executive Director was notified. Director of Nursing was notified. At approximately 8:00 AM, staff noticed that the resident's window in (Resident #1's room) was open and that the screen was pushed out. 911 was notified. Staff continued searching for resident outside of the building and began searching in the community. A staff member found the resident approximately 2.6 miles from facility at Veterans Square at 8:25 AM. Resident refused to get in the car with the staff member. Director of Nursing arrived and spoke with resident. The resident was in agreement to go with the Director of Nursing when the police arrived on the scene. The police officer then spoke to the resident and resident agreed to ride with the police officer. Resident keep saying that he needed to get to Alabama. He was outside approximately 2 to 3 hours, according to staff statements. It was approximately 71 degrees he was wearing blue jeans, dark colored pull over shirt with a vest on, tennis shoes and carrying a garbage bag with his belongings. He suffered no injuries .II. Investigation: (Formal Name of Resident #1) resident of Tupelo Nursing and Rehabilitation admitted on [DATE]. (Formal Name of Resident #1) had diagnosis of Major depressive disorder, Gout, anxiety disorder, and [CONDITION(S)]. Resident has not had exit seeking behavior since admission. He does state that he wants to leave go home to Alabama when he is in an anxiety state. (Formal Name of Resident #1) is alert can state date and time, person and place, current events. But he is paranoid and speaks about wanting to leave since admission to facility. He feels his family stole from him and becomes agitated at times with staff and other residents thinking someone will harm him, he is redirected easily. (Formal Name of Resident #1) was able to sign himself into facility and can make decisions. He sleeps fully dressed with shoes on. Gets up frequently at night, has history of pacing and wandering halls, sits in lobby frequently, but has never actually attempted to exit. On 6/10/22 he did state he was going to Alabama and his nurse was able to redirect him and he laid down in his bed as usual. (Formal Name of Certified Nursing Assistant (CNA) #4) states she was in the room between 5:00 am and 6:30 am to assist with the other 2 roommates, and he was not in his room, nor did she notice anything at window, employee states she did not go over to the window. (Formal Name of CNA#4) did not feel this was an unusual occurrence due to resident gets up and down frequently every night. Neither staff member felt there was anything unusual with this resident's behavior. (Formal Name of Resident #1) was taken to hospital after he was found at Veterans Square for examination. He was not injured but was sent to (Formal Name of Hospital) for evaluation and possible treatment .After a thorough investigation, Tupelo Nursing and Rehabilitation was able to substantiate that the resident did exit the premises by leaving out of his window On 6/20/2022 at 5:00 PM, an observation by the SA retraced the possible route that Resident #1 could have taken on 6/10/2022. The nursing facility is located on a highway that is given a street name as it runs through town. Resident #1 may have possibly walked to the intersection of Highway 6 and [NAME] Boulevard turning right and making his way past the college campus on a busy two-lane road. The quick stop where Resident #1 was reported to be seen by the manager, is located on the left of the road requiring the resident to cross the street at a traffic light to continue his way onto Veterans Memorial Boulevard to the local shopping center where he was located. Record review of Hourly Weather Forecast for Tupelo MS dated 6/10/2022, revealed that at 6:30 AM to 7:00 AM the temperature was 67 degrees Fahrenheit (F), mostly sunny with winds at 1 mile per hour (mph) with humidity at 84% . at 8:00 AM the temp was 71 degrees and partly cloudy with winds at 2 mph. On 6/20/22 at 10:30 AM, an interview with the Director of Nurses (DON) revealed that on 6/10/2022 around 7:15 AM, the day shift staff could not locate Resident #1 when they were serving breakfast and immediately started checking the rooms and some checked the lobby, therapy department, and went outside around the building. The DON revealed staff called a Dr. Wander Code (code to alert staff a resident cannot be located, possible elopement) at 7:52 AM, on 6/10/2022. On 6/20/22 at 10:40 AM, an interview with the Administrator (ADM)/Executive Director revealed that she was called by the facility Social Worker (SW) at 7:54 AM, on 6/10/22 while she was in route to the facility and reported that the staff could not locate Resident #1 and that they had looked inside and outside the building. The ADM revealed she pulled up to the facility while speaking with the SW and went to Resident #1's room. The ADM immediately noticed that the window was opened, and that the screen was pushed outward a good way. She called 911 at 8:03 AM and some of the staff jumped in their cars to search in the community. One of the CNAs stopped at the nearest gas station and inquired if Resident #1 had been seen. The attendant reported that they had not seen a man walking. She continued to the gas station near Veterans Boulevard and the attendant had seen a man fitting the description and pointed out the direction that the resident had taken. The CNA continued the search and she located Resident #1 at a local shopping center. The CNA was speaking with Resident #1 trying to get him to allow her to take him back when the DON pulled up, but Resident #1 would not get in either car. The police arrived, and Resident #1 agreed to ride in the police truck. The ADM revealed that Resident #1 rode back to the facility with the officer and was sent out by ambulance with Emergency Medical Team (EMT) to the local emergency room (ER) for evaluation and he was admitted to the local hospital and later transferred to a Behavioral Health Unit for Geri-Psych. The ADM called the elopement to the state on 6/10/2022 at 8:22 AM. The ADM revealed that the facility does have the police report, in-services were done with staff, windows were adjusted to only open 4 inches, audits for risk of wandering /elopement completed for all residents. The ADM revealed that the Wandering/Risk for Elopement Assessment is completed on admission, quarterly, hospital return, and as needed for all the residents at the facility and interventions are initiated as score indicates. On 6/20/2022 at 11:55 AM, an interview with CNA #1 confirmed that on 6/10/2022 while passing out breakfast trays in the dining room she noticed that Resident #1's breakfast tray was still on the cart and that he was not in the dining room. She went to get him but was unable to locate him in his room or the usual areas that he would be. She notified the nurse and immediately began to search for him inside and outside the building and then a few staff went searching the highway. The staff were keeping in contact with each other via cell phone, each searching in a different direction. CNA #1 revealed that she was surprised that Resident #1 went outside as he has never attempted to exit the building to her knowledge. Resident #1 usually walks around offering to help someone or he visits other residents, therapy, or social worker. On 6/20/2022 at 12:25 PM, an interview with CNA #3 revealed that on 6/10/2022 she was passing breakfast when she noticed Resident #1 was not sitting in his usual place. She went to check on him in his room and bathroom, he was not in his room and the nurse was notified and a further search was initiated. When Resident #1 could not be located in his usual areas a Dr. Wander code was called, and a more extensive search began. CNA #3 revealed that she went out one door and another aide went out the front door and they searched all the grounds of the facility including sheds/outbuildings. CNA #3 revealed that they got in cars and began searching the roads stopping at businesses asking had they seen a man by the resident's description. When CNA #3 got to the gas station/convenience store near Veterans Boulevard the store owner had seen the resident and pointed her to the direction he had gone. CNA #3 revealed she turned on Veterans Boulevard and located Resident #1 at a local shopping center that was across from a restaurant. He was wearing a hunter's orange cap, blue jeans, dark colored pull over shirt with vest on, tennis shoes and was carrying a clear garbage bag with clothes, toothpaste, toothbrush, Pepsi soda, and other of his belongings. CNA #3 revealed she notified the facility that the resident was found and that the DON arrived and then the police arrived. CNA #3 revealed that the resident wanted to ride with the police officer back to the facility. On 6/20/2022 at 12:40 PM, an interview with CNA #4 revealed that when she made rounds between 5:00 AM to 6:30 AM that she noticed that Resident #1 was not in his bed however the bed was unmade, and she revealed it was his habit to walk in the halls and to visit other residents and making his way to breakfast so she did not think anything of him not being in his room. CNA #4 revealed that she did not notice the window while she was in that room. She checked Resident #1's two roommates, she never noticed Resident #1 and finished her shift leaving the facility. On 6/20/2022 at 1:45 PM, an interview with Licensed Practical Nurse (LPN) #1 revealed that she worked the 11 to 7 shift on 6/9/2022 which ended on 6/10/2022. LPN #1 revealed that she last personally laid eyes on Resident #1 around midnight, he walked up to the desk fully dressed, with a hat on wanting to show her something in his room. LPN #1 went to Resident #1's room where he showed her some pictures that he wanted her to keep for him as he was going to Alabama. LPN #1 revealed that she talked to him, and he agreed to lay down and go to sleep. She left the room while he was laying on the bed. She revealed that she failed to go back and do follow up checks on Resident #1. LPN #1 revealed that Resident #1 had never tried to leave and that he did have a wander-guard on, he did have orders to be seen every 1 hour and that she should have laid eyes on him again. She revealed she failed to recheck on him. LPN #1 revealed that she had received a reprimand for her inaction. On 6/20/2022 at 2:00 PM, an interview with the DON revealed that she had been notified by cell phone while in route to work on 6/10/2022 that Resident #1 was missing. She had made calls to the 11-7 shift staff while in route to determine when the resident was last seen in the facility. Upon arriving to the facility, the DON revealed that several staff were searching outside the building and that the ADM was with the police who were discussing starting a search in the nearby wooded area. The DON revealed that she got back in her car and started searching the community, she searched the college campus and nearby streets then she turned on Veterans Boulevard and saw the CNA pulled over talking to the resident trying to get him in her car, but he would not get in the car. The DON was coaxing him to get in her car when the police arrived. The policeman spoke with the resident and the resident wanted to ride with the police officer. The DON revealed that the resident rode back to the facility and the EMTs were waiting to transfer him to the local hospital ER for an evaluation and possible admit. On 6/20/2022 at 3:30 PM, an interview with the DON revealed that on 6/10/2022 that she retraced the possible route using interviews from business owners along the way to retrace Resident #1's possible route. The DON revealed that the resident was seen at 6:16 AM and again at about 6:33 AM, leaving the convenience store crossing the street to continue on Veterans Blvd. The DON calculated the resident walked approximately 2.6 miles. On 6/21/2022 at 9:15 AM, an interview with LPN #3 revealed that he was working the 7 AM to 3 PM shift on 6/10/2022 and that when he arrived for his shift, he did not see Resident #1 in the dining room where he usually would be at that time. LPN #3 revealed that he made his rounds to check on all his residents and when he came to Resident #1's room he wasn't in the bed, and he believed Resident #1 to be in the bathroom. LPN #3 revealed that the CNA passing trays for breakfast went to the room to get Resident #1 and discovered that he was not in the room or bathroom, she reported to me, and we started looking for him in all the places he usually visited. LPN #3 revealed the SW had arrived, and she helped as well. The SW called a Dr. Wander code and we all started looking even outside. On 6/21/2022 at 9:26 AM, an interview with the Social Worker (SW) revealed that when she got to work on the morning of 6/10/2022 she was told by a CNA that Resident #1 was missing, she assisted with looking for him at his usual hang outs