Does DIVERSICARE OF RIPLEY have any serious inspection findings?

Yes, DIVERSICARE OF RIPLEY has 6 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 33 total deficiencies from recent inspections.

What are the staffing levels at DIVERSICARE OF RIPLEY?

DIVERSICARE OF RIPLEY has a four-star staffing rating from CMS with 0.69 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is DIVERSICARE OF RIPLEY located?

DIVERSICARE OF RIPLEY is located in RIPLEY, MS. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does DIVERSICARE OF RIPLEY have?

DIVERSICARE OF RIPLEY has 140 certified beds.

Who owns DIVERSICARE OF RIPLEY?

DIVERSICARE OF RIPLEY is a for profit - corporation facility and is part of the DIVERSICARE HEALTHCARE chain.

What questions should families ask when visiting DIVERSICARE OF RIPLEY?

Families visiting DIVERSICARE OF RIPLEY should ask about what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does DIVERSICARE OF RIPLEY compare to other nursing homes?

DIVERSICARE OF RIPLEY has a 1-star overall rating, which is below average compared to other nursing homes in MS. Families should carefully review inspection findings and consider alternatives.

DIVERSICARE OF RIPLEY

Q: What is DIVERSICARE OF RIPLEY's CMS rating?

DIVERSICARE OF RIPLEY has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Is DIVERSICARE OF RIPLEY safe?

DIVERSICARE OF RIPLEY has documented safety concerns including 6 immediate jeopardy citations. Families should ask about corrective actions taken.

Q: Do nurses at DIVERSICARE OF RIPLEY stick around?

DIVERSICARE OF RIPLEY has average staff turnover at 41%, which is typical for the nursing home industry.

Q: Was DIVERSICARE OF RIPLEY ever fined?

Yes, DIVERSICARE OF RIPLEY has been fined $72,793 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Q: Is DIVERSICARE OF RIPLEY on any federal watch list?

No, DIVERSICARE OF RIPLEY is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

101 CUNNINGHAM DR, RIPLEY, MS 38663 · (662) 837-3011

For profit - Corporation 140 Beds DIVERSICARE HEALTHCARE Data: November 2025 6 Immediate Jeopardy citations

Trust Grade

0/100

#157 of 200 in MS

Share this report:

DIVERSICARE OF RIPLEY nursing home in RIPLEY, MS - Photo 1 of 4

DIVERSICARE OF RIPLEY nursing home in RIPLEY, MS - Photo 2 of 4

Photo by Kenneth Lee Anderson

View 360° on Google Maps

Last Inspection: December 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Diversicare of Ripley has received a Trust Grade of F, indicating a poor performance with significant concerns about resident care. In Mississippi, it ranks #157 out of 200 facilities, placing it in the bottom half of the state. However, it has shown improvement in recent years, reducing its number of issues from 17 in 2024 to 2 in 2025. Staffing is a relative strength, with a rating of 4 out of 5 stars and a turnover rate of 41%, which is below the state average. On the downside, the facility has accumulated $72,793 in fines, which is concerning as it is higher than 89% of Mississippi facilities, signaling ongoing compliance issues. Specific incidents of concern include a resident who eloped from the facility unnoticed, wandering outside without shoes or a coat, prompting police intervention. Additionally, the facility failed to implement proper care plan measures to prevent this elopement, which occurred multiple times. Overall, while there are some strengths in staffing, the facility has serious weaknesses that families should carefully consider.

Trust Score: F
In Mississippi: #157/200
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 41% turnover. Near Mississippi's 48% average. Typical for the industry.
Penalties: $72,793 in fines. Lower than most Mississippi facilities. Relatively clean record.
Skilled Nurses: Each resident gets 41 minutes of Registered Nurse (RN) attention daily — about average for Mississippi. RNs are the most trained staff who monitor for health changes.
Violations: 33 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★★☆

4.0

Staff Levels

★☆☆☆☆

1.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 17 issues

2025: 2 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (41%)
7 points below Mississippi average of 48%

Facility shows strength in staffing levels, fire safety.

The Bad

1-Star Overall Rating

Below Mississippi average (2.6)

Significant quality concerns identified by CMS

Staff Turnover: 41%

Near Mississippi avg (46%)

Typical for the industry

Federal Fines: $72,793

Well above median ($33,413)

Moderate penalties - review what triggered them

Chain: DIVERSICARE HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 33 deficiencies on record