in the facility and when he wasn't located, she called a Code Dr. Wanderer, and everyone assisted with locating the resident. One of the staff noticed the window was opened in Resident #1 room with the screen pushed out and that's when 911 was called and the emergency responders came, some of the staff got in their cars and searched in the community. The SW revealed that one of the CNA's located Resident #1 a little over 2 miles away in front of a local shopping center. Record review of the facility electronic record titled Face Sheet for Resident #1 revealed that the resident was admitted on [DATE]. Admitting diagnoses included Gout, Major depressive disorder recurrent unspecified, Anxiety Disorder, Essential Hypertension, Unspecified Open Angle [CONDITION(S)], and Unspecified [CONDITION(S)]. Record review of the elopement care plan for Resident #1 revealed, Problem Onset: 12/16/2020 Problem/Need: Risk for elopement .Approaches: Check placement and function of wander guard every shift . Visual Checks every hour . Record review of the Risk of Elopement Evaluation form dated 12/15/2020 for Resident #1 revealed that Resident #1 was oriented to person, place, and situation, he had a history of wandering aimlessly, he made statements such as I'm going home, how do I get there and have to catch a bus? His ability is that he ambulates (walks) independently. The evaluation revealed that it was necessary for the resident to be wearing a monitoring bracelet that would alarm when he got too close to the doors. This evaluation was updated and reviewed in March of 2022 by the SW. Record review of the Physician Orders for Resident #1 revealed that on 12/15/2020 an order was written for visual checks every hour. The same day an order was written to check Wander Guard placement and function every shift. Record review of Resident #1's Section C of the Minimum Data Set (MDS) revealed that on 5/23/2022 the Brief Interview for Mental Status (BIMS) score was 99 due to the resident was unable to complete the BIMS. Record review of facility electronic record titled Departmental Notes revealed that on 6/10/2022 at 12:04 AM, a nurse's note was written by LPN #1 that revealed . Resident awake et (and) alert stated, I'm Going to Alabama for three days, Redirected per this nurse with success. Resident lying in bed resting at this time. Skin warm and dry. Resp. (respirations) even/unlabored without SOB (shortness of breath) noted. No adverse reactions noted. 0 (no) acute distress noted, call light within reach. Record review of police report titled Tupelo Police Department Offense/Incident Report revealed that on 6/10/2022 at approximately 8:03 AM an Officer was dispatched to the facility in regard to a missing person. Upon arrival, he made contact with the administrator of the nursing home. She stated that one of their residents identified as Resident #1 was last seen around 1:00 o'clock this morning or two o'clock this morning. The officer was provided all relevant information on Resident #1 and a photo to identify him. A Detective was notified of the incident. The employees from the nursing rehab located Resident #1 at a business and the Detective Transported Resident #1 back to the facility where Medics were waiting, and Resident #1 left in ambulance in route to the local hospital. Record review of LPN #1's New Hire Orientation Acknowledgement of Receipt Form revealed that on 10/12/21 that LPN #1 signed the form that stated I have read and acknowledge receipt of the following facility, policies and procedures or have been provided training in the areas listed. I will comply with guidelines outlined in the policies and training and I understand that failure to do so may result in disciplinary or legal action. Abuse Prevention Policy and Video . Electronic record review titled E flowsheet for Resident #1 revealed that it is documented by LPN #1 that his visual checks were completed on every hour from 12:00 AM to 6 AM on 6/10/2022. Tupelo Nursing and Rehabilitation Center, LLC IJ Removal Plan The facility failed to provide supervision to prevent an elopement for Resident #1, who was a wandering risk and had an order for visual checks every hour. Resident #1 was diagnosed with anxiety disorder and Major Depressive Disorder. The resident left the facility through a window unnoticed and unsupervised until the resident was located in a community approximately 2.6 miles away from the facility. The Resident was last seen in the facility at 12:04 AM on 6/10/22 and was not discovered to be missing until 7:15 AM and was later located by staff at 8:25 AM on 6/10/22. Immediate Actions: On 6/10/2022 these actions were initiated and completed. On 6/10/ 2022 8:15 AM, the facility performed a 100% head count, to ascertain location of every resident this was completed by charge nurse on each unit. On 6/10/2022 8:22 AM, the Mississippi State Department of health notified of missing resident by Executive Director. On 6/10/2022 8:25 AM, the Director of Nursing and a Certified Nursing Assistant located resident in community approximately 2.6 miles away per private car. Resident was returned to facility by police car. Resident #1 appeared to have no injuries when returned to the facility. No body audit was completed by staff due to ambulance on site to transfer to local hospital for full evaluation, where resident was found to have no body injuries. Resident #1 was fully supervised by Director of Nursing until transferred to local hospital by Emergency Medical Teams (EMTs) at 8:40 AM. On 6/10/22 at 8:50 AM, the Maintenance Director and assistant placed screws in all windows to prevent opening greater than 4 inches. Facility Staff was in-serviced how to open windows with screwdriver by Maintenance Director, and screwdriver was placed on each med-cart. On 6/10/22 at 9:00 AM, an in-service was initiated on elopement protocol to include every one-hour checks on all residents assessed with elopement risk and abuse prevention for all staff by Executive Director and Director of Nursing completed by 6/15/2022 with no staff allowed to work until in-service completed. On 6/10/2022 at 9:00 AM, through 4 :00 PM All residents with risk of elopements were reevaluated, pocket care guides, and care plans were updated by Director of Nursing, Social Service, and unit manager to ensure all residents for risk for elopement had appropriate interventions in place. On 6/10/22 at 4:00 PM, emergency Quality Assurance (QA) meeting held related to elopement, and interventions put in place. No changes in policy and procedures made. Attendees for this meeting were Executive Director, Social Service, Director of Nursing and Medical Director per phone. On 6/10/22 Social service Director initiated Elopement Alarm Drill calling a Dr. Wander with the 7-3 shift at 7:52 AM, 3-11 shift at 3:24 AM. Then 6/11/22 11-7 shift at 6:36 AM. On 6/14/22 at 4:40 PM, Licensed Practical Nurse (LPN#1) called Executive Director and stated she was going to tell the truth, that she did not do visual checks on this resident as documentation indicated on Electronic Flow Sheet. On 6/15/22 at 6:40 AM, Disciplinary action for falsifying documentation was given to LPN #1 by Executive Director. On 6/22/2022 at 3:09 PM, the Executive Director filed a complaint with The Mississippi Board of Nursing concerning LPN #1 for false documentation on Resident #1 Electronic Flow Record. On 6/22/2022 at 3:30 PM, LPN # 1 was terminated by Executive Director for falsifying documentation. On 6/22/2022 at 3:40 PM, Emergency QA called with the following attendance: Executive Director, Director of Nurses, Social Services, Minimum Data Sets (MDS). Director, Maintenance Director, Medical Director and Vice President. No policy and procedure changes made, QA reviewed Immediate Jeopardy Removal Plans deficiencies and plans of corrections. On 6/22/2022 at 5:00 PM, Executive Director and Director of Nursing were In-serviced on Abuse and Neglect by Vice President to include instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. Facility alleges compliance and removal of immediate jeopardy as of 6/23/2022. State Agency (SA) Validation on 6/24/2022: The State Agency (SA) validated through record review and interview with the Executive Director that on 6/10/2022 at 8:15 AM, the facility performed a 100% head count, to ascertain location of every resident this was completed by charge nurse on each unit. The SA validated through record review and interview with the Executive Director (ADM) that on 6/10/2022 at 8:22 AM, the Mississippi State Department of health notified of missing resident by the Executive Director. The SA validated through interview with the Director of Nursing (DON) and record review that on 6/10/2022 at 8:25 AM the Director of Nursing and a Certified Nursing Assistant located resident in community approximately 2.6 miles away per private car. Resident was returned to facility by police car. Resident #1 appeared to have no injuries when returned to the facility. No body audit was completed by staff due to ambulance on site to transfer to local hospital for full evaluation, where resident was found to have no body injuries. Resident #1 was fully supervised by Director of Nursing until transferred to local hospital by the Emergency Medical Teams (EMTs) at 8:40 AM. The SA validated through interview with the Maintenance Director and record review that on 6/10/22 at 8:50 AM, the Maintenance Director and assistant placed screws in all windows to prevent opening greater than 4 inches. Facility Staff was in-serviced how to open windows with screwdriver by Maintenance Director, and screwdriver was placed on each med-cart. The SA validated through interviews with the ADM and DON, and record review that on 6/10/22 at 9:00 AM, an in-service was initiated on elopement protocol to include every one-hour checks on all residents assessed with elopement risk and abuse prevention for all staff by Executive Director and Director of Nursing completed by 6/15/2022 with no staff allowed to work until in-service completed. The State Agency SA validated through interview with the DON and record review that on 6/10/2022 at 9:00 AM, through 4 :00 PM, that all residents with the risk of elopements were reevaluated, pocket care guides, and care plans were updated by Director of Nursing, Social Service, and unit manager to ensure all residents for risk for elopement had appropriate interventions in place. The SA validated through interview with the ADM, DON, Social Services, and Medical Director and record review that on 6/10/22 at 4:00 PM, an emergency Quality Assurance (QA) meeting was held related to elopement, and interventions put in place. No changes in policy and procedures made. Attendees for this meeting was Executive Director, Social Service, Director of Nursing and Medical Director per phone. The SA validated through interview with the Social Services Director and record review that on 6/10/22 the Social Service Director initiated Elopement Alarm Drill calling a Dr. Wander with the 7-3 shift at 7:52 AM, 3-11 shift at 3:24 AM. Then on 6/11/22 11-7 shift at 6:36 AM. The SA validated through Interview with the ADM and record review that on 6/14/22 at 4:40 PM, Licensed Practical Nurse (LPN#1) called Executive Director and stated she was going to tell the truth, that she did not do visual checks on this resident as documentation indicated on Electronic Flow Sheet. The SA validated through interview with the ADM and record review that on 6/15/22 at 6:40 AM, Disciplinary action for falsifying documentation was given to LPN #1 by Executive Director. The SA validated through interview with the ADM and record review that on 6/22/2022 at 3:09 PM, the Executive Director filed a complaint with The Mississippi Board of Nursing concerning LPN #1 for false documentation on Resident #1 Electronic Flow Record. The SA validated through interview with the ADM and record review that on 6/22/2022 at 3:30 PM LPN #1 was terminated by Executive Director for falsifying documentation. The SA validated through interview with the ADM, DON, and Medical Director and record review that on 6/22/2022 at 3:40 PM, an emergency QA was called with the following attendance: Executive Director, Director of Nurses, Social Services, Minimum Data Sets (MDS). Director, Maintenance Director, Medical Director and Vice President. No policy and procedure changes made, QA reviewed Immediate Jeopardy Removal Plans deficiencies and plans of corrections. The State Agency (SA) validated through interview with the ADM and DON and record review that on 6/22/2022 at 5:00 PM, the Executive Director (ADM) and Director of Nursing were In-serviced on Abuse and Neglect by Vice President to include instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. The SA validated that all corrective actions to remove the IJ had been completed as of 6/22/2022, and the IJ was removed on 6/23/2022, prior to exit.

Based on interview, record review, and facility policy review, the facility failed to ensure the medical record was accurately documented in accordance with accepted professional standards and practices for one (1) of five (5) residents reviewed, Resident #1. The facility failed to provide supervision to prevent an elopement for Resident #1, who was a wandering risk and had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was last seen in the facility at 12:04 AM on 6/10/2022. The medical record was documented that the resident received visual checks every hour on 6/10/2022 from 12:00 AM until 6:00 AM. The facility nurse later admitted on [DATE] that she had falsely documented the visual checks. The resident was not discovered to be missing until 7:15 AM on 6/10/2022 and was later located by facility staff at 8:25 AM on 6/10/2022. The facility's failure to provide supervision to a resident who was a wandering risk and had orders for hourly visual checks placed this resident and other residents at risk of elopement a situation that has caused or is likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 6/10/2022 when Resident #1 left the facility through a window unnoticed and unsupervised until the resident was located in the community approximately 2.6 miles away from the facility. The facility Administrator was notified of the IJ on 6/22/2022 at 2:35 PM. The facility provided an acceptable Removal Plan on 6/23/22, in which the facility alleged all corrective actions were completed to remove the IJ on 6/22/2022, and the IJ removed on 6/23/2022. The State Agency (SA) determined the IJ was removed on 6/23/2022, prior to exit, and the scope and severity for F 842 was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled Medical Records dated 2/17 revealed Policy: The facility shall have a system that facilitates the retrieval of information regarding individual residents .Procedure # 2: Shall meet the following requirements: a. Record entries shall be made by the person providing or service or observing the occurrence that is being recorded . Record review of the facility investigation Supervisor Investigation Summary Form revealed . Date of Event: 6-10-22, Time of Event: 7:52 AM, How and When was event discovered: On 6-10-22, staff went to resident's room to get him for breakfast and noticed that he was not in the room. Briefly describe event: On 6/10/2022 at approximately 7: 15 AM, staff went into the resident's room to get him for breakfast. Resident was noted to not be in his room. Staff then began to look about the facility for the resident and still could not find the resident. Staff then began to look outside of the facility for the resident. Social Service was notified. Dr. Wander was called, and all staff immediately begin looking for the resident. Executive Director was notified. Director of Nursing was notified. At approximately 8:00 AM, staff noticed that the resident's window in (Resident #1's room) was open and that the screen was pushed out. 911 was notified. Staff continued searching for resident outside of the building and began searching in the community. A staff member found the resident approximately 2.6 miles from facility at Veterans Square at 8:25 AM. Resident refused to get in the car with the staff member. Director of Nursing arrived and spoke with resident. The resident was in agreement to go with the Director of Nursing when the police arrived on the scene. The police officer then spoke to the resident and resident agreed to ride with the police officer. Resident keep saying that he needed to get to Alabama. He was outside approximately 2 to 3 hours, according to staff statements. It was approximately 71 degrees he was wearing blue jeans, dark colored pull over shirt with a vest on, tennis shoes and carrying a garbage bag with his belongings. He suffered no injuries .II. Investigation: (Formal Name of Resident #1) resident of Tupelo Nursing and Rehabilitation admitted on [DATE]. (Formal Name of Resident #1) had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident has not had exit seeking behavior since admission. He does state that he wants to leave go home to Alabama when he is in an anxiety state. (Formal Name of Resident #1) is alert can state date and time, person and place, current events. But he is paranoid and speaks about wanting to leave since admission to facility. He feels his family stole from him and becomes agitated at times with staff and other residents thinking someone will harm him, he is redirected easily. (Formal Name of Resident #1) was able to sign himself into facility and can make decisions. He sleeps fully dressed with shoes on. Gets up frequently at night, has history of pacing and wandering halls, sits in lobby frequently, but has never actually attempted to exit. On 6/10/22 he did state he was going to Alabama and his nurse was able to redirect him and he laid down in his bed as usual. (Formal Name of Certified Nursing Assistant (CNA) #4) states she was in the room between 5:00 am and 6:30 am to assist with the other 2 roommates, and he was not in his room, nor did she notice anything at window, employee states she did not go over to the window. (Formal Name of CNA#4) did not feel this was an unusual occurrence due to resident gets up and down frequently every night. Neither staff member felt there was anything unusual with this resident's behavior. (Formal Name of Resident #1) was taken to hospital after he was found at Veterans Square for examination. He was not injured but was sent to (Formal Name of Hospital) for evaluation and possible treatment .After a thorough investigation, Tupelo Nursing and Rehabilitation was able to substantiate that the resident did exit the premises by leaving out of his window Electronic record review titled e Flowsheet for Resident #1 revealed that it is documented by Licensed Practical Nurse (LPN) #1 that her visual checks were completed on every hour from 12:00 AM to 6 AM on 6/10/2022. Record review of the Physician Orders for Resident #1 revealed that on 12/15/2020 an order was written for visual checks every hour. On 06/20/2022 at 1:45 PM, an interview with Licensed Practical Nurse (LPN) #1 revealed she admitted that she had initialed in the electronic record titled e Flowsheet for Resident #1's visual checks as if she had laid eyes on him hourly. She revealed that she worked the 11 to 7 shift on 6/9/2022 which ended on 6/10/2022. LPN #1 revealed that she last personally laid eyes on Resident #1 around midnight, he walked up to the desk fully dressed, with a hat on wanting to show her something in his room. LPN #1 went to Resident #1's room where he showed her some pictures that he wanted her to keep for him as he was going to Alabama. LPN #1 revealed that she talked to him, and he agreed to lay down and go to sleep. She left the room while he was laying on the bed. She revealed that she failed to go back and do follow up visual checks on Resident #1. LPN #1 revealed that Resident #1 had never tried to leave and that he did have a wander-guard on. She stated that he did have orders to be seen every 1 hour and that she should have laid eyes on him again. On 06/22/2022 at 11:30 AM, an interview with the Administrator (ADM)/Executive Director revealed that on 6/10/2022, when they first knew of the elopement of Resident #1, she was unaware that the nurse had not seen him since midnight and that at first LPN #1 reported to her that she had seen him between 5 AM and 6 AM. On 6/14/2022, the nurse phoned the ADM admitting that she had not actually laid eyes on Resident #1 since around midnight. The ADM then scheduled a time the morning of 6/15/2022 to meet with LPN #1 for counseling conference and she was reprimanded. Record review of the Employee Personnel file revealed that on 6/15/2022 LPN #1 received an Employee Corrective Counseling Memorandum .Category One Warning: If a further incident of this nature occurs, your employment will be terminated. from the ADM related to the Employee falsified inaccurate information on a resident's e-Tar who was not in the facility . Record review of the Job Description signed by LPN#1 on 10/12/21, revealed, Job Title: LPN Charge Nurse, Effective Date: 1/01/2017 .Essential Duties .7. Updates and maintains accurate resident clinical files Tupelo Nursing and Rehabilitation Center, LLC IJ Removal Plan The facility failed to provide supervision to prevent an elopement for Resident #1, who was a wandering risk and had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident left the facility through a window unnoticed and unsupervised until the resident was located in a community approximately 2.6 miles away from the facility. The Resident was last seen in the facility at 12:04 AM on 06/10/22 and was not discovered to be missing until 7:15 AM and was later located by staff at 8:25 AM on 06/10/22. Immediate Actions: On 6/10/2022 these actions were initiated and completed. On 6/10/ 2022 8:15 AM, the facility performed a 100% head count, to ascertain location of every resident this was completed by charge nurse on each unit. On 6/10/2022 8:22 AM, the Mississippi State Department of health notified of missing resident by Executive Director. On 6/10/2022 8:25 AM, the Director of Nursing and a Certified Nursing Assistant located resident in community approximately 2.6 miles away per private car. Resident was returned to facility by police car. Resident #1 appeared to have no injuries when returned to the facility. No body audit was completed by staff due to ambulance on site to transfer to local hospital for full evaluation, where resident was found to have no body injuries. Resident #1 was fully supervised by Director of Nursing until transferred to local hospital by Emergency Medical Teams (EMTs) at 8:40 AM. On 6/10/22 at 8:50 AM, the Maintenance Director and assistant placed screws in all windows to prevent opening greater than 4 inches. Facility Staff was in-serviced how to open windows with screwdriver by Maintenance Director, and screwdriver was placed on each med-cart. On 6/10/22 at 9:00 AM, an in-service was initiated on elopement protocol to include every one-hour checks on all residents assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/10/2022 at 9:00 AM, through 4 :00 PM All residents with risk of elopements were reevaluated, pocket care guides, and care plans were updated by Director of Nursing, Social Service, and unit manager to ensure all residents for risk for elopement had appropriate interventions in place. On 6/10/22 at 4:00 PM, emergency Quality Assurance (QA) meeting held related to elopement, and interventions put in place. No changes in policy and procedures made. Attendees for this meeting were Executive Director, Social Service, Director of Nursing and Medical Director per phone. On 6/10/22 Social service Director initiated Elopement Alarm Drill calling a Dr. Wander with the 7-3 shift at 7:52 AM, 3-11 shift at 3:24 AM. Then 6/11/22 11-7 shift at 6:36 AM. On 6/14/22 at 4:40 PM, Licensed Practical Nurse (LPN#1) called Executive Director and stated she was going to tell the truth, that she did not do visual checks on this resident as documentation indicated on Electronic Flow Sheet. On 6/15/22 at 6:40 AM, Disciplinary action for falsifying documentation was given to LPN #1 by Executive Director. On 6/22/2022 at 3:09 PM, the Executive Director filed a complaint with The Mississippi Board of Nursing concerning LPN #1 for false documentation on Resident #1 Electronic Flow Record. On 6/22/2022 at 3:30 PM, LPN # 1 was terminated by Executive Director for falsifying documentation. On 6/22/2022 at 3:40 PM, Emergency QA called with the following attendance: Executive Director, Director of Nurses, Social Services, Minimum Data Sets (MDS). Director, Maintenance Director, Medical Director and Vice President. No policy and procedure changes made, QA reviewed Immediate Jeopardy Removal Plans deficiencies and plans of corrections. On 6/22/2022 at 5:00 PM, Executive Director and Director of Nursing were In-serviced on Abuse and Neglect by Vice President to include instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. Facility alleges compliance and removal of immediate jeopardy as of 6/23/2022 State Agency (SA) Validation on 06/24/2022 The State Agency (SA) validated through record review and interview with the Executive Director that on 6/10/ 2022 at 8:15 AM, the facility performed a 100% head count, to ascertain location of every resident this was completed by charge nurse on each unit. The SA validated through record review and interview with the Executive Director (ADM) that on 6/10/2022 at 8:22 AM, the Mississippi State Department of health notified of missing resident by the Executive Director. The SA validated through interview with the Director of Nursing (DON) and record review that on 6/10/2022 at 8:25 AM the Director of Nursing and a Certified Nursing Assistant located resident in community approximately 2.6 miles away per private car. Resident was returned to facility by police car. Resident #1 appeared to have no injuries when returned to the facility. No body audit was completed by staff due to ambulance on site to transfer to local hospital for full evaluation, where resident was found to have no body injuries. Resident #1 was fully supervised by Director of Nursing until transferred to local hospital by the Emergency Medical Teams (EMTs) at 8:40 AM. The SA validated through interview with the Maintenance Director and record review that on 6/10/22 at 8:50 AM, the Maintenance Director and assistant placed screws in all windows to prevent opening greater than 4 inches. Facility Staff was in-serviced how to open windows with screwdriver by Maintenance Director, and screwdriver was placed on each med-cart. The SA validated through interviews with the ADM and DON, and record review that on 6/10/22 at 9:00 AM, an in-service was initiated on elopement protocol to include every one-hour checks on all residents assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The State Agency SA validated through interview with the DON and record review that on 6/10/2022 at 9:00 AM, through 4 :00 PM, that all residents with the risk of elopements were reevaluated, pocket care guides, and care plans were updated by Director of Nursing, Social Service, and unit manager to ensure all residents for risk for elopement had appropriate interventions in place. The SA validated through interview with the ADM, DON, Social Services, and Medical Director and record review that on 6/10/22 at 4:00 PM, an emergency Quality Assurance (QA) meeting was held related to elopement, and interventions put in place. No changes in policy and procedures made. Attendees for this meeting was Executive Director, Social Service, Director of Nursing and Medical Director per phone. The SA validated through interview with the Social Services Director and record review that on 6/10/22 the Social Service Director initiated Elopement Alarm Drill calling a Dr. Wander with the 7-3 shift at 7:52 AM, 3-11 shift at 3:24 AM. Then on 6/11/22 11-7 shift at 6:36 AM. The SA validated through Interview with the ADM and record review that on 6/14/22 at 4:40 PM, Licensed Practical Nurse (LPN#1) called Executive Director and stated she was going to tell the truth, that she did not do visual checks on this resident as documentation indicated on Electronic Flow Sheet. The SA validated through interview with the ADM and record review that on 6/15/22 at 6:40 AM, Disciplinary action for falsifying documentation was given to LPN #1 by Executive Director. The SA validated through interview with the ADM and record review that on 6/22/2022 at 3:09 PM, the Executive Director filed a complaint with The Mississippi Board of Nursing concerning LPN #1 for false documentation on Resident #1 Electronic Flow Record. The SA validated through interview with the ADM and record review that on 6/22/2022 at 3:30 PM LPN #1 was terminated by Executive Director for falsifying documentation. The SA validated through interview with the ADM, DON, and Medical Director and record review that on 6/22/2022 at 3:40 PM, an emergency QA was called with the following attendance: Executive Director, Director of Nurses, Social Services, Minimum Data Sets (MDS). Director, Maintenance Director, Medical Director and Vice President. No policy and procedure changes made, QA reviewed Immediate Jeopardy Removal Plans deficiencies and plans of corrections. The State Agency (SA) validated through interview with the ADM and DON and record review that on 6/22/2022 at 5:00 PM, the Executive Director (ADM) and Director of Nursing were In-serviced on Abuse and Neglect by Vice President to include instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. The SA validated that all corrective actions to remove the IJ had been completed as of 6/22/2022, and the IJ was removed on 6/23/2022, prior to exit.