6 life-threatening 2 actual harm

Jan 2025 2 deficiencies

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on observations and interviews the facility failed to ensure sufficient staffing in the dietary department to meet the nutritional needs of residents for eight (8) of 12 sampled residents (Resident #2, Resident #3, Resident 4, Resident #5, Resident #6, Resident #7, Resident #9, Resident #10.) Specifically, the facility did not employ adequate dietary staff to prepare and serve meals in a timely manner, resulting in residents receiving cold meals and prolonged delays during meal service. Findings include: Review of the facility policy titled Food: Quality and Palatability with a revision date of 2/2023 revealed under, Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Initial observation on 01/21/25 at 8:15 PM revealed one (1) employee in the kitchen preparing food for 122 resident census. On 1/21/25 at 9:15 AM, an interview with the Regional Dietary Manager (RDM) #1 revealed that the kitchen staffing continued to be the biggest concern for the dietary department. He stated that he has been at this facility for two months and has never seen a building so hard to find dietary staff that will work. He explained that the kitchen staff continued to work with short staff and that for the last two weeks he has been in the kitchen preparing meals. He revealed that the other day they had an employee get sick in the dietary department and had to call an ambulance for her and that the Administrator went to a local restaurant and bought breakfast for the residents because they did not have anyone to prepare the meal that morning. The RDM revealed just this morning he had a staff member to walk out and quit despite being aware of the staff shortage and offering him a bonus to stay. On 1/21/25 at 9:20 AM, an interview with Resident #4 revealed the food continued to be a big concern for the residents. She stated, It's horrible. The resident explained that she ate grilled cheese and soup every day because what was served from the menu, she could not eat, and it was always cold. On 1/21/25 at 9:28 AM, an interview with Resident #3 revealed her only concern with the facility was the food. She stated, It's not fit to eat and it's not good. She stated the food was not properly cooked and that the vegetables were mushy, and the meat was tough. On 1/21/25 at 9:33 AM, an interview with Resident #5 revealed the food was no better. She stated, The food is slop, and our food choices are limited. She explained that last night at dinner she received chicken strips that were overcooked and were too tough to chew and that she just ate the fruit off her tray. She revealed the dietary department was always late getting the meal trays out and the food was always cold. She stated, they don't have any help in there. On 1/21/25 at 9:52 AM, during an interview with Resident #2 the resident voiced his food had been cold every meal. He stated, I'm not talking about lukewarm; I'm talking about cold like it's been in the refrigerator. He revealed he wished the facility could do something to fix the problem. On 1/21/25, an observation revealed, between 8:30 AM-9:00 AM and again at 11:35 AM-12:15 PM, the breakfast and lunch trays were placed on uncovered tray racks and then were later retrieved from the dining room by the aides then distributed to the residents in their rooms. On 1/21/25 at 11:35 AM, an interview with the Administrator (ADM) revealed the kitchen was in transition and the current RDM was leaving, and a new person was starting. He revealed he was not involved in the decision about the change and verbalized it was a corporate decision and that he was not happy about it because they have had so many issues with staff not being available to work in the dietary department as it is currently. The ADM revealed he would like to keep the same consistent staff in the kitchen to carry out food services. On 1/21/25 at 12:50 PM, an observation and interview with Resident #9 revealed he was sitting in his chair in his room. The resident voiced his lunch tray was just brought in to him and stated, The food here is lousy. He revealed last night for dinner he received a Swiss steak fried so hard it was not eatable, which was often the case with a lot of the meats served. He explained the dietary department did not know how to cook the foods properly without overcooking them. Resident #9 revealed cold food had been an issue for a while and stated, The food is never warm. An observation of the lunch meal provided revealed pulled pork loin, mashed potatoes, and Brussel sprouts and it was observed that the resident could not cut the meat with his utensils. On 1/21/25 at 1:02 PM, an observation and interview with Resident #6 revealed, she was sitting on the side of the bed eating her lunch meal. The resident stated, The food is horrible, and it's horrid to chew. She stated, When you all were here last, the kitchen put on a show and the food was good, but when you all left, it went back to the same old thing. Resident #6 revealed they had been served Chef Boyardee out of a can a couple of times and stated, I wouldn't serve that to my kids, but they serve it to us. An observation revealed the resident was eating a piece of cut-up bologna and not eating her lunch meal because the pork meat was too tough to chew. On 1/22/25 at 1:11 PM, an observation and interview with Resident #7 revealed she motioned for the Survey Agent (SA) to enter her room. The resident was observed eating her lunch meal and stated, It's cold. She picked up her fork and began pushing around the meat and stated, That's so tough, I can't chew it. An observation of the lunch meal revealed she received pork loin, au gratin potatoes, Brussel sprouts, corn bread and a cookie. She stated, They need some help in the kitchen. On 1/21/25 at 1:21 PM, an observation and interview with Resident #10 revealed he came to the facility last Friday and he had not had a warm meal since he came to the facility and stated, It's cold every day. The lunch meal was sitting untouched on the bedside table. The meal consisted of pork loin, au gratin potatoes, Brussel sprouts, and cornbread. On 1/21/25 at 2:35 PM, during an interview with Registered Nurse (RN) #1 revealed, the biggest complaint she gets is about the food. She explained we try to do what we can to make sure the residents have snacks and stuff, so they do not get hungry. RN #1 revealed the food had been an issue for a while and the dietary staff have struggled to find help. On 1/21/25 at 3:05 PM, an interview and observation with the RDM #1 confirmed the current dietary manager was stepping down to become the cook and acknowledged there was a lot of transition in the dietary department along with staffing concerns. On 01/21/25 at 3:11 PM in an interview RDM #2 confirmed that this was her second day on the job as the new replacement for RDM #1. She revealed one of the things she had noticed about the kitchen was they did not have a steamer. She revealed her experience had shown that anytime a kitchen did not have a steamer, the vegetables such as broccoli tend to get softer and softer until mushy. revealed she observed the meal tray line at lunch and the temperatures were adequate upon leaving the kitchen. She revealed after the tray carts leave the kitchen, they have no control over how quickly the trays were distributed and explained that could be how the food was becoming cold. She confirmed uncovered tray racks were used to distribute the food on the halls and revealed without insulated boxes, it would be impossible to keep the food warm. She confirmed that she was aware of the ongoing concerns with RDM #1 not being able to find staff that will work in the dietary department. Record review of the admission Record revealed the facility admitted Resident #2 on 5/30/24 with a medical diagnosis that included Malignant neoplasm of stomach. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/24 revealed under, section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #2 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #3 on 4/01/24 with a medical diagnosis that included Irritable Bowel Syndrome. Record review of the MDS with an ARD of 1/10/25 revealed under, section C, a BIMS summary score of 15, which indicated Resident #3 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #4 on 11/01/22 with medical diagnoses that included Chronic Obstructive Pulmonary Disease and Dysphasia. Record review of the MDS with an ARD of 11/11/24 revealed under, section C, a BIMS summary score of 14, which indicated Resident #4 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #5 on 6/06/24 with medical diagnoses that included Chronic Obstructive Pulmonary Disease and Dysphasia. Record review of the MDS with an ARD of 12/13/24 revealed under, section C, a BIMS summary score of 15, which indicated Resident #5 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #6 on 3/05/24 with a medical diagnosis that included Cerebral Ischemia. Record review of the MDS with an ARD of 11/29/24 revealed under section C, a BIMS summary score of 13, which indicated Resident #6 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #7 on 2/05/19 with medical diagnoses that included Parkinson's Disease and Dysphasia. Record review of the MDS with an ARD of 12/16/24 revealed under section C, a BIMS summary score of 15, which indicated Resident #7 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #9 on 9/13/18 with a medical diagnosis that included Type 2 Diabetes Mellitus. Record review of the MDS with an ARD of 11/12/24 revealed under section C, a BIMS summary score of 15, which indicated Resident #9 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #10 on 1/16/25 with a medical diagnosis that included Acute Chronic Diastolic Heart Failure. Record review of the admission BIMS dated 1/17/25 revealed Resident #10 was cognitively intact.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on observation, resident and staff interviews, and facility policy review, the facility failed to ensure the food was palatable and had an appetizing appearance for eight (8) of twelve sampled residents. Resident #2, Resident #3, Resident 4, Resident #5, Resident #6, Resident #7, Resident #9, and Resident #10 Findings Include: Review of the facility policy titled Food: Quality and Palatability with a revision date of 2/2023 revealed under, Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. An interview with the Regional Dietary Manager (RDM) #1 on 1/21/25 at 9:15 AM revealed the kitchen staffing continued to be the biggest concern for the dietary department. He explained this area was the hardest to staff and they continued to work short in the dietary department. The RDM revealed just this morning he had a staff member to walk out despite him being aware of the staff shortage and offering him a bonus to stay. An interview with Resident #4 on 1/21/25 at 9:20 AM revealed that the food continued to be a big concern with the residents. She stated, It's horrible. The resident explained that she ate grilled cheese and soup every day because what was served from the menu, she could not eat. An interview with Resident #3 on 1/21/25 at 9:28 AM revealed her only concern with the facility was the food. She revealed the food was not good and stated, It's not fit to eat. Resident #3 explained the food was not properly cooked and revealed that sometimes the food was not done, and sometimes it was overcooked so hard she could not eat it. She further explained the vegetables were almost always mushy, and the meat was tough. The resident voiced she never asked for an alternate meal because the food always came out the same way, which was not good. An interview with Resident #5 on 1/21/25 at 9:33 AM revealed the food was no better. The resident stated, The food is slop, and our food choices are limited. She explained that last night at dinner she received chicken strips that were overcooked and were too tough to chew. She revealed that she ate the fruit off her tray and then ate left over cold pizza that she had in her refrigerator. Furthermore, she revealed the dietary department was always late getting the meal trays out and the food was always cold. An interview with Resident #2 on 1/21/25 at 9:52 AM revealed his food had been cold every meal. He stated, I'm not talking about lukewarm; I'm talking about cold like it's been in the refrigerator. Resident #2 explained that most of the time, he could not eat the food, but he had family and friends that would often bring in food for him. He revealed he wished the facility could do something to fix the problem. On 1/21/25, an observation revealed, between 8:30 AM-9:00 AM and again at 11:35 AM-12:15 PM, the breakfast and lunch trays were placed on uncovered tray racks and retrieved from the dining room by the aides then distributed to the residents on the halls. An interview with the Administrator (ADM) on 1/21/25 at 11:35 AM revealed the kitchen was in transition and the current RDM was leaving and a new person starting. He revealed he was not involved in the decision for the change and verbalized it was a corporate decision. The ADM revealed he would like to keep the same consistent staff in the kitchen to carry out food services. The ADM confirmed he was aware of concerns in the dietary department and had worked to fix the issues. He stated, There's always room for improvement. He explained that he had spoken to dietary regarding ensuring the meal tray carts were pushed out to the floor and notifying the nurse if an aide was not in the dining room when the carts were ready. An observation and interview with Resident #9 on 1/21/25 at 12:50 PM revealed he was sitting in his chair in his room. The resident voiced his lunch tray was just brought in and stated, The food here is lousy. He revealed last night for dinner he received a Swiss steak fried so hard it was not eatable, which was often the case with a lot of the meats served. He explained the dietary department did not know how to cook the foods properly without overcooking them. Resident #9 revealed cold food had been an issue for a while and stated, The food is never warm. An observation of the lunch meal provided revealed pulled pork loin, mashed potatoes, and brussel sprouts and it was observed that the resident could not cut the meat with his utensils. An observation and interview with Resident #6 on 1/21/25 at 1:02 PM revealed, she was sitting on the side of the bed eating her lunch meal. The resident stated, The food is horrible, and it's horrid to chew. She stated, When you all were here last, the kitchen put on a show and the food was good, but when you all left, it went back to the same old thing. Resident #6 revealed they had been served Chef Boyardee out of a can a couple of times and stated, I wouldn't serve that to my kids, but they serve it to us. An observation revealed the resident was eating a piece of cut up bologna and not eating her lunch meal because the pork meat was too tough to chew. An observation and interview with Resident #7 on 1/22/25 at 1:11 PM revealed, she was motioning with her hand for the Survey Agent (SA) to enter her room. The resident was observed eating her lunch meal and stated, It's cold. She picked up her fork and began pushing around the meat and stated, That's so tough, I can't chew it. An observation of the lunch meal revealed she received pork loin, au gratin potatoes, brussel sprouts, corn bread and a cookie. An observation and interview with Resident #10 on 1/21/25 at 1:21 PM revealed, he was sitting on the edge of his bed. He revealed he came to the facility last Friday and he had not had a warm meal since he came to the facility and stated, It's cold every day. The lunch meal was sitting on the bedside table and the meal was untouched. The meal consisted of pork loin, au gratin potatoes, brussel sprouts, and cornbread. An interview with Registered Nurse (RN) #1 on 1/21/25 at 2:35 PM revealed she did the Minimum Data Set (MDS) assessments. She confirmed that when she goes into the resident rooms to complete interviews, the biggest complaint she gets is about the food. She explained we try to do what we can to make sure the residents have snacks and stuff, so they do not get hungry. RN #1 revealed the food had been an issue for a while. An interview and observation with the RDM on 1/21/25 at 3:05 PM confirmed the meals provided to the residents should be attractive, taste good and warm when they receive it and he confirmed that the meat served today was tough and the meal was cold because it sits uncovered until the staff can serve it to the residents. He confirmed the palatability of the food had been an ongoing issue for the facility. He revealed the current dietary manager was stepping down to become the cook and acknowledged there was a lot of transition in the dietary department along with staffing concerns. In an interview with on 01/21/25 at 3:11 PM RDM #2 confirmed that this was her second day on the job as the new replacement RDM. She revealed one of the things she had noticed about the kitchen was they did not have a steamer. She revealed her experience had shown that anytime a kitchen did not have a steamer, the vegetables such as broccoli tend to get softer and softer until mushy. revealed she observed the meal tray line at lunch and the temperatures were adequate upon leaving the kitchen. She revealed after the tray carts leave the kitchen, they have no control over how quickly the trays were distributed and explained that could be how the food was becoming cold. She confirmed uncovered tray racks were used to distribute the food on the halls and revealed without insulated boxes, it would be impossible to keep the food warm. Record review of the admission Record revealed the facility admitted Resident #2 on 5/30/24 with a medical diagnosis that included Malignant neoplasm of stomach. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/24 revealed under, section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #2 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #3 on 4/01/24 with a medical diagnosis that included Irritable Bowel Syndrome. Record review of the MDS with an ARD of 1/10/25 revealed under, section C, a BIMS summary score of 15, which indicated Resident #3 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #4 on 11/01/22 with medical diagnoses that included Chronic Obstructive Pulmonary Disease and Dysphasia. Record review of the MDS with an ARD of 11/11/24 revealed under, section C, a BIMS summary score of 14, which indicated Resident #4 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #5 on 6/06/24 with medical diagnoses that included Chronic Obstructive Pulmonary Disease and Dysphasia. Record review of the MDS with an ARD of 12/13/24 revealed under, section C, a BIMS summary score of 15, which indicated Resident #5 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #6 on 3/05/24 with a medical diagnosis that included Cerebral Ischemia. Record review of the MDS with an ARD of 11/29/24 revealed under section C, a BIMS summary score of 13, which indicated Resident #6 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #7 on 2/05/19 with medical diagnoses that included Parkinson's Disease and Dysphasia. Record review of the MDS with an ARD of 12/16/24 revealed under section C, a BIMS summary score of 15, which indicated Resident #7 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #9 on 9/13/18 with a medical diagnosis that included Type 2 Diabetes Mellitus. Record review of the MDS with an ARD of 11/12/24 revealed under section C, a BIMS summary score of 15, which indicated Resident #9 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #10 on 1/16/25 with a medical diagnosis that included Acute Chronic Diastolic Heart Failure. Record review of the admission BIMS dated 1/17/25 revealed Resident #10 was cognitively intact.