Based on observation, staff and resident interview, facility policy review, Mississippi (MS) State Board of Nursing website review, and the Nurse Practice Act, the facility failed to ensure qualified staff, a Registered Nurse (RN) and/or Respiratory Therapist (RT), were available 24 hours each day and designated on the care plan, to perform deep suctioning (if needed), provide consistent respiratory care services, and/or provide other emergency care, to a resident with a [MEDICAL CONDITION] (Trach), for one (1) of 1 resident reviewed with a [MEDICAL CONDITION], Resident #99. On 02/02/2020, an observation was made of Resident # 99, lying in the bed, alert and oriented to surroundings, with [MEDICAL CONDITION] in place, securing the resident'[MEDICAL CONDITION]. Review of the facility's Daily Nursing Staff Posting dated 02/02/2020, indicated there was one (1) RN scheduled for the 7A-3P shift, but lacked RN coverage for the 3 PM-11 PM and 11 PM-7 AM shift. Review of the staffing schedule and time cards, during the period of 03/22/2019 through 02/02/2020, revealed the facility had 137 days without 24 hour Registered Nurse (RN) or Respiratory Therapist (RT) coverage for the 3 PM-11 PM and 11 PM-7 AM shifts to [MEDICAL CONDITION] for Resident #99, in the event of a need for deep suctioning or emergency care. The facility's failure to provide 24 hour per day services of a RN or a RT for possible deep suctioning and other emergency [MEDICAL CONDITION] care, had caused, or was likely to cause, serious harm, injury, impairment, or death to residents with a [MEDICAL CONDITION]. This affected Resident #99. The situation was identified as an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 03/22/2019, and was present until 02/02/2020, which was for 137 days that the facility did not provide RN or RT coverage for all 24 hour a day shifts. The SA notified the Administrator on 02/03/2020 of the IJ and SQC. The facility submitted an acceptable Removal Plan on 02/03/2020, in which the facility alleged all corrective actions were completed on 02/03/2020, and the IJ was removed as of 02/03/2020. The SA validated the Removal Plan on 02/04/2020 and determined that the IJ was removed prior to exit. Therefore, the scope and severity for the IJ at CFR(s): 483.21(b)(3)(ii), Comprehensive Resident Centered Care Plans-Qualified Persons, (F659), was lowered to a D level, while the facility develops and implements a Plan of Correction (POC) and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory requirements. Findings include: Review of the facility's Comprehensive Person Centered Care Plans policy, dated 03/2018, revealed: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Review of the facility's statement, undated and signed by the Administrator, revealed the facility does not have a written policy related to staffing. The statement further revealed the facility follows the MS Minimum Standard for the Aged and Infirm guidelines, related to staffing. Review of the MS State Board of Nursing (BON) website, revealed frequently asked questions (FAQ's). The BON's statement regarding the LPN's scope of practice with [MEDICAL CONDITION] care revealed: It is within the scope of practice of the LPN to [MEDICAL CONDITION] and suction secretions from [MEDICAL CONDITION]. However, it is not within the scope of practice for the LPN to perform deep right main stem suctioning. If deep suctioning is required for a patient, a Registered Nurse (RN) must perform the procedure. Review of the facility's Face Sheet, revealed the facility initially admitted Resident #99 on 08/31/2011, and readmitted on [DATE]. Resident #99's [DIAGNOSES REDACTED]. Review of Resident #99's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/19, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. Review of Resident #99's Plan of Care, with a problem onset date of 11/27/2012, revealed Resident #99 was at risk for increased respiratory difficulties related to having a [MEDICAL CONDITION]. The goal included Resident #99 would not display any unnoted respiratory difficulty through target date. The approaches revealed, may suction trach, [MEDICAL CONDITION] as per physician's orders [REDACTED]. Review of Resident #99's physician's orders [REDACTED].#14 French (FR) Suction Catheter as needed for excessive secretions. The order did not address whether to shallow suction or deep suction, nor who was responsible to carry out this order. Review of the medical record revealed Resident #99 had an Emergency Department visit with a [DIAGNOSES REDACTED]. Resident #99 was also seen by the Pulmonologist on 01/23/2020 with a [DIAGNOSES REDACTED]. On 02/02/2020 at 10:30 AM, an observation and review of the facility staffing posted in the front lobby revealed the Daily Nursing Staff Posting, dated 02/02/2020, which indicated the 7 AM-3 PM shift had one (1) RN scheduled for an eight (8) hour shift. The daily staffing lacked RN coverage for the 3 PM-11 PM and 11 PM-7 AM shifts for 02/02/2020. On 02/02/2020 at 10:40 AM, the Director of Nursing (DON) stated they typically have RN coverage on a twenty-four a day, and seven days a week (24/7) basis. The DON confirmed they did not have a RN for the 3 PM-11 PM and 11 PM-7 AM shifts for 02/02/2020 and did not have a Respiratory Therapist (RT) in the building to provide emergency care to a resident who has a [MEDICAL CONDITION] in the event that emergency care was needed. The DON also confirmed that she was aware that a resident with a [MEDICAL CONDITION] required either an RN or an RT for deep suctioning. The DON stated Resident #99 had not required deep suctioning that she knew of. The DON confirmed that the Care Plan did not indicate who was responsible for providing deep suction of Resident #99. On 02/02/2020 at 10:45 AM, an interview with the Staff Development Nurse revealed, she stated, We have RN coverage during the week, but it varies on the weekends. During an observation and interview, on 02/02/2020 at 11:15 AM, Resident #99 was observed lying in the bed, alert and oriented to surroundings, [MEDICAL CONDITION] in place securing resident'[MEDICAL CONDITION]. [MEDICAL CONDITION] capped with a speaking valve. An observation was made of a suction machine at Resident #99's bedside. Resident #99 stated [MEDICAL CONDITION] was done every three (3) days on Monday, Wednesday and Friday. Resident #99 also stated he goes to the Pulmonologist every 3 months to have his inner cannula changed at the pulmonology clinic. Resident #99 stated he has had deep suctioning to [MEDICAL CONDITION] the past, but it's been months ago. Resident #99 couldn't recall the exact date or month, and wasn't able to recall if it was a RN or a LPN that provided deep suctioning. On 02/02/2020 at 12:25 PM, an interview with the Administrator, revealed he had served as the interim Administrator since December 2019, and he did not think that they have had fulltime RN coverage since he had been there. The Administrator stated he thought the DON was handling it and she should have brought it to his attention that they did not have RN or RT coverage for the care of the [MEDICAL CONDITION] in an event that emergency care was needed. On 02/02/2020 at 1:15 PM, the DON began reviewing the staffing schedule and time cards to verify the days that the facility was without 24/7 RN or RT coverage. During an interview, with the DON, on 02/03/2020 at 8:45 AM, she stated, We were so short on staff that I was trying to keep nurses in the building and I didn't even think about having RN coverage around the clock for the [MEDICAL CONDITION]. The DON stated she was aware that they did not have RN coverage 24/7. On 02/03/2020 at 9:45 AM, during an interview with the Nurse Practitioner (NP), she stated, she was aware that they have had issues with finding an RN. The NP stated they may have an RN on the schedule, but if the RN called in, they had been replacing the RN with an LPN, which doesn't meet the requirements due to the resident with the [MEDICAL CONDITION]. The NP stated that she had worked at the facility for the past seven (7) years and Resident #99 had been the only [MEDICAL CONDITION] in the building, and he had not been sent out for emergency care due to the lack of an RN or RT in the building to provide deep suctioning On 02/03/2020 at 11:25 AM, the DON completed review of the staffing schedules and time cards for the period of time from March 2019 to February 2020. The review revealed there were 137 days without 24 hour RN or RT coverage for the 3 PM-11 PM and 11 PM-7 AM shifts, during the time frame of 03/22/2019 through 02/01/2020. The facility submitted an acceptable Removal Plan on 02/03/2020 at 5:30 PM, in which the facility alleged all corrective actions were completed and the IJ was removed on 02/03/2020. The SA validated the removal Plan on 02/04/2020 and determined the IJ was removed on 02/03/2020. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit: The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), on 02/03/2020, when the facility failed to ensure qualified staff were present 24 hours per day to perform deep suctioning of a [MEDICAL CONDITION] and other emergency procedures if needed, for Resident #99. The facility Executive Director, Director of Nursing and Assistant Director of Nursing were notified 2/3/2020 at 12:10 PM of Immediate Jeopardy (IJ)and Substandard Quality of Care (SQC) due to the facility failure to have a Registered Nurse or Respiratory Therapist available 24 hours per day, 7 days per week to provide deep suctioning in the event emergency care was needed. Resident #99 was admitted to the facility on [DATE] with a [MEDICAL CONDITION]. This placed Resident #99 at risk for serious injury, harm, impairment or death. He was identified as the only resident with a [MEDICAL CONDITION]. During the period of March 2019-February 2020 the staffing schedule and time cards revealed 137 days without 24 hour Registered Nurse or Respiratory Therapist coverage for the 3 PM-11 PM and 11 PM-7 AM shifts during the time frame of March 22, 2019 through February 1, 2020. 1. Facility Actions: Upon identification of a lack of Registered Nurse coverage on 02/02/2020 by the State Agency (SA), the Director of Nursing immediately verified Registered Nurse coverage for 02/02/2020 and going forward for each shift for [MEDICAL CONDITION] needs for Resident #99. The Medical Director was notified on 02/02/2020 at 12:22 PM of the need for 24 hour coverage by Registered Nurse or Respiratory Therapist by the Director of Nursing. The Medical Director and Attending Physician for Resident #99 was notified of the Immediate Jeopardy and Substandard Quality of Care at 12:28PM on 02/03/2020 by the Director of Nursing. The comprehensive care plan for Resident #99 was reviewed and updated to reflect the Registered Nurse will provide deep suctioning to the [MEDICAL CONDITION] if needed per MD orders by the Director of Nursing on 02/03/2020 at 3:00PM. 2. Assessment: Resident #99 was fully assessed by the Nurse Practitioner on 02/03/2020 and documentation signed off at 9:15 AM with no acute findings or evidence of respiratory distress. 3. Quality Assurance: An emergency Quality Assurance Committee meeting was held 02/03/2020 at 3:15 PM to review and revise the facility policy for [MEDICAL CONDITION] suctioning which states that all licensed Nursing Personnel or per State Nurse Practice Act/Respiratory Therapist is to be followed regarding [MEDICAL CONDITION] suctioning. Policy has been revised to state that only a Registered Nurse or Respiratory Therapist may perform deep suctioning. In addition, discussion was held regarding the need for 24 hour Registered Nurse or Respiratory Therapist coverage 7 days per week. The Director of Nursing will be responsible for ensuring 24 hours Registered Nurse or Respiratory Therapist coverage 7 days per week. Attendees: Executive Director, Medical Director (via Phone), Director of Nursing, Assistant Director of Nursing, Staff Development, Business office manager and Director of Social Services. 4. In-service: In-service education was initiated on 02/03/2020 by the Staff Development Nurse with all licensed staff regarding the need for a Registered Nurse or Respiratory Therapy coverage 24 hours per day 7 days per week as long as there is a [MEDICAL CONDITION] resident in the facility. The Director of Nursing is to be immediately notified of any schedule change to ensure coverage. No licensed nurse will be allowed to work until in-service education is completed to include new hires. The facility policy for [MEDICAL CONDITION] suctioning will be reviewed as part of the in-service to ensure licensed staff understand the Mississippi Nurse Practice Act which restricts deep right main stem suctioning to be performed only by a Registered Nurse or Respiratory Therapist. The Facility alleged that the Immediate Jeopardy was removed as of February 3, 2020. The SA validated the facility's Removal Plan on 02/04/2020: 1. Facility Actions: The SA validated by record review and interview, the Registered Nurse coverage on 02/04/2020, which the Director of Nursing implemented, for the Registered Nurse coverage for 02/02/2020 and going forward for each shift for [MEDICAL CONDITION] needs for Resident #99. The SA validated by record review and interview, the Medical Director was notified on 2/02/2020 at 12:22 PM of the need for 24 hour coverage by Registered Nurse or Respiratory Therapist by the Director of Nursing. The SA validated by record review and interview, the Medical Director and Attending Physician for Resident #99 was notified of the Immediate Jeopardy and Substandard Quality of Care at 12:28 PM on 02/03/2020 by the Director of Nursing. The SA validated by record review, the comprehensive care plan for Resident #99 was reviewed and updated to reflect the Registered Nurse will provide deep suctioning to the [MEDICAL CONDITION] if needed per MD orders by the Director of Nursing on 02/03/2020 at 3:00 PM. 2. Assessment: The SA validated by interview and record review, Resident #99 was fully assessed by the Nurse Practitioner on 02/03/2020 and documentation signed off at 9:15 AM with no acute findings or evidence of respiratory distress. 3. Quality Assurance: The SA validated by record review and interview, an emergency Quality Assurance Committee meeting was held 02/03/2020 at 3:15 PM. to review and revise the facility policy for [MEDICAL CONDITION] suctioning which stated that all licensed Nursing Personnel or per State Nurse Practice Act/Respiratory Therapist is to be followed regarding [MEDICAL CONDITION] suctioning. Policy has been revised to state that only a Registered Nurse or Respiratory Therapist may perform deep suctioning. In addition, discussion was held regarding the need for 24 hour Registered Nurse or Respiratory Therapist coverage 7 days per week. The Director of Nursing will be responsible for ensuring 24 hours Registered Nurse or Respiratory Therapist coverage 7 days per week. Attendees: Executive Director, Medical Director (via Phone), Director of Nursing, Assistant Director of Nursing, Staff Development, Business office manager and Director of Social Services. 4. In-service: The SA validated by record review and interview, in-service education was initiated on 02/03/2020 by the Staff Development Nurse with all licensed staff regarding the need for a Registered Nurse or Respiratory Therapy coverage 24 hours per day 7 days per week as long as there is a [MEDICAL CONDITION] resident in the facility. The Director of Nursing is to be immediately notified of any schedule change to ensure coverage. No licensed nurse will be allowed to work until in-service education is completed to include new hires. The facility policy for [MEDICAL CONDITION] suctioning will be reviewed as part of the in-service to ensure licensed staff understand the Mississippi Nurse Practice Act which restricts deep right main stem suctioning to be performed only by a Registered Nurse or Respiratory Therapist. The SA validated all corrective actions were taken by the facility and the actions were completed as of 02/03/2020 and the IJ was removed on 02/03/2020, prior to exit.