Dec 2024 10 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #103 An observation on 12/15/24 at 5:30 PM, and again on 12/16/24 at 9:30 AM, revealed Resident #103 lying in bed with a urinary catheter bag and tubing exposed with approximately 100 cc (cubic centimeters) of a brown substance in the catheter bag and no privacy covering. The catheter bag and tubing were exposed and visible to anyone entering the room. An interview and observation on 12/16/24 at 12:30 PM, Resident #103 revealed he has stomach cancer, and his tubing connects to his stomach. He stated, I don't even know what kind of stuff is in that bag, but it sure looks nasty. He revealed he doesn't like that people can see what's in the bag because it's kind of disgusting. During an observation and interview on 12/16/24 at 2:25 PM, Licensed Practical Nurse (LPN) #1 revealed all catheter bags are to always be in a privacy bag. She confirmed that the uncovered catheter bag was a dignity issue for the resident and revealed it should have a privacy covering over the tubing and bag. An interview on 12/16/24 at 3:00 PM, with the Director of Nurses (DON) confirmed Resident #103's dignity was not honored by leaving his catheter bag exposed. She revealed all catheter bags are supposed to have a covering over them. A record review of Resident #103's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Stomach, Obstructive and Reflux Uropathy, and Acquired Absence of Other Specified Parts of Digestive Tract. Record review of the MDS with an ARD of 12/5/24, under Section C revealed a BIMS score of 15 which indicated that the resident was cognitively intact. Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide dignity to residents, as evidenced by leaving indwelling urinary catheter bags and tubing uncovered for three (3) of eleven residents with a catheter reviewed. Resident #58, #99 and #103. Findings include: A review of the facility policy, Rights of Nursing Facility Residents dated May 1, 2012, revealed By law, every nursing facility resident has the right .To be treated with dignity, respect, courtesy and consideration . Resident #58 An observation on 12/15/24 at 3:43 PM, revealed Resident #58 lying in his bed in his room. A urinary catheter bag containing 100 milliliters of yellow urine was hanging on his bed and visible from the hall with no privacy bag in place. An interview on 12/16/24 at 2:30 PM, with Certified Nursing Assistant (CNA) #5, confirmed that Resident #58's catheter bag was hanging on his bed and there was no privacy bag. She revealed that the catheter bags were supposed to be placed inside a privacy bag. CNA #5 confirmed that not having a privacy bag was a dignity issue. An interview on 12/17/24 at 8:45 AM, with the Assistant Director of Nursing (ADON) confirmed that Resident #58's urinary catheter bag should have been in a privacy bag out of sight. She confirmed that it was a dignity issue for a resident not to be provided with a privacy bag for a urinary catheter. Record review of Resident #58's admission Record revealed the facility admitted the resident on 07/18/22 and that he had diagnoses that included Obstructive and Reflux Uropathy. Record review of Resident #58's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/08/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 04 which indicated that the resident had severe cognitive deficits. Resident #99 An observation on 12/15/24 at 3:20 PM, revealed Resident #99 sitting in his room with a urinary catheter bag containing 300 milliliters of urine hanging on his wheelchair visible from the hall with no privacy bag in place. He revealed that sometimes they placed the catheter bag in a black satchel to keep it covered but most of the time they did not. He revealed that it made him feel bad when he went out of his room to see people when his catheter bag was exposed for everyone to see, and he would rather it be covered. An observation on 12/15/24 at 5:25 PM, revealed Resident #99 sitting in his wheelchair. The urinary catheter bag was hanging on the right side of the wheelchair with amber colored urine visible from the hallway. There was no privacy bag in place. An interview on 12/16/24 at 8:15 AM, with CNA #6, confirmed that Resident #99's catheter bag was hooked to his wheelchair this morning and was not in a privacy bag. She revealed that they were supposed to always keep the urinary catheter bags covered and she agreed that this was a dignity issue. An interview on 12/17/24 at 8:40 AM, with the ADON confirmed that resident's urinary catheter bags should always be placed in a privacy bag and out of sight to promote the residents dignity. Record review of Resident #99's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Obstructive and Reflux Uropathy and Retention of Urine. Record review of Resident #99's MDS with an ARD of 09/20/24 under Section C revealed a BIMS score of 11 which indicated that the resident had moderate cognitive deficits.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure that oxygen tubing and an oxygen concentrator humidifier water bottle was changed as ordered for one (1) of eight (8) residents with oxygen observed. Resident #73 Findings include: Review of the facility policy titled, Oxygen Guideline updated 8/1/2024 revealed, Policy .Medical oxygen is classified by the food and drug Administration as a drug and therefore it is provided in accordance with a health care provider's order and in accordance with acceptable standards of practice. Procedure: Oxygen with humidification will be provided in accordance to a physician's order . Record review of Resident #73's Order Summary Report revealed an order dated 12/6/24 to change oxygen tubing and humidifier bottle weekly. Cleanse any external filters one time a day every Friday. On 12/15/24 at 3:55 PM, Resident #73's oxygen concentrator was observed with an undated, empty humidifier water bottle. The oxygen tubing connected to the humidifier water bottle was dated 11/29. An observation on 12/16/24 at 12:39 PM, revealed the oxygen tubing connected to the humidifier water bottle remained dated 11/29. During an interview and observation on 12/16/24 at 2:10 PM, Licensed Practical Nurse (LPN) #1 revealed that the nightshift nurses are to change out the oxygen tubing and water humidification bottles weekly. She confirmed that the oxygen tubing was dated 11/29 and revealed that it is important for the tubing to be changed as ordered to possibly prevent any infections. In an interview on 12/16/24 at 2:30 PM, the Director of Nurses (DON) revealed that the nurses on Friday nights are responsible for changing the oxygen tubing and water humidification bottles. She revealed she put a new water bottle on this morning when she noticed the humidifier bottle had no water and was unsure why the oxygen tubing and water bottle had not been changed since 11/29. She confirmed the facility failed to follow the physician's order by not changing out the oxygen tubing and water humidifier bottle as ordered. She revealed it's important for the tubing and humidification bottle to be changed weekly to prevent infection. A record review of Resident #73's admission Record revealed she was admitted to the facility on [DATE] with medical diagnoses that included Acute Respiratory Failure with Hypoxia, Unspecified Asthma, and Chronic Obstructive Pulmonary Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/24 revealed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide sufficient nursing staff to meet the resident's activities of daily living (ADL) needs for for three (3) of five (5) residents reviewed for ADLs. (Resident # 8, #55 and #104) Findings included: Cross-reference with F677 Record review of facility policy titled, Staffing, revealed, It is the practice of (proper name of facility) to assure that adequate staffing is maintained to provide the necessary care and services for each resident. Resident #8 During an observation and interview on 12/15/24 at 4:00 PM revealed Resident #8's fingernails were 1/2 inch long, jagged in appearance, with a thick brown substance under the nails, facial hair/beard were unkempt. During the interview, Resident #8 stated that he would love to have his nails cut and his beard trimmed but cannot get anyone to do it. During an interview on 12/16/24 at 2:10 PM, Certified Nurse Assistant (CNA) #4 revealed that when she arrived at work, she observed that Resident #8's nails were long and jagged with a thick brown substance under them and appeared to have not been trimmed and cleaned in a while. She also confirmed his beard, and facial hair were long and unkempt and needed to be shaved. She revealed she felt that staffing was a big issue with residents not getting the care they needed, due to staff calling in, this lead to the staff working short-staffed all the time. Review of the admission Record revealed the facility admitted Resident #8 on 8/24/19 with a diagnosis of Need for Assistance with Personal Care and Contracture, Left Hand. Record review of Resident #8's Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/16/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #58 During an observation on 12/15/24 at 3:42 PM, it was revealed that Resident #58 was lying in bed and his fingernails on his right hand were noted to have a brown substance underneath them. During an observation on 12/16/24 at 2:15 PM revealed Resident #58 lying in bed. He continued to have a brown substance underneath the fingernails on his right hand. On 12/16/24 at 2:25 PM, in an observation of Resident #58 nails with CNA #5, she confirmed that Resident #58 had long fingernails and had gunk underneath the fingernails on his right hand. She revealed that it was the CNAs responsibility to clean the resident's fingernails during their bath or shower and as needed. An interview on 12/17/24 at 8:40 AM, with CNA # 1, she confirmed that they run low on staffing due to people calling in and being absent. Record review of Resident #58's admission Record revealed an admission date of 07/18/22 and that he had diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction, Aphasia, and Chronic Obstructive Pulmonary Disease. Record review of Resident #58's MDS with an ARD of 11/08/24 under Section C revealed a BIMS Score of 04, which indicated that he had severe cognitive deficits. Resident #104 In an interview on 12/15/24 at 4:00 PM with Resident #104, she revealed that the staff were so busy, they did not give her a shower last night, and they never came in to offer her a bath. She stated that she missed her bath last night because they did not have time and had missed a couple of baths, including this past Tuesday night. She revealed that her scheduled bath times were Tuesday, Thursday, and Saturday on night shifts. She revealed that on Tuesday night, the CNA said it was too late by the time they got to her and gave an excuse that they really didn't have time. During an observation and interview with Resident #104 on 12/16/24 at 2:10 PM, revealed her sitting up in her wheelchair in her room. The resident's hair appeared greasy and was pulled up into a ponytail. A mild odor was noted while standing next to the resident. Resident #104 revealed that it had been so long since she had had her hair washed, her head had started itching. CNA #5 confirmed during an interview on 12/16/24 at 2:17 PM, that Resident #104 hair was greasy when she brushed it for her that morning and it should have been washed on her scheduled bath days, but it was not. Record review of Resident #104's admission Record revealed the resident was admitted to the facility on [DATE] and that she had diagnoses that included Difficulty in Walking, Need for Assistance with Personal Care, and Type 2 Diabetes Mellitus. Record review of Resident #104's MDS with an ARD of 12/11/24 revealed under Section C a BIMS Score of 15 which indicated the resident was cognitively intact. During an interview on 12/18/24 at 9:33 AM, the Director of Nursing (DON) confirmed that the facility did have a staffing concern regarding aides. She stated they may have 10 or 15 aides on the schedule and five (5) may call in and not show up for their shift. She revealed the scheduler will get on the phone and start trying to get aides to come in and work, and at times, the aides that are already at the facility will work a double shift. She revealed the facility gave incentives and bonuses to try to get the staff to work and if they could not get any aides to come in, the nurses on the floor would help. She confirmed that this had been an ongoing issue, especially on the 3 PM-11 PM shift. Record reviews of a list provided by the facility revealed there were 46 residents that required two people to assist with care.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review the facility failed to ensure medications were stored appropriately and not left in the resident's room for one (1) of 23 sampled residents. Resident #68 Findings include: A review of the statement on facility letterhead, signed by the Administrator and dated 12/20/24, revealed, (Proper Name) does not have a specific policy for medication storage. The center utilizes the medication administration competencies that refers to returning medications back to medication cart as well as standards of practice. An observation and interview on 12/16/24 at 9:35 AM revealed Resident #68 had two (2) inhalers lying on his bedside table. The inhalers were labeled 1. Spiriva Respimat Inhalation Aerosol Solution 2.5 MCG/ACT(micrograms/actuation) and 2. Symbicort Inhalation Aerosol 80-4.5 MCG/ACT. A nebulizer machine was observed on the bedside table with two (2) unopened Ipratropium-Albuterol Inhalation Solution 0.5-2.5 packages. Resident #68 stated those are my emergency inhalers. During an observation and interview on 12/16/24 at 2:00 PM, Licensed Practical Nurse (LPN) #1 confirmed that the medications were left unattended on the bedside table and should have been locked in the medication cart. She revealed that the medicines are supposed to be given as the physician ordered, and with the inhalers being in the resident's room then they don't know if she is using them or how much she is taking. During an interview on 12/16/24 at 2:25 PM, the Director of Nurses (DON) confirmed that medications should not be left at the bedside unattended but should always be kept locked up in the medication cart. Otherwise, a wandering resident could enter a resident's room and take the medicines. A record review of Resident #68's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Chronic Respiratory Failure, Pulmonary Fibrosis, and Atelectasis. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #68 was cognitively intact.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, and facility policy review, the facility failed to provide a resident with alternative food items (Resident #59) and failed to honor a resident's food preferences (Resident #83) for two (2) of nine (9) residents sampled for dining services. Findings include: A review of the facility policy titled, Dining and Food Preferences, revealed , revised 9/2017 revealed Policy Statement: Individual dining, food and beverage preferences are identified for all residents .Procedures: 7. The individual tray assembly ticket will identify all food items appropriate for the resident based on diet order, and preferences . 8. Upon meal service, any resident with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value . 9. The alternate meal and/or beverage will be provided in a timely manner . Resident # 59 An interview with Resident #59 on 12/16/24 at 5:00 PM, she revealed that she was unhappy with the food, stating that if she does not like something it does not help to ask for something else because you won't get it. She stated that the dietary staff tell her they have to wait until all residents in the facility have been served to make sure they have enough food. An observation of the evening meal for Resident #59 on 12/15/24 at 5:45 PM, revealed the resident to have a ground turkey patty, green beans, cornbread dressing, a wet roll, and iced tea. Resident #59 asked Certified Nurse Assistant (CNA) #2 if she would ask the kitchen for another helping of the cornbread dressing because that is all she liked on the tray. CNA # 2 returned from the kitchen and stated the Dietary Manager told her she could not give her anymore dressing until all the meal trays were made for all the residents. In an interview with CNA #2 on 12/15/24 at 5:55 PM, she revealed this is a problem every day and when we ask for an alternative, or something different, the dietary staff state they cannot do that, or they don't have the food items. In an interview with the Dietary Manager (DM) on 12/16/24 at 12:10 PM, she revealed she was trained that all residents had to be served before giving any resident any other food to ensure they don't run out of food. In an interview with the District Dietary Manager on 12/18/24 at 8:10 AM, stated there was no reason someone should be told to wait until everybody else is served because they always have plenty of food and alternates they can provide the residents with. An interview with CNA #3 on 12/16/24 at 3:00 PM revealed that if a resident does not like what they get from the kitchen the dietary staff will not give them any extra servings or alternates because they say they may run out of food. Review of the admission Record revealed the facility admitted Resident #59 on 11/1/22. Record review of Resident #59's Section C of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Resident #83 An observation and interview on 12/16/24 at 8:27 AM revealed Resident #83 was sitting up in her bed eating breakfast. She had oatmeal, eggs, toast, and two slices of bacon on her plate. She stated that she could not eat the bacon because she did not have bottom dentures to chew it. She revealed that she had told nurses, aides, and the Dietary Manager but they continued to put bacon on her plate. She stated, They won't fix it. She admitted that she had told the Dietary Manager several times and she was supposed to change it in the computer then stated, You can't get anything done around here. An observation of the meal ticket on the resident's tray indicated that she preferred bacon in place of sausage. An interview on 12/17/24 at 8:50 AM with the Dietary Manager (DM) confirmed that Resident #83 had talked to her about her preference for sausage instead of bacon and she had changed it in the computer. The DM revealed that they had completed a food preference interview with Resident #83 on 09/16/24 and Resident #83 had voiced that she wanted no bacon and that she preferred sausage. She revealed that the meal ticket continued to print off as a preference for bacon instead of sausage, so it had to be a glitch in the computer system. The DM confirmed that Resident #83 had told her that she continued to receive bacon instead of sausage on her plate. She also confirmed that she had not followed up with Resident #83 like she should have to make sure it was resolved. The Dietary Manager revealed that the residents should be able to make their own food choices and receive what they requested. Record review of Resident #83's Food Preference Interview form dated 09/16/24 revealed under Dining Preferences that she preferred no bacon!!! for breakfast. She also had marked an x beside bacon under food dislikes. Record review of Resident #83's Meal Ticket dated for Monday, 12/16/24 revealed that she prefers bacon in place of sausage. Record review of Resident #83's admission Record revealed an admission date of 06/06/24. Record review of Resident #83's MDS with ARD of 09/12/24 under Section C revealed a BIMS Score of 15 which indicated that she was cognitively intact.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, staff interview, and facility policy review, the facility failed to keep kitchen trash properly contained and disposed of safely for one (1) of two (2) kitchen tours. Findings include: Review of the facility policy titled Dispose of Garbage and Refuse unrevised, revealed under, Policy Statement: All garbage and refuse will be collected and disposed of in a safe and efficient manner .Procedures: 2. The dining service director will ensure that: Garbage and refuse is removed from the kitchen area routinely during the day and at the end of the work day . An observation during the initial kitchen tour on 12/15/24 at 3:10 PM revealed 2 trash barrels that were full and overflowing with trash and uncovered. Multiple empty boxes were stacked on top of both garbage barrels. An interview with Dietary Staff #1 on 12/15/24 at 3:16 PM confirmed that the overflowing garbage in the kitchen was unsanitary. She revealed they (the Dietary Staff) had not had time to empty the garbage today and were in the middle of shift change while preparing for the dinner meal. An interview with the Regional Dietary Manager on 12/18/24 at 8:10 AM confirmed the kitchen trash should be emptied once a shift and when needed and the trash lid should remain intact to ensure safe waste disposal.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement a care plan for Activities of Daily Living) (ADL) care plan (Resident #8, #58, and #104) and for respiratory care (Resident #73) for (4) four of twenty-four care plans reviewed. Findings Include: Review of the facility policy titled, Care Area Assessment (CAA) Process and Care Planning, dated October 2024, revealed, under The RAI (Resident Assessment Instrument) and Care Planning: the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives, and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident#8 A record review of Resident #8's care plan titled; Self-care deficit related to mobility impairment . His deficits make it hard for him to perform his ADLs without assistance . Interventions: Nail, hair, and oral care daily and as needed. Date initiated 10/25/23. On 12/15/24 at 4:00 PM, an observation and interview revealed Resident #8's fingernails to be 1/2 inch long, jagged in appearance, with a thick brown substance under the nail beds, his facial hair/beard was unkept. Resident #8 stated that he would love his nails cut, and his beard trimmed, but he can't get anyone to do it. In an interview with the Minimum Data Set (MDS) nurse on 12/17/24 at 10:50 AM, she revealed the purpose of the care plan is to identify the needs of each resident for the staff to know how specifically to care for each resident. She then stated if staff did not trim and clean Resident #8's beard /facial hair or clean and trim his nails per the care plan interventions, staff did not follow the care plan. Record review of the admission Record revealed the facility admitted Resident #8 on 8/24/19 with medical diagnosis that included Need for Assistance with Personal Care and Contracture, Left Hand. Record review of Resident #8's Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/16/24 revealed on a Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. Resident #73 A record review of the Care plan revealed Resident #73 has an alteration in Respiratory Status due to Asthma, Chronic Obstructive Pulmonary Disease, and Sleep Apnea with interventions initiated on 11/18/2024 that included Change oxygen tubing and humidifier bottle weekly. An observation on 12/15/24 at 3:55 PM, revealed Resident #73's oxygen concentrator with an undated, empty humidifier water bottle. The oxygen tubing connected to the humidifier water bottle was dated 11/29. An observation on 12/16/24 at 12:39 PM, revealed no change in the oxygen tubing. During an interview and observation on 12/16/24 at 2:10 PM, Licensed Practical Nurse (LPN) #1 confirmed that the oxygen tubing was dated 11/29 and revealed that it is important for the tubing to be changed as ordered to prevent the possibility of infections. In an interview on 12/16/24 at 2:30 PM, the Director of Nurses (DON) confirmed that Resident #73's care plan was not followed since the oxygen tubing and the water bottle were not changed as the physician had ordered. In an interview on 12/17/24 at 02:35 PM, the MDS Coordinator revealed that the care plan is developed so that the staff knows the individual needs of the residents. She revealed that the plan of care is patient-centered, and if the oxygen tubing and humidifier bottles were not changed out weekly, then the plan of care was not being followed as it should have been. A record review of Resident #73's admission Record revealed the facility admitted the resident on 11/11/2024 with medical diagnoses that included Acute Respiratory Failure with Hypoxia, Unspecified Asthma, and Chronic Obstructive Pulmonary Disease. Record review of the MDS with an ARD of 11/19/24, revealed Resident #73 had a BIMS score of 15, which indicated the resident is cognitively intact. Resident #58 Record review of Resident #58's Care Plan revealed that he had self-care deficit related to mobility impairment with interventions that included nail, hair, and oral care daily and as needed. On 12/15/24 at 3:42 PM an observation revealed Resident #58's fingernails on his right hand had a brown substance underneath them. On 12/16/24 at 2:15 PM, observation revealed Resident #58 lying in bed with no change in the resident's fingernails. On 12/16/24 at 2:25 PM, an observation in Resident #58's room and an interview with Certified Nursing Assistant (CNA) #5 confirmed that Resident #58 had dirty fingernails with gunk underneath the fingernails on his right hand. An interview on 12/17/24 at 3:20 PM with the MDS Coordinator revealed that nail care was included in Resident #58's Care Plan to be completed daily and as needed and since his nails were observed to be dirty, the care plan was not followed. Record review of Resident #58's admission Record revealed the facility admitted the resident on 07/18/22 with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction. Record review of Resident #58's MDS with an ARD of 11/08/24 under Section C a BIMS Score of 04 which indicated that he had Severe Cognitive Deficits. Resident #104 On 12/15/24 at 4:00 PM, an interview with Resident #104 revealed that she hadn't had a shower since Wednesday night, 12/11/24. She stated, I sure need one. She revealed that they were so busy, they did not give her a shower last night, 12/14/24, and that she had missed one other bath last week. She stated, The aide never came in to offer me a shower. Record review of Resident #104's Care Plan revealed that she had a self-care deficit and had interventions in place that included to assist with bathing as needed and nail, hair, and oral care daily and as needed. On 12/16/24 at 2:10 PM, an observation and interview with Resident #104 revealed her hair was greasy with a mild odor observed while standing next to the resident. She stated, I'm fat, I sweat underneath my boobs and if I don't get proper care, I smell. Resident #104 also revealed that it had been several days since she had her hair washed and her head had started itching. During an interview with CNA #5 on 12/16/24 at 2:17 PM, she confirmed that Resident #104's hair was greasy and needed to be washed. On 12/17/24 at 9:00 AM, an interview with the MDS Coordinator confirmed that Resident #104's Care Plan included interventions to assist with bathing as needed and to complete nail, hair, and oral care daily and as needed. She confirmed that since Resident #104 did not receive her scheduled shower and hair care, her care plan was not followed. Record review of Resident #104's admission Record revealed an admission date of 06/03/24 and that she had diagnoses that included Difficulty in Walking, Need for Assistance with Personal Care, and Type 2 Diabetes Mellitus. Record review of Resident #104's MDS with ARD of 12/11/24 under Section C revealed a BIMS Score of 15 which indicated that she was cognitively intact.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to provide needed services for residents who were unable to carry out their Activities of Daily Living (ADL's) for three (3) of 23 sampled residents. (Resident #8, Resident # 58, and Resident #104) This was cited as a pattern due to a previous citation with the last Annual Recertification Survey 8/31/23. Findings Include: (Cross-reference F725) Review of the facility policy titled, ADL's (Activities of Daily Living) with effective date of August 2021 revealed Policy: Ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences. Resident #8 An observation and interview on 12/15/24 at 4:00 PM revealed Resident #8's fingernails to be one-half (1/2) inch long past the tip of the fingers, jagged in appearance, with a thick brown substance under the nail beds, his facial hair/beard was unkempt. He stated that he would love his nails cut, and his beard trimmed, but he can't get anyone to do it. In an interview with Certified Nurse Assistant (CNA) #4 on 12/16/24 at 2:10 PM, confirmed Resident #8 's nails were long and jagged with a thick brown substance underneath. She stated that they appeared to have not been trimmed and cleaned in a while. She also confirmed his beard and facial hair was unkempt, long, and needed to be shaved. In an interview with Licensed Practical Nurse (LPN) #2 on 12/16/24 at 3:21 PM, she revealed that concerns from residents not having their dirty jagged nails cut included scratching themselves possibly leading to a skin infection from the dirty nails. She then revealed that not shaving a resident could be irritating to the resident. In an interview with the Director of Nursing (DON) on 12/17/24 at 9:48 AM, she revealed she was unable to find any documentation of recent refusals of ADL care for Resident #8 and confirmed the resident should have been shaved and nail care provided. Record review of the admission Record revealed the facility admitted Resident #8 on 8/24/19 with a diagnosis that included Need for Assistance with Personal Care and Contracture, Left Hand. Record review of Resident #8's Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/16/24 revealed a Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. Resident #58 An observation on 12/15/24 at 3:42 PM, revealed Resident #58's fingernails on his right hand had a brown substance underneath them. An observation on 12/16/24 at 2:15 PM, revealed Resident #58 continued to have a brown substance underneath his fingernails on his right hand. An observation in Resident #58's room and an interview on 12/16/24 at 2:25 PM with CNA #5, revealed that ADL included nail care. She confirmed that Resident #58's fingernails were dirty with gunk underneath them on his right hand. CNA #5 revealed that dirty fingernails could cause issues like spreading germs, sickness or infection. She revealed that it was their (CNA's) responsibility to clean out from under resident fingernails during their bath or shower and as needed. She revealed that Resident #58 is a two-person assist with ADLs. Record review of Resident #58's admission Record revealed the facility admitted the resident on 07/18/22 and that he had diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction, Aphasia, and Chronic Obstructive Pulmonary Disease. Record review of Resident #58's MDS with an ARD of 11/08/24 under Section C revealed a BIMS Score of 04 which indicated that the resident had severe cognitive deficits. Resident #104 An interview on 12/15/24 at 4:00 PM, with Resident #104 revealed that she hadn't had a shower since Wednesday night, 12/11/24 and stated, I sure need one. She revealed that they were so busy, they did not give her a shower last night, 12/14/24. She stated, The aide never came in to offer me a shower. An observation and interview with Resident #104 on 12/16/24 at 2:10 PM, revealed her sitting up in her wheelchair in her room with her hair pulled up on her head appearing greasy with a mild odor observed while standing next to the resident. She stated, I'm fat, I sweat underneath my boobs and if I don't get proper care, I smell. Resident #104 also revealed that it had been several days since she had her hair washed and her head had started itching. An interview with CNA #5 on 12/16/24 at 2:17 PM, CNA #5 confirmed that Resident #104's hair was greasy and that it had not been washed in a few days. She revealed that Resident #104 was scheduled to get her showers on the 3PM-11AM shifts on Tuesdays, Thursdays, and Saturdays and that Resident #104 reported to her this morning that she missed her shower on Saturday night. She also revealed that Resident #104 should have had a shower, and her hair washed on her scheduled days to make sure she was clean and to prevent body odor. An observation and interview with the Assistant Director of Nursing (ADON) on 12/17/24 at 8:30 AM, confirmed that Resident #104 and all residents should receive their scheduled showers and that residents' hair should be washed during that time. She confirmed that Resident #104's hair was oily and that she should have received her shower as scheduled on Saturday night. Resident #104 reported to the ADON that she had not had a shower since Wednesday night, 12/11/24. She revealed that on Saturday night, the aide never came in to get her for her shower. Record review of Resident #104's admission Record revealed the facility admitted the resident on 06/03/24 and that she had diagnoses that included Difficulty in Walking, Need for Assistance with Personal Care, and Type 2 Diabetes Mellitus. Record review of Resident #104's MDS with an ARD of 12/11/24 under Section C revealed a BIMS Score of 15 which indicated that she was cognitively intact.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on observation, staff interview, and facility policy review, the facility failed to prevent the possibility of the spread of foodborne illness as evidenced by thawing meat at room temperature and using unsafe food handling practices for food preparation for one (1) of two (2) kitchen tours. Findings include: Record review of the facility policy titled, Food: Preparation with a revision date of 9/2017 revealed under, Procedures: . 2. Dining Services will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination . 5. The Cook(s) thaws frozen items that requires defrosting prior to preparation using one of the following methods: Thawing in the refrigerator, in a drip-proof container, and in a manner that prevents cross-contamination; . Completely submerging the item under cold water (at a temperature of 70° [degrees] F [Fahrenheit] or below) that is running fast enough to agitate and float off loose particles . During the initial kitchen tour, on 12/15/24 at 3:10 PM, an observation of the two (2)-compartment sink revealed, five (5) packs of kielbasa sausages that were placed in the sink to thaw at room temperature with no running water. Dietary Staff #1 confirmed that meat should not be left out to thaw at room temperature and should have been placed in the cooler to prevent the potential for bacteria growth during the thawing process. Further observation revealed, a brown box placed on the kitchen floor that contained raw chicken skin inside the box and resting on the outer edges. Dietary Staff #1 confirmed the box contained raw chicken skin that had been removed during preparation of the chicken for the upcoming dinner meal. Dietary Staff #1 picked up the box to remove it and the box dripped a pink tinged watery drainage onto the floor and onto the drainboard of the 2-compartment sink. An interview with Dietary Staff #1 revealed the chicken skin should have been disposed of in the garbage during the preparation of the chicken. She revealed the raw chicken skin and drainage could contaminate surfaces and spread salmonella and potentially make someone sick. An interview with the Regional Dietary Manager on 12/18/24 at 8:10 AM confirmed that frozen meat should be thawed under running water or placed in a bin and into a cooler to thaw. He revealed the purpose was to prevent the growth of bacteria on the meat. He confirmed that raw chicken skin should be disposed of in the trash to prevent the possibility of contamination. The Regional Dietary Manager confirmed unsafe food handling practices could make someone sick.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Staffing Data (Tag F0851)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on staff interviews, record review, and facility policy review, the facility failed to submit accurate data into the Payroll Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. Fiscal Year Quater 2024 (July 1-September 30) Findings include: Record review of the facility policy titled, Payroll Based Journal Entry Submission, dated 2022, revealed, CMS (Centers for Medicare and Medicaid Services) regulations for Payroll Based Journal (PBJ) entries submission are adhered to. The policy also revealed, Procedure: 1. Collaboration with Human Resources and Payroll must occur to capture payroll hours for clinical team in centers and submission. 2. CMS allows manual input data or through the use of automatic reports generated by time-tracking or payroll software. If necessary, you may use both types of submissions for your facility. 7. Hours that each team member works each day must be submitted. Per CMS training hours and corporate team member hours may be included if the team member is providing direct care or performing direct care duties. On 12/16/24 at 2:00PM, an interview with the Workforce Management Coordinator confirmed that the facility did not accurately report to PBJ. She stated that there were salary employees that worked the weekends sometimes and their work hours had to be put in manually instead of by the time clock. She revealed that she thinks the numbers entered into PBJ were not accurate. During an interview on 12/16/24 at 2:30 PM, the Human Resource Coordinator confirmed she was responsible for submitting the information for any staff schedule changes into the computer system. She stated this was generally done on Monday or Tuesday after each weekend, and if the report was sent out prior to that, then it was not accurate since it did not reflect all of the staff that worked during the weekend. An interview with the Administrator on 12/18/24 at 8:20 AM confirmed that he felt this was an inaccurate submission concern for PBJ showing they were having low weekend staffing. He stated he pulled the salary employees' time and validation report, and it was noted that these employees were not entered manually into the computer system timely. He stated the PBJ information was submitted to the corporate staff on Monday morning and if the weekend changes were not entered at that time, the information submitted was inaccurate. He confirmed the facility was responsible for submitting PBJ information accurately to reflect the staffing in the facility and the facility failed to do this. Record review of the PBJ for the fourth quarter of 2024 revealed the facility triggered for low weekend staffing. Record review of the facility's staffing validation computer printout revealed the additional staff that worked had not been entered. Verification by the State Agency was conducted through documentation that those staff members were in the facility and performing resident care.