Based on observation, staff interview, resident interview, facility policy review, Mississippi (MS) State Board of Nursing website review, and the Nurse Practice Act, the facility failed to provide consistent respiratory care services to a resident with a [MEDICAL CONDITION] (Trach) by qualified personnel, a Registered Nurse (RN) and/or Respiratory Therapist (RT), 24 hours each day to deep suction the Trach, if needed and/or provide other emergency care related to the Trach, for one (1) of 1 resident reviewed with a [MEDICAL CONDITION], Resident #99. During a review of the facility's nursing schedule, between March 22, 2019 through February 03, 2020, interview, and record review, the facility did not have Registered Nurse (RN) or Respiratory Therapist (RT) coverage for all shifts for 137 days, which included 3:00 PM-11:00 PM and 11:00 PM - 7:00 AM shifts that weren't covered. Resident #99 had a [DIAGNOSES REDACTED]. Resident #99 had an Emergency Department visit with a [DIAGNOSES REDACTED]. The facility's failure to provide 24 hours per day services of a RN or a RT for possible deep suctioning and other emergency [MEDICAL CONDITION], had caused, or was likely to cause, serious harm, impairment, or death to residents with a [MEDICAL CONDITION]. This affected Resident #99. The SA identified the situation as an Immediate Jeopardy ( IJ) and Substandard Quality of Care (SQC), which began on 03/22/2019 and was present until 02/03/2020, which was a total of 137 days that the facility did not provide RN or RT coverage for all 24 hour a day shifts, to provide deep suctioning and/or [MEDICAL CONDITION], if needed, for Resident #99. The SA notified the Administrator on 02/03/2020 of the IJ and SQC. The facility submitted an acceptable Removal Plan on 02/03/2020, in which the facility alleged all corrective actions were completed on 02/03/2020, and the IJ was removed as of 02/03/2020. The SA validated the Removal Plan on 02/04/2020 and determined that the IJ was removed prior to exit. The scope and severity for the IJ and SQC at CFR 483.25(i) was lowered to a D level, while the facility develops and implements a Plan of Correction (POC) and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory requirements. Findings include: Review of the facility's [MEDICAL CONDITION] Suctioning policy, dated 08/2014, revealed: [MEDICAL CONDITION] suctioning is done to clear the trachea of secretions. Responsibility: All licensed Nursing Personnel or per state practice act/Respiratory Therapist. Review of the Mississippi (MS) State Board of Nursing Laws and Rules Administrative Code Part 2830 Practice of Nursing Title 30: Professions and Occupations Chapter 2, Functions of the Licensed Practical Nurse, (LPN) revealed: Rule 2.1-LPN Supervision, The LPN gives nursing care which does not require the specialized skill, judgement, and knowledge required of an RN, Advanced Practice Registered Nurse (APRN), Licensed Physician, or Licensed Dentist. Review of the MS State Board of Nursing (BON) website, revealed frequently asked questions (FAQ's). The BON's statement regarding the LPN's scope of practice with [MEDICAL CONDITION] care revealed: It is within the scope of practice of the LPN to [MEDICAL CONDITION] and suction secretions from [MEDICAL CONDITION]. However, it is not within the scope of practice for the LPN to perform deep right main stem suctioning. If deep suctioning is required for a patient, a Registered Nurse (RN) must perform the procedure. Review of Resident #99's physician's orders [REDACTED].#14 French (FR) Suction Catheter as needed for excessive secretions. The order did not address whether to shallow suction or deep suction, nor who was responsible to carry out this order. Review of the medical record revealed Resident #99 had an Emergency Department visit with a [DIAGNOSES REDACTED]. Resident #99 was prescribed antibiotics and returned to the facility at that time. Review of the working schedule, from 03/22/2019 to 02/02/2020, revealed a total of 137 days of shifts (3 PM-11 PM, 11 PM-7 AM), in which there was no documented RN coverage for the facility. The facility did not employ a Respiratory Therapist. The facility readmitted Resident #99 on 06/11/2013, with [DIAGNOSES REDACTED]. Review of Resident #99's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2019, revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated full cognitive ability. During an observation and interview, on 02/02/2020 at 11:15 AM, Resident #99 was observed lying in the bed, alert and oriented, with a capped trach, which had a speaking valve attached. There was a suction machine noted at his bedside. Resident #99 revealed he [MEDICAL CONDITION] done every three (3) days on Monday, Wednesday and Friday. Resident # 99 stated he goes to the Pulmonologist every 3 months to have his inner cannula changed at the Pulmonology clinic. Resident #99 stated that he has had deep suctioning to [MEDICAL CONDITION] the past, but it's been months ago. Resident #99 couldn't recall exact date or month, nor recall if the staff that provided deep suctioning, was a Registered Nurse (RN) or a Licensed Practical Nurse (LPN). On 02/02/2020 at 10:30 AM, an observation and review of the facility's Daily Nursing Staff Posting, dated 02/02/2020, posted in the front lobby, indicated on the 7 AM-3 PM shift, there was one (1) RN for an eight hour shift. An observation of the 3 PM-11 PM and 11 PM-7 AM shift, on the daily staffing, dated 02/02/2020, revealed the facility lacked RN coverage. During an interview, on 02/02/2020 at 10:40 AM, the Director of Nursing (DON) stated they typically have RN coverage on a twenty-four a day, and seven days a week (24/7) basis. The DON confirmed the facility did not have a RN for the 3 PM-11 PM and 11 PM-7 AM shifts for 02/02/2020 and did not have a Respiratory Therapist (RT) in the building to provide emergency care to a resident who has a [MEDICAL CONDITION] in the event that emergency care is needed. The DON confirmed she was aware that a resident with a [MEDICAL CONDITION] required either an RN or an RT for deep suctioning. The DON stated Resident #99 had not required deep suctioning that she knew of. The DON revealed she reviewed the medical record back until March 2019 and could not find where Resident #99 was deep suctioned by the nursing staff. On 02/02/2020 at 10:45 AM, during an interview with the Staff Development Nurse, she stated, We have RN coverage during the week, but it varies on the weekends. On 02/02/2020 at 12:25 PM, during an interview with the Administrator, he revealed that he had served as the interim Administrator since December 2019 and he did not think they have had full time RN coverage since he had been there. The Administrator stated the DON should have brought it to his attention that they did not have RN or RT coverage for the care of the [MEDICAL CONDITION], in an event that emergency care was needed. During an interview with the DON, on 02/03/2020 at 8:45 AM, she revealed that she didn't even think about having RN coverage around the clock for the [MEDICAL CONDITION]. The DON stated Resident #99 had been there so long, that she guessed that she just wasn't thinking about it. On 02/03/2020 at 9:45 AM, during an interview with the Nurse Practitioner (NP), she stated, I was aware that they have had issues with finding an RN. They may have an RN on the schedule, but if she calls in, they have been replacing the RN with an LPN, which doesn't meet the requirements due to the resident with the [MEDICAL CONDITION]. But if something happens, we are close to the hospital and they could be here in five minutes. The NP stated she had worked at the facility for the past seven years, and that Resident #99 had been the only [MEDICAL CONDITION] in the building and that he had not been sent out for emergency care due to the lack of an RN or RT in the building to provide deep suctioning. On 02/03/2020 at 11:25 AM, the DON completed review of the staffing schedules and time cards for the period of time from March 22, 2019 to February 3, 2020, and it revealed there were 137 days without 24 hours RN or RT coverage for the 3-11 and 11-7 shifts. The facility submitted an acceptable Removal Plan on 02/03/2020 for the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). Review of the facility's Removal Plan revealed, the facility took the following corrective actions to remove the IJ prior to exit: The SA identified an IJ and SQC, on 02/03/2020, when the facility failed to ensure qualified staff were present 24 hours per day to perform deep suctioning of a [MEDICAL CONDITION] and other emergency procedures if needed, for Resident #99. The facility Executive Director, Director of Nursing and Assistant Director of Nursing were notified 02/03/2020 at 12:10 PM of Immediate Jeopardy (IJ)and Substandard Quality of Care (SQC) due to the facility failure to have a Registered Nurse or Respiratory Therapist available 24 hours per day, 7 days per week to provide deep suctioning in the event emergency care was needed. Resident #99 was readmitted to the facility on [DATE] with a [MEDICAL CONDITION]. This placed resident #99 at risk for serious injury, harm, impairment or death. He was identified as the only resident with a [MEDICAL CONDITION]. During the period of March 2019-February 2020 the staffing schedule and time cards revealed 137 days without 24 hour Registered Nurse or Respiratory Therapist coverage for the 3-11 and 11-7 shifts during the time frame of March 22, 2019 through February 1, 2020. 1. Facility Actions: Upon identification of a lack of Registered Nurse coverage on 02/02/2020 by the State Agency (SA), the Director of Nursing immediately verified Registered Nurse coverage for 02/02/2020 and going forward for each shift for [MEDICAL CONDITION] needs for Resident #99. The Medical Director was notified on 02/02/2020 at 12:22 PM of the need for 24 hour coverage by Registered Nurse or Respiratory Therapist by the Director of Nursing. The Medical Director and Attending Physician for Resident #99 was notified of the Immediate Jeopardy and Substandard Quality of Care at 12:28PM on 02/03/2020 by the Director of Nursing. The comprehensive care plan for Resident #99 was reviewed and updated to reflect the Registered Nurse will provide deep suctioning to the [MEDICAL CONDITION] if needed per MD orders by the Director of Nursing on 02/03/2020 at 3:00PM. 2. Assessment: Resident #99 was fully assessed by the Nurse Practitioner on 02/03/2020 and documentation signed off at 9:15 AM with no acute findings or evidence of respiratory distress. 