Sept 2024 3 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Comprehensive Care Plan (Tag F0656)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to ensure that a comprehensive care plan was implemented for a dependent resident who was transferred via a mechanical lift using the wrong size sling which resulted in the sling breaking and causing the resident to sustain a fall with fracture for one (1) of three (3) residents reviewed. Resident #1. Based on implementation of corrective actions completed on 8/30/24 prior to the State Agency (SA) entrance on 9/11/24, it was determined to be Past Non-Compliance (PNC). Findings Included: Review of the facility policy, MDS (Minimum Data Set) and Care Plans with effective date of August 2019, revealed that care plans and MDS will be developed and maintained per RAI (Resident Assessment Instrument) Guidelines. Record review of Resident #1's Care Plan initiated on 07/17/24 revealed that she had a physical functioning deficit with interventions that included to use a total lift with blue sling. On 09/11/24 at 8:55 AM, an observation and interview with Resident #1, revealed that she had a bad fall last month. She confirmed that on the day of the fall, there were two aides in the room to transfer her out of bed into the wheelchair using a lift. She revealed that they lifted her up off her bed, pushed the lift towards the wheelchair and as soon as she was out of reach of her bed, the strap on the sling broke and she fell to the floor. On 09/11/24 at 9:22 AM, an interview with Administrator (ADM) revealed that on 08/21/24, the staff came to his office and reported that Resident #1 fell from the lift sling to the floor. He revealed that the right shoulder strap on the sling broke while Resident #1 was in it during a transfer from her bed to her wheelchair. ADM revealed that the Certified Nursing Assistants (CNA) used the green sling with Resident #1 and confirmed that the CNAs did not use the bariatric sling which was safe up to 750 pounds. On 09/11/24 at 1:40 PM, an interview with CNA #1, revealed that on 08/21/24, she and CNA #2 had gotten Resident #1 in the sling, raised her up to get her in the wheelchair. She revealed that when they raised her up over the bed and moved the lift towards the chair, the right shoulder strap on the sling snapped and Resident #1 fell to the floor and landed on her right shoulder. CNA #1 revealed that they used the green lift sling because that's the one they had always used with her. She stated, We went along with everyone else. CNA #1 revealed that they realized that she was supposed to be in the extra large blue lift sling because of her weight but they didn't know this until after the fall. She revealed that they were supposed to look in the Kiosk to find out which sling to use. She stated, We felt terrible about it. CNA revealed that Resident #1 had always been in a green sling and they (CNAs) did what everyone else was doing. She revealed that they should have gone to the Kiosk and seen what sling was on her care plan to use. She said, This really upset me because I have always tried to do the right thing and I was just not aware that her care plan stated something different. On 09/11/24 at 2:35 PM, a phone interview with CNA #2, revealed that on 08/21/24, she and CNA #1 were getting Resident #1 up for an activity. She revealed that they got her ready, positioned her in the green sling and moved the lift off of the bed to move towards her wheelchair. She revealed that as soon as they cleared the bed with her, the right shoulder strap on the green sling snapped and Resident #1 fell to the floor. CNA #2 revealed that they always used the green sling with Resident #1 like everyone else did but said they should have used the extra-large blue sling that was care planned. CNA #2 revealed that they should have looked it up in their computer system before they grabbed the green sling because the type of sling to use was care planned. She revealed that the care plan also included what care needed to be done for each resident. She stated, I will definitely look at the [NAME] from now on. On 09/11/24 at 3:15 PM, an interview with MDS Coordinator, revealed that the purpose of the care plan was to set up what individualized care was needed for each resident, so the staff knew how to provide for them. She revealed that the care plans were specific to each resident and should be followed by all staff members. MDS Coordinator confirmed that Resident #1's care plan related to the hoyer lift was not followed when the CNAs used the green sling instead of the blue sling that was care planned and it resulted in a fall with injury. Record review of Resident #1's Lift Transfer Evaluation dated 05/28/24 revealed that a total lift was required and the sling size marked to use was the extra large blue sling which had weight ranges of 275 lbs - 500 lbs Under Total Lift Required section of the Lift Transfer Evaluation was documented, Focus: I have a physical functioning deficit with transfers and require assistance of Intervention: Hoyer Total Lift XLarge (Blue) Sling Record review of the Lift Transfer Evaluation also revealed that the Large green sling weight ranges were 175 lbs - 300 lbs. Record review of Resident #1's Weight Summary revealed that she weighed 376.3 pounds on 08/08/24. Record review of Resident #1's admission Record revealed an admission date of 10/13/20 and had diagnoses that included Morbid (Severe) Obesity, Type 2 Diabetes Mellitus, and Need for Assistance with Personal Care. Record review of Resident #1's MDS with Assessment Reference Date (ARD) of 09/08/24 under Section C revealed a Brief Interview for Mental Status Score of 15 which indicated that she was cognitively intact. Record review revealed the following measures were taken and plans put in place to correct the deficient practice prior to the State Agency's (SA) entrance into the facility on [DATE]: Resident #1 was assessed by Nurse Practitioner immediately after the fall and was sent out to the emergency room on [DATE]. Lift was inspected on 08/22/24 following the incident with no identified concerns by Maintenance. The lift and sling involved in the accident were removed from the floor by Administrator and remained out of service immediately on 08/21/24. All lifts and slings were assessed by the for any disrepair on 08/21/24 by Administrator and four yellow slings, one blue sling and one green sling were removed due to being worn, and in ill repair. New replacements were ordered on 08/26/24. New lift slings arrived on 08/29/24, they were numbered, dated, and put in service. The [NAME] was reviewed for all residents for appropriate lift and sling use on 08/22/24 by the Director of Clinical Education (DCE). CNA #1 and CNA #2 were educated on proper lift and sling use and return demonstration was completed on 08/21/24 by the DCE. Checkoffs were completed by the DCE with all staff which were initiated on 08/21/24 and continue throughout all shifts until everyone completed. New Lift Transfer assessments were completed by the ADON on all current residents and care plans were updated on 08/22/24. Therapy referrals were made as needed by the ADON on 08/22/24 for anyone who required a lift and lift sling. Care Plans and [NAME] updated as needed on 08/22/24 by the ADON. Team huddles with lift/transfer education completed 08/21/24 - 08/22/24 by the DCE. State Agency, Ombudsman, and Attorney General (AG's) office notified on 08/22/24 by Director of Nursing. In-Service on Lift/Transfer Program and Transfer Belts, Abuse/Neglect/Exploitation, and Elder Justice Program were completed by the DCE for all staff members with 100% compliance on 08/21/24 - 08/23/24. Topics included: Performance of lift usage, inspecting the sling prior to use, laundering slings and where to find them, and on the [NAME] - only using care planned sling colors. In-Services initiated on 08/23/24 with Housekeeping and Laundry Manager on sling inspection and guidelines by the DCE. Hoyer Lift Policy and Procedures were reviewed with CNA #1 and CNA #2 and all other staff beginning on 08/21/24-08/22/24 by the DCE. Audits on all Lift Assessments were completed on 08/21/24 and are on-going by the ADON. Quality Assurance and Performance Improvement (QAPI) meeting was held on 08/30/24 and all required staff members were in attendance. Plan to continue the weekly audits and bring results to the monthly QAPI meetings for three (3) months.

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and facility policy review the facility failed to ensure the safety of a dependent resident during a lift transfer by using the wrong lift sling resulting in a strap on the sling breaking. Resident #1 fell to the floor and sustained fractures as a result of the fall for one (1) of three (3) residents reviewed for falls. Resident #1 Based on implementation of corrective actions completed on 8/30/24 prior to the State Agency (SA) entrance on 9/11/24, it was determined to be Past Non-Compliance (PNC). Findings Included: Review of the facility policy, Lift 4 Care - Safe 4 All dated May 2024, revealed under guideline, 7. In order to maintain patient's and residents' safety, patients and residents should be lifted or transferred by the lift and sling which is deemed appropriate after the lift evaluation is completed. There should be no interchanging of lifts and slings . Record review of the Investigation of Resident #1's fall revealed that on 08/21/24 at 2:00 PM, Resident #1 had a fall with injury in her room. The incident was reported to Resident #1's representative, her daughter. Resident #1 experienced a witnessed fall with two witnesses, Certified Nursing Assistant (CNA) #1 and CNA #2. Interviews with CNA #2 revealed the fall occurred during an active staff transfer from bed to wheelchair for Resident #1 to attend activities. CNA #2 revealed that during the transfer, Resident #1's right shoulder strap disconnected from the sling which caused immediate fall to floor with resident landing on right side. Staff did witness Resident #1 hitting her head with complaints expressed from resident of right shoulder and left hip pain. CNA #1 revealed through investigative interview that while transferring Resident #1 from bed to chair, resident was up in the lift, the lift was guided to the middle of the room, before the wheelchair could be placed under her, the upper right strap broke and the resident fell to the floor, landing on her right side. Record review of the Emergency Department (ED) notes dated 08/21/24-08/22/24 revealed, the right lower extremity is shortened, externally rotated and tender to movement. Left hip x-ray and computed tomography scan (CT) revealed a comminuted mildly displaced left intertrochanteric femur fracture deformity. Resident #1 was transferred from the local ED to a hospital for surgical repair of the fracture. On 09/11/24 at 8:55 AM, an observation and interview with Resident #1, revealed her lying in her bariatric bed in her room. She had bruising to her right upper arm and shoulder and a healing surgical site to her left leg. Resident #1 was morbidly obese. Resident #1 revealed that she had a bad fall last month. She revealed that there were two aides in the room to transfer her out of bed into the wheelchair using a lift. She revealed that they lifted her up off her bed, pushed the lift towards the wheelchair and as soon as she was out of reach of her bed, the strap on the sling broke and she fell to the floor. Resident #1 revealed that she fell face down on the floor, she heard a loud pop and stated, It hurt so bad. She revealed that the nurses and nurse practitioner came immediately to her room, checked her out, called the ambulance and she went to the hospital. She confirmed that she had to have surgery and that her staples were removed yesterday and stated that she was still in pain, but it was much better. On 09/11/24 at 9:05 AM, an interview with Licensed Practical Nurse (LPN) #2, revealed that she worked the day of Resident #1's fall but was not in the room when it happened. LPN #2 revealed that she heard a scream for help from down the hall and that when she entered Resident #1's room, she found her lying with her head on the floor at the foot of her roommate's bed and Resident #1 was positioned on her right side. LPN #2 noticed that her left leg was shorter than her right leg and that she was screaming for help and complaining of pain. LPN #2 revealed that the nurse practitioner came immediately into her room, checked her out, and they called for an ambulance. LPN #2 revealed that Resident #1 complained of pain to her right arm, right shoulder and left leg. LPN #2 revealed that Resident #1 went out to the hospital, had surgery and was back at the facility about a week later and stated that this was very traumatic for her. On 09/11/24 at 9:22 AM, an interview with Administrator (ADM), revealed that on 08/21/24, the staff came and got him when Resident #1 fell from the sling. He revealed that the strap on the sling broke while Resident #1 was in it during a transfer from her bed to her wheelchair and she fell to the floor. ADM revealed that he reported this to the lift manufacturer, they inspected the lift and found nothing wrong with it. ADM revealed that the laundry staff inspected the slings every time they go to laundry and if they looked ragged out they discarded them. He clarified that ragged out meant that the material on the sling was worn thin, tattered or torn or if the straps were in disrepair. ADM confirmed that they used the green sling with Resident #1, and that the Certified Nursing Assistants (CNAs) did not use the bariatric sling which was safe up to 750 pounds. ADM revealed that Resident #1 was sent to the hospital and was found that she had a fractured hip and fractured femur. ADM revealed that they started an immediate investigation and reported the witnessed fall. He revealed that this was an unfortunate accident, and he hated it for the resident. On 09/11/24 at 9:35 AM, an interview with Family Nurse Practitioner (FNP), revealed that she was in the facility working on the day that Resident #1 fell from the lift, on 08/21/24. She stated that the staff came and got her when it happened, and she went and immediately assessed the resident. FNP revealed that Resident #1 was stunned, and she complained of left leg and hip pain. FNP revealed that she observed that her left leg was externally rotated and was shorter than her right leg. She revealed that the ambulance arrived within a couple of minutes, they gave her some pain medication and transported her to the hospital. On 09/11/24 at 10:00 AM, an interview with Director of Clinical Education (DCE), revealed that each specific sling had weight ranges to go by and that the blue sling was for bariatric residents up to 750 pounds. She revealed that the green sling shouldn't have been used with Resident #1, the CNAs should have used the blue sling. DCE revealed that the slings were inspected as they came through the laundry department, but she had educated the CNAs to inspect them prior to use as well to prevent other incidents. On 09/11/24 at 12:15 PM, an interview with Assistant Director of Nursing (ADON), revealed on 08/21/24, that CNA #1 and CNA #2 were transferring Resident #1 using a lift and one of the straps on the sling broke and she fell to the floor. ADON verified that the guidelines on the proper lift sling use on the Lift Assessments for Resident #1 revealed that the green sling was a size large, and its weight ranges were 175 - 300 pounds and the blue sling was an extra-large and it's weight ranges were 275 - 500 pounds. ADON confirmed that the blue sling was care planned to be used with Resident #1 and the green sling should not have been used. On 09/11/24 at 1:40 PM, an interview with CNA #1, revealed that on 08/21/24, she and CNA #2 had gotten Resident #1 in the sling and raised her up to get her into the wheelchair. She confirmed that when they raised her up over the bed and moved the lift towards the chair, the right shoulder strap on the sling snapped and Resident #1 fell to the floor and landed on her right shoulder and was in pain. CNA #1 revealed that they used the green sling because that's the one they had always used. She stated, We went along with everyone else. CNA #1 revealed that they realized that she was supposed to be in the extra-large blue sling because of her weight but they didn't know this until after the fact. She revealed that they were supposed to look it up in the Kiosk to find out which sling to use. She stated, We felt terrible about it. CNA #1 revealed that Resident #1 had always been in a green sling and she did what everyone else was doing. She revealed that they should have gone to the Kiosk and looked up what sling was on her care plan to use. She said, This really upset me because I have always tried to do the right thing and be diligent with these residents. On 09/11/24 at 2:35 PM, a phone interview with CNA #2, revealed that on 08/21/24, she and CNA #1 were getting Resident #1 up for an activity, that they got her ready, positioned her in the green sling and moved the lift off of the bed to move towards her wheelchair. She revealed that as soon as they cleared the bed with her, the strap snapped, and she fell to the floor. CNA #2 revealed that the green sling was always used with Resident #1. She confirmed that they should have used the blue sling that was care planned, they just followed suit and did what everyone else was doing. CNA #2 revealed that the [NAME] told them which sling to use and what care was needed to be done for each resident. She stated, I will definitely look at the [NAME] from now on. Record review of Resident #1's Lift Transfer Evaluation dated 05/28/24 revealed that a total lift was required, and the sling size marked to use was the extra-large blue sling which had weight ranges of 275 pounds (lbs.) - 500 lbs. Total Lift Required section was documented, Focus: I have a physical functioning deficit with transfers and require assistance of .Intervention: Hoyer Total Lift XLarge (Blue) Sling Record review also revealed that the Large green sling weight ranges were 175 lbs. - 300 lbs. Record review of Resident #1's Weight Summary revealed that she weighed 376.3 pounds on 08/08/24. Record review of Resident #1's Progress Note dated 08/21/24 completed by Family Nurse Practitioner, revealed, complains of left hip and leg pain. Hit back of head on wheel of roommate's bed. Near Syncope after fall, difficulty breathing immediately following fall, 02 (oxygen) applied via mask. LLE (left lower extremity) with external rotation and LLE shortened compared to RLE (right lower extremity). Record review of Resident #1's admission Record revealed an admission date of 10/13/20 and diagnoses that included Morbid (Severe) Obesity and Need for Assistance with Personal Care. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/08/24 under Section C revealed a Brief Interview for Mental Status Score of 15 which indicated that she was cognitively intact. Record review revealed the following measures were taken and plans put in place to correct the deficient practice prior to the State Agency's (SA) entrance into the facility on [DATE]: Resident #1 was assessed by Nurse Practitioner immediately after the fall and was sent out to the emergency room on [DATE]. Lift was inspected on 08/22/24 following the incident with no identified concerns by Maintenance. The lift and sling involved in the accident were removed from the floor by Administrator and remained out of service immediately on 08/21/24. All lifts and slings were assessed by the for any disrepair on 08/21/24 by Administrator and four yellow slings, one blue sling and one green sling were removed due to being worn, and in ill repair. New replacements were ordered on 08/26/24. New lift slings arrived on 08/29/24, they were numbered, dated, and put in service. The [NAME] was reviewed for all residents for appropriate lift and sling use on 08/22/24 by the DCE. CNA #1 and CNA #2 were educated on proper lift and sling use and return demonstration was completed on 08/21/24 by the DCE. Checkoffs were completed by the DCE with all staff which were initiated on 08/21/24 and continue throughout all shifts until everyone completed. New Lift Transfer assessments were completed by the ADON on all current residents and care plans were updated on 08/22/24. Therapy referrals were made as needed by the ADON on 08/22/24 for anyone who required a lift and lift sling. Care Plans and [NAME] updated as needed on 08/22/24 by the ADON. Team huddles with lift/transfer education completed 08/21/24 - 08/22/24 by the DCE. State Agency, Ombudsman, and Attorney General (AG's) office notified on 08/22/24 by Director of Nursing. In-Service on Lift/Transfer Program and Transfer Belts, Abuse/Neglect/Exploitation, and Elder Justice Program were completed by the DCE for all staff members with 100% compliance on 08/21/24 - 08/23/24. Topics included: Performance of lift usage, inspecting the sling prior to use, laundering slings and where to find them, and on the [NAME] - only using care planned sling colors. In-Services initiated on 08/23/24 with Housekeeping and Laundry Manager on sling inspection and guidelines by the DCE. Hoyer Lift Policy and Procedures were reviewed with CNA #1 and CNA #2 and all other staff beginning on 08/21/24-08/22/24 by the DCE. Audits on all Lift Assessments were completed on 08/21/24 and are on-going by the ADON. Quality Assurance and Performance Improvement (QAPI) meeting was held on 08/30/24 and all required staff members were in attendance. Plan to continue the weekly audits and bring results to the monthly QAPI meetings for three (3) months.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on observation, staff and resident interview, record review and facility policy review the facility failed to provide meals that included palatable food for five (5) of five (5) residents reviewed. Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. Findings Include: Record review of the facility policy titled, Dining and Meal Service with effective date of January 1, 2017, revealed .Individuals will be provided with nourishing, palatable, attractive meals that meet daily nutritional and special dietary needs. Resident #2 On 09/11/24 at 8:25 AM, an interview and observation revealed Resident #2 sitting up in his bed in his room with his breakfast tray on his overbed table. He revealed that he had been at that facility about 18 months and stated, You don't need to ask me about the food here because it's not good. He revealed that they served the same food over and over, the meat was half done sometimes and much of the food was hard, tough, and difficult to chew. An observation of Resident #2's breakfast tray revealed two pancakes, two slices of ham, and hot cereal. Resident #2 revealed that the pancakes were hard, and he could not cut them up to eat them this morning and stated, I don't eat most of the food. On 09/11/24 at 8:28 AM, an observation revealed Registered Nurse (RN) #1 enter Resident #2's room and confirmed that the pancakes were too hard to eat and she tried to cut them up for Resident #2 so he could eat them, but was unsuccessful. RN #1 was not able to cut the pancakes with a fork and stated, This is horrible. She revealed that they've had issues with the food for a while now and that they had been trying to get a different dietary company. RN #1 revealed that she knew of several complaints about food being too tough and hard to chew and stated, The bread is always hard. On 09/11/24 at 12:44 PM, an observation revealed Resident #2 sitting up in his wheelchair in his room with his lunch meal tray on his over bed table. He revealed that his chicken was overcooked, tough, and hard to chew. He revealed that he wasn't eating that stuff, it was too hard to cut up and it wasn't worth the trouble. Resident #3 On 09/11/24 at 8:40 AM, an observation and interview with Resident # 3 revealed that he had been there since August 2021. He revealed that the care was good, but the food was terrible. Resident #3 stated, If it's a blue moon out, the food might be good. He revealed that his pancakes were dry and so hard, he couldn't cut them to eat them. Resident #3 revealed that sometimes they had cinnamon rolls that were so hard that if you threw them at someone, you might put an eye out. He also revealed that some days the meat was tough and hard as shoe leather. Resident #3 revealed that he ordered door dash this morning and his breakfast was delivered to him and stated that that he just couldn't eat this food sometimes. On 09/11/24 at 9:30 AM, an interview with Administrator (ADM) revealed that they had issues with the food but he thought it was getting better since they had the new District Dietary Manager. ADM revealed that he had heard a few complaints about the food lately, but nothing major. He revealed that someone complained that the bread on their tray was hard, but he couldn't recall who had complained. ADM revealed that he hoped the new District Dietary Manager could make a difference. He revealed that there had been a lot of dietary staff turnover with the past district manager, and it seemed to be more consistent now and he was hoping things would improve. Resident #5 On 09/11/24 at 10:14 AM, an interview with Resident #5, Resident Council President, revealed that she had pancakes, ham, cereal and oatmeal this morning and it was just okay. She revealed that she didn't eat anything last night and she was hungry this morning. She revealed that the food really wasn't the best and if she didn't like it what was on her tray, she didn't eat it. On 09/11/24 at 12:50 PM, an interview with Resident #5, Resident Council President, revealed her sitting up in her recliner in her room and she said she had not received her lunch tray yet. She revealed that most of the time the food was so bad, she didn't eat it but when she was really hungry, she ate it anyway. Resident #5 revealed that everybody complained about the food. On 09/11/24 at 1:00 PM, an interview with Certified Occupational Therapy Assistant (COTA), revealed that they had a lot of residents complaining about the food. She revealed that the dietary department served frozen pancakes a lot and the edges were always hard and sometimes the whole pancake was too tough to eat. She revealed that they served French toasts sometimes for breakfast and they were always too hard for them to eat. COTA revealed that a lot of the residents had dentures, and some didn't have any teeth at all and stated, I don't see how they eat this stuff. She revealed that they had a lot of staff turnover in the dietary department and was hoping it would get better for the residents. On 09/11/24 at 1:19 PM, an observation revealed Resident #5, Resident Council President, sitting up in her recliner in her room with her lunch tray on her over bed table. There was a piece of fried chicken, mashed potatoes, spinach, and cornbread on her plate. Resident #5 stated, I don't know how this chicken is, I can't' get into it to see. She revealed that the chicken was too brown, overcooked and too hard. She revealed that she couldn't chew that outside part, it was too tough. Resident #5 stated, Looks like they cooked it too long. She revealed that they just can't get the food right. On 09/11/24 at 1:22 PM, an observation revealed COTA, enter Resident #5's room and looked at her lunch tray and confirmed that the chicken on her plate was overcooked, hard and observed resident trying to cut the skin off with her fork. Resident #5 stated, I can't chew that chicken, it's too tough. An observation also revealed COTA offer to assist Resident #5 to cut up her chicken, but resident declined, put her fork down and left the piece of chicken on her plate. On 09/11/24 at 1:25 PM, an observation revealed ADON enter Resident #5's room and stated, That chicken looks way over cooked and way too hard. ADON said that there was very little chicken meat there to eat because it was all dried out. ADON revealed if they got anything right at the facility, it should be their meals because that's all they had to look forward to. She offered to get Resident #5 something else to eat and she asked for a peanut butter and jelly sandwich. Resident #4 On 09/11/24 at 1:09 PM an interview with Resident #4, revealed that he was pleased with the care he received at the facility, but they had problems with the food. He revealed that a lot of times the meat was not good, it was cooked too long, it was hard and tough to chew and that they served old, hard bread too. On 09/11/24 at 1:14 PM, an interview with Licensed Practical Nurse (LPN) #1, revealed that she had worked in that facility for four and a half years. She revealed that the residents complained often about the food. LPN #1 revealed that food was sometimes cold when the residents received it and often the French toasts and pancakes were hard as a brick bat. On 09/11/24 at 2:00 PM, District Dietary Manager, walked to Resident #4's room, looked at her meal tray and confirmed that her piece of fried chicken was hard, overcooked and non-palatable and that she was not able to eat it. Resident #6 On 09/11/24 at 1:30 PM, an observation and interview with Certified Nursing Assistant (CNA) #1 in the hallway, revealed that she was going to the kitchen to get Resident #6 a ham and cheese sandwich he requested because his chicken was overcooked, hard and not fit to eat. CNA #1 confirmed that the chicken was tough, overcooked, and stated, It's hard as a brick. She also revealed that there was very little meat on the inside of the tough skin and what was there was dried throughout. She stated, I wouldn't give it to my dog. On 09/11/24 at 1:35 PM, an observation and interview with Resident #6 revealed a piece of fried chicken on his lunch tray and it was dark brown and hard to the touch. He revealed that the piece of fried chicken was tough and cooked too long and stated, I couldn't eat it. He revealed that CNA #1 was getting him a sandwich from the kitchen. He revealed that sometimes the food was good and sometimes it wasn't. Resident #6 revealed that his breakfast this morning was okay, that one of his pancakes was hard but he ate it anyway because he was hungry. Resident #6 revealed that he looked forward to his meals and wished that the food was better. On 09/11/24 at 1:55 PM, an interview with District Dietary Manager (DDM), revealed that providing palatable meals meant that the food should look appealing, should taste good, and the resident should be able to chew it. He revealed that they checked the chicken to make sure that it reached an internal temperature of 165 degrees. He revealed that they tried to make sure that the meat was not red or pink on the inside, so they often cooked it a little longer to make sure of it. He revealed that leaving food on the steam table too long could be making the food tough, but he wanted to keep it warm for the residents. DDM agreed that the food needed to be enjoyable because that's one thing the residents looked forward to. He revealed that he had been in that position about a month, and they were trying to fix the issues in all his facilities to make things better for the residents. He stated, It's all about keeping them happy and he revealed that he'd like to provide everything they wanted and needed. DDM revealed that he would work with his dietary staff on the food issues and try to come up with a plan to fix the problems. On 09/11/24 at 2:45 PM an interview with Social Worker (SW), revealed that she handled the facility grievances to make sure they were handled and resolved promptly. She revealed that there had been some issues with the food, they had new staff in the dietary department, and it was getting better. SW revealed that they had a lot of staff turnover in the dietary department and now had a new District Dietary Manager. She revealed that the food situation wasn't a one-person fix, it was going to take the team to work together to resolve the issues. SW revealed that there had been complaints about the toast being too hard to eat, the meat being tough, and the food often cold by the time the residents received it. SW revealed that this was the residents' home, and they deserved better. She revealed that she had talked to dietary staff, and they needed to do better with preparing the meals. She also revealed that they were working on getting a plan in place to make the food situation better. Record review of the facility Weekly Menu revealed that the breakfast meal on Wednesday, 09/11/24, was Buttermilk Pancakes, Hot Cereal, Breakfast Ham, Milk, Coffee or Hot Tea, and Orange Juice. On Wednesday, 09/11/24, the lunch meal was Fried Chicken, Mashed Potatoes, Seasoned Spinach, Cornbread, and Mandarin Oranges. Record review of Resident #2's admission Record revealed an admission date of 01/06/23 with diagnoses that included Need for Assistance with Personal Care, Dysphagia, and Type 2 Diabetes Mellitus. Record review of Resident #2's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/22/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated that he was cognitively intact. Record review of Resident #3's admission Record revealed an admission date of 08/31/21 and had diagnoses that included End Stage Renal Disease, Need for Assistance with Personal Care, and Type 2 Diabetes Mellitus. Record review of Resident #3's MDS with ARD of 08/23/24 under Section C revealed a BIMS score of 15 which indicated that he was cognitively intact. Record review of Resident #4's admission Record revealed an admission date of 03/21/18 and had diagnoses that included Chronic Obstructive Pulmonary Disease and Dysphagia. Record review of Resident #4's MDS with ARD of 07/11/24 under Section C revealed a BIMS score of 15 which indicated that he was cognitively intact. Record review of Resident #5's admission Record revealed an admission date of 02/05/19 and had diagnoses that included Unspecified Dementia, Parkinson's Disease, and Need for Assistance with Personal Care. Record review of Resident #5's MDS with ARD of 07/02/24 under Section C revealed a BIMS score of 15 which indicated that she was cognitively intact. Record review of Resident #6's admission Record revealed an admission date of 05/12/24 and had diagnoses that included Dysphagia and Need for Assistance with Personal Care. Record review of Resident #6's MDS with ARD of 07/09/24 under Section C revealed a BIMS score of 14 which indicated that he was cognitively intact.