3. Quality Assurance: An emergency Quality Assurance Committee meeting was held 02/03/2020 at 3:15 PM to review and revise the facility policy for [MEDICAL CONDITION] suctioning which states that all licensed Nursing Personnel or per State Nurse Practice Act/Respiratory Therapist is to be followed regarding [MEDICAL CONDITION] suctioning. Policy has been revised to state that only a Registered Nurse or Respiratory Therapist may perform deep suctioning. In addition, discussion was held regarding the need for 24 hour Registered Nurse or Respiratory Therapist coverage 7 days per week. The Director of Nursing will be responsible for ensuring 24 hours Registered Nurse or Respiratory Therapist coverage 7 days per week. Attendees: Executive Director, Medical Director (via Phone), Director of Nursing, Assistant Director of Nursing, Staff Development, Business office manager and Director of Social Services. 4. In-service: In-service education was initiated on 02/03/2020 by the Staff Development Nurse with all licensed staff regarding the need for a Registered Nurse or Respiratory Therapy coverage 24 hours per day 7 days per week as long as there is a [MEDICAL CONDITION] resident in the facility. The Director of Nursing is to be immediately notified of any schedule change to ensure coverage. No licensed nurse will be allowed to work until in-service education is completed to include new hires. The facility policy for [MEDICAL CONDITION] suctioning will be reviewed as part of the in-service to ensure licensed staff understand the Mississippi Nurse Practice Act which restricts deep right main stem suctioning to be performed only by a Registered Nurse or Respiratory Therapist. The Facility alleged that the Immediate Jeopardy was removed as of February 3, 2020. The SA validated the facility's Removal Plan on 02/04/2020: 1. Facility Actions: The SA validated by record review and interview, the Registered Nurse coverage on 02/04/2020, which the Director of Nursing implemented, for the Registered Nurse coverage for 02/02/2020 and going forward for each shift for [MEDICAL CONDITION] needs for Resident #99. The SA validated by record review and interview, the Medical Director was notified on 2/02/2020 at 12:22 PM of the need for 24 hour coverage by Registered Nurse or Respiratory Therapist by the Director of Nursing. The SA validated by record review and interview, the Medical Director and Attending Physician for Resident #99 was notified of the Immediate Jeopardy and Substandard Quality of Care at 12:28 PM on 02/03/2020 by the Director of Nursing. The SA validated by record review, the comprehensive care plan for Resident #99 was reviewed and updated to reflect the Registered Nurse will provide deep suctioning to the [MEDICAL CONDITION] if needed per MD orders by the Director of Nursing on 02/03/2020 at 3:00 PM. 2. Assessment: The SA validated by interview and record review, Resident #99 was fully assessed by the Nurse Practitioner on 02/03/2020 and documentation signed off at 9:15 AM with no acute findings or evidence of respiratory distress. 3. Quality Assurance: The SA validated by record review and interview, an emergency Quality Assurance Committee meeting was held 02/03/2020 at 3:15 PM. to review and revise the facility policy for [MEDICAL CONDITION] suctioning which stated that all licensed Nursing Personnel or per State Nurse Practice Act/Respiratory Therapist is to be followed regarding [MEDICAL CONDITION] suctioning. Policy has been revised to state that only a Registered Nurse or Respiratory Therapist may perform deep suctioning. In addition, discussion was held regarding the need for 24 hour Registered Nurse or Respiratory Therapist coverage 7 days per week. The Director of Nursing will be responsible for ensuring 24 hours Registered Nurse or Respiratory Therapist coverage 7 days per week. Attendees: Executive Director, Medical Director (via Phone), Director of Nursing, Assistant Director of Nursing, Staff Development, Business office manager and Director of Social Services. 4. In-service: The SA validated by record review and interview, in-service education was initiated on 02/03/2020 by the Staff Development Nurse with all licensed staff regarding the need for a Registered Nurse or Respiratory Therapy coverage 24 hours per day 7 days per week as long as there is a [MEDICAL CONDITION] resident in the facility. The Director of Nursing is to be immediately notified of any schedule change to ensure coverage. No licensed nurse will be allowed to work until in-service education is completed to include new hires. The facility policy for [MEDICAL CONDITION] suctioning will be reviewed as part of the in-service to ensure licensed staff understand the Mississippi Nurse Practice Act which restricts deep right main stem suctioning to be performed only by a Registered Nurse or Respiratory Therapist. The SA validated all corrective actions were taken by the facility and the actions were completed as of 02/03/2020 and the IJ was removed on 02/03/2020, prior to exit.

Based on observation, staff interview, resident interview, and facility policy review, the facility failed to provide qualified, consistent and sufficient staff, a Registered Nurse (RN) and/or Respiratory Therapist (RT), 24 hours each day to deep suction the Trach, if needed and/or provide other emergency care to render respiratory care services to a resident with a [MEDICAL CONDITION] (Trach), for one (1) of 1 resident reviewed with a [MEDICAL CONDITION], Resident #99. Review of the nursing schedule revealed the facility did not have RN or RT coverage for all shifts for 137 days, which included 3 PM- 11 PM and 11 PM - 7 AM shifts. Resident #99 had a [DIAGNOSES REDACTED]. Resident #99 had an Emergency Department visit on 06/20/2019, with a [DIAGNOSES REDACTED]. Resident #99 was also seen by the Pulmonologist on 01/23/2020, with a [DIAGNOSES REDACTED]. The facility's failure to provide 24 hour per day services of a RN and/or RT, for possible deep suctioning and other emergency [MEDICAL CONDITION], had caused, or was likely to cause, serious harm, impairment, or death to Resident #99 and other residents with a [MEDICAL CONDITION]. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), on 02/03/2020, when the facility failed to ensure qualified staff, a RN and/or RT, were present 24 hours per day to perform deep suctioning of a [MEDICAL CONDITION] and other emergency procedures if needed, for Resident #99. The SA notified the Administrator on 02/03/2020 of the IJ and SQC. The facility submitted an acceptable Removal Plan, in which the facility alleged all corrective actions were completed on 02/03/2020, and the IJ was removed as of 02/03/2020. The SA validated the Removal Plan on 02/04/2020 and determined the IJ was removed prior to exit. The scope and severity for the IJ at CFR 483.35(a)(1)(2), F725, was lowered to a D level, while the facility develops and implements a Plan of Correction (POC) and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory requirements. Findings include: The facility did not have a policy related to Sufficient Staffing or adequate staffing. Review of the Mississippi State Board of Nursing Laws and Rules Administrative Code Part 2830 Practice of Nursing Title 30: Professions and Occupations Chapter 2, Functions of the Licensed Practical Nurse, (LPN) revealed: Rule 2.1 LPN Supervision, The LPN gives nursing care which does not require the specialized skill, judgement, and knowledge required of an RN, Advanced Practice Registered Nurse (APRN), Licensed Physician, or Licensed Dentist. Review of the MS State Board of Nursing (BON) website, revealed frequently asked questions (FAQ's). The BON's statement regarding the LPN's scope of practice with [MEDICAL CONDITION] care revealed: It is within the scope of practice of the LPN to [MEDICAL CONDITION] and suction secretions from [MEDICAL CONDITION]. However, it is not within the scope of practice for the LPN to perform deep right main stem suctioning. If deep suctioning is required for a patient, a Registered Nurse (RN) must perform the procedure. Review of the facility's working schedule from 03/22/2019 to 02/02/2020, revealed a total of 137 days (3 PM-11 PM, 11 PM- 7 AM shifts), in which there were no documented RN coverage for the facility. The facility did not employ a Respiratory Therapist. The facility readmitted Resident #99 on 06/11/2013, with [DIAGNOSES REDACTED]. Review of Resident #99's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2019, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated full cognitive ability. On 02/02/2020 at 10:30 AM, an observation and review of the facility's Daily Nursing Staff Posting dated 02/02/2020, revealed there was one (1) RN on the 7 AM-3 PM shift, and no RN coverage for the 3 PM-11 PM and 11 PM-7 AM shift. During an interview and observation, on 02/02/2020 at 11:15 AM, Resident #99 was observed lying in bed, alert and oriented. Resident #99 was noted to have a [MEDICAL CONDITION] speaking valve intact and secured [MEDICAL CONDITION]. An observation was also made of a suction machine at the resident's bedside. Resident #99 revealed [MEDICAL CONDITION] was done every three (3) days, on Monday, Wednesday, and Friday. Resident #99 stated that he goes to the Pulmonologist every 3 months to have his inner cannula changed. Resident #99 also stated he has had deep suctioning to [MEDICAL CONDITION] the past, but it's been months ago. Resident #99 couldn't recall the exact date or month, nor was he able to recall if a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) that performed the deep suctioning. On 02/02/2020 at 10:40 AM, during an interview, the Director of Nursing (DON) stated they typically have RN coverage on a twenty-four hours a day, and seven days a week (24/7) basis. The DON confirmed they did not have a RN for the 3 PM-11 PM and 11 PM-7 PM shifts for 02/02/2020, didn't have a Respiratory Therapist (RT) in the building to provide emergency care to a resident who has a [MEDICAL CONDITION] in the event that emergency care was needed. The DON confirmed she was aware that a resident with a [MEDICAL CONDITION] required either an RN or an RT for deep suctioning. During an interview, on 02/02/2020 at 10:45 AM, the Staff Development Nurse stated, We have RN coverage during the week, but it varies on the weekends. In an interview with the DON, on 02/03/2020 at 8:45 AM, she stated, We were so short on staff that I was trying to keep nurses in the building, and I didn't even think about having RN coverage around the clock for the [MEDICAL CONDITION]. He's (Resident #99) been here so long that I guess I just wasn't thinking about it. The DON stated they might have an RN scheduled, but if the RN calls in, they have just been replacing her with a Licensed Practical Nurse (LPN). I was aware that we did not have RN coverage 24/7. On 02/02/20 at 12:25 PM, during an interview with the Administrator, he stated that he had served as the interim Administrator since December 2019 and did not think that they had full time RN coverage since he had been here. The Administrator stated the DON should have brought it to his attention that they did not have RN or RT coverage for the care of the [MEDICAL CONDITION] in an event that emergency care was needed. On 02/03/2020 at 9:45 AM, an interview with the Nurse Practitioner (NP), revealed she stated she was aware that the facility had issues with finding an RN. The NP stated they may have had an RN on the schedule, but if the RN called in, they had been replacing the RN with an LPN, which doesn't meet the requirements, due to the resident with the [MEDICAL CONDITION]. The NP revealed if something happened, they were close to the hospital and they could be there in five minutes. On 02/03/20 at 11:25 AM, the DON completed a review of the staffing schedules and time cards for the period of time from March 22, 2019 to February 1, 2020 and it revealed there were 137 days without 24 hour RN or RT coverage for the 3 PM-11 PM and 11 PM-7 AM shifts. The facility submitted an acceptable Removal Plan on 02/03/2020 at 5:30 PM, in which the facility alleged all corrective actions were completed and the IJ was removed on 02/03/2020. The SA validated the removal Plan on 02/04/2020 and determined the IJ was removed on 02/03/2020. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit: The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), on 02/03/20, when the facility failed to ensure qualified staff were present 24 hours per day to perform deep suctioning of a [MEDICAL CONDITION] and other emergency procedures if needed, for Resident #99. The facility Executive Director, Director of Nursing and Assistant Director of Nursing were notified 2/3/2020 at 12:10 PM of Immediate Jeopardy (IJ)and Substandard Quality of Care (SQC) due to the facility failure to have a Registered Nurse or Respiratory Therapist available 24 hours per day, 7 days per week to provide deep suctioning in the event emergency care was needed. Resident #99 was admitted to the facility on [DATE] with a [MEDICAL CONDITION]. This placed Resident #99 at risk for serious injury, harm, impairment or death. He was identified as the only resident with a [MEDICAL CONDITION]. During the period of March 2019-February 2020 the staffing schedule and time cards revealed 137 days without 24 hour Registered Nurse or Respiratory Therapist coverage for the 3 PM -11 PM and 11 PM-7 PM shifts during the time frame of March 22, 2019 through February 1, 2020. 1. Facility Actions: Upon identification of a lack of Registered Nurse coverage on 02/02/2020 by the State Agency (SA), the Director of Nursing immediately verified Registered Nurse coverage for 02/02/2020 and going forward for each shift for [MEDICAL CONDITION] needs for Resident #99. The Medical Director was notified on 02/02/2020 at 12:22 PM of the need for 24 hour coverage by Registered Nurse or Respiratory Therapist by the Director of Nursing. The Medical Director and Attending Physician for Resident #99 was notified of the Immediate Jeopardy and Substandard Quality of Care at 12:28PM on 02/03/2020 by the Director of Nursing. The comprehensive care plan for Resident #99 was reviewed and updated to reflect the Registered Nurse will provide deep suctioning to the [MEDICAL CONDITION] if needed per MD orders by the Director of Nursing on 02/03/2020 at 3:00 PM. 2. Assessment: Resident #99 was fully assessed by the Nurse Practitioner on 02/03/2020 and documentation signed off at 9:15 AM with no acute findings or evidence of respiratory distress. 3. Quality Assurance: An emergency Quality Assurance Committee meeting was held 02/03/2020 at 3:15 PM to review and revise the facility policy for [MEDICAL CONDITION] suctioning which states that all licensed Nursing Personnel or per State Nurse Practice Act/Respiratory Therapist is to be followed regarding [MEDICAL CONDITION] suctioning. Policy has been revised to state that only a Registered Nurse or Respiratory Therapist may perform deep suctioning. In addition, discussion was held regarding the need for 24 hour Registered Nurse or Respiratory Therapist coverage 7 days per week. The Director of Nursing will be responsible for ensuring 24 hours Registered Nurse or Respiratory Therapist coverage 7 days per week. Attendees: Executive Director, Medical Director (via Phone), Director of Nursing, Assistant Director of Nursing, Staff Development, Business office manager and Director of Social Services. 4. In-service: In-service education was initiated on 02/03/2020 by the Staff Development Nurse with all licensed staff regarding the need for a Registered Nurse or Respiratory Therapy coverage 24 hours per day 7 days per week as long as there is a [MEDICAL CONDITION] resident in the facility. The Director of Nursing is to be immediately notified of any schedule change to ensure coverage. No licensed nurse will be allowed to work until in-service education is completed to include new hires. The facility policy for [MEDICAL CONDITION] suctioning will be reviewed as part of the in-service to ensure licensed staff understand the Mississippi Nurse Practice Act which restricts deep right main stem suctioning to be performed only by a Registered Nurse or Respiratory Therapist. The Facility alleged that the Immediate Jeopardy was removed as of February 3, 2020. The SA validated the facility's Removal Plan on 02/04/2020: 1. Facility Actions: The SA validated by record review and interview, the Registered Nurse coverage on 02/04/2020, which the Director of Nursing implemented, for the Registered Nurse coverage for 02/02/2020 and going forward for each shift for [MEDICAL CONDITION] needs for Resident #99. The SA validated by record review and interview, the Medical Director was notified on 2/02/2020 at 12:22 PM of the need for 24 hour coverage by Registered Nurse or Respiratory Therapist by the Director of Nursing. The SA validated by record review and interview, the Medical Director and Attending Physician for Resident #99 was notified of the Immediate Jeopardy and Substandard Quality of Care at 12:28 PM on 02/03/2020 by the Director of Nursing. The SA validated by record review, the comprehensive care plan for Resident #99 was reviewed and updated to reflect the Registered Nurse will provide deep suctioning to the [MEDICAL CONDITION] if needed per MD orders by the Director of Nursing on 02/03/2020 at 3:00 PM. 2. Assessment: The SA validated by interview and record review, Resident #99 was fully assessed by the Nurse Practitioner on 02/03/2020 and documentation signed off at 9:15 AM with no acute findings or evidence of respiratory distress. 3. Quality Assurance: The SA validated by record review and interview, an emergency Quality Assurance Committee meeting was held 02/03/2020 at 3:15 PM. to review and revise the facility policy for [MEDICAL CONDITION] suctioning which stated that all licensed Nursing Personnel or per State Nurse Practice Act/Respiratory Therapist is to be followed regarding [MEDICAL CONDITION] suctioning. Policy has been revised to state that only a Registered Nurse or Respiratory Therapist may perform deep suctioning. In addition, discussion was held regarding the need for 24 hour Registered Nurse or Respiratory Therapist coverage 7 days per week. The Director of Nursing will be responsible for ensuring 24 hours Registered Nurse or Respiratory Therapist coverage 7 days per week. Attendees: Executive Director, Medical Director (via Phone), Director of Nursing, Assistant Director of Nursing, Staff Development, Business office manager and Director of Social Services. 4. In-service: The SA validated by record review and interview, in-service education was initiated on 02/03/2020 by the Staff Development Nurse with all licensed staff regarding the need for a Registered Nurse or Respiratory Therapy coverage 24 hours per day 7 days per week as long as there is a [MEDICAL CONDITION] resident in the facility. The Director of Nursing is to be immediately notified of any schedule change to ensure coverage. No licensed nurse will be allowed to work until in-service education is completed to include new hires. The facility policy for [MEDICAL CONDITION] suctioning will be reviewed as part of the in-service to ensure licensed staff understand the Mississippi Nurse Practice Act which restricts deep right main stem suctioning to be performed only by a Registered Nurse or Respiratory Therapist. The SA validated all corrective actions were taken by the facility and the actions were completed as of 02/03/2020 and the IJ was removed on 02/03/2020, prior to exit.