Jan 2024 4 deficiencies 4 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and facility policy review the facility failed to protect the resident's right to be free from neglect as evidenced by failure of the staff to communicate and put measures in place to prevent the second elopement of Resident #1 who left the faciity on [DATE] unnoticed and unsupervised. Resident #1 was one (1) of three (3) residents reviewed. Resident #1 was allowed to exit the facility on 01/07/24 unnoticed and unsupervised at an unknown time and was discovered to be missing from the facility at approximately 8:10 PM. On 01/07/24 at approximately 8:00 PM, the police department received a 911 call from an unknown bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. A local Police Officer was dispatched and found Resident #1 walking in the middle of the street approximately 1850 feet from the facility and she had no shoes and no coat on. The Police Officer assisted Resident #1 into the backseat of his car and took her to the facility where he discovered that the facility staff were looking for her. Resident #1 was last observed in the facility at 7:55 PM, a Code 10 (elopement) was called at 8:10 PM, and Resident #1 was returned to the facility at 8:25 PM. A head-to-toe assessment was completed immediately upon her return to the facility. Resident #1 was a wandering risk and had previously exited the facility on 12/14/23 and once again eloped from the facility without staff knowledge on 1/7/24. The facility's failure to provide supervision to prevent an elopement for Resident #1 who was actively exit seeking and diagnosed with Alzheimer's and Dementia allowed her to leave the facility unnoticed and unsupervised until she was picked up by a local Police Officer in the middle of the street about 1850 feet away from the facility. The elopement placed Resident #1 and other residents who were at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ), and Substandard Quality of Care (SQC) which began on 01/07/24 when Res #1 eloped from the facility unsupervised. The SA notified the facility's Administrator (ADM) of the IJ and SQC on 01/11/24 at 3:19 PM, and provided IJ templates to the ADM. The facility submitted an acceptable Removal Plan on 1/12/24, in which they alleged all corrective actions to remove the IJ were completed on 1/12/24, and the IJ removed on 1/13/24. The SA validated the Removal Plan on 1/22/24 and determined the IJ was removed on 1/13/24, prior to exit. Therefore, the scope and severity for 42 CFR (s): 483.12 (a) (1) - Free from Abuse and Neglect (F600), was lowered from a J to a D, while the facility develops a plan of correction to monitor 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, Neglect, Misappropriation, Exploitation Policy with effective date of January 2019 revealed Purpose: To prohibit and prevent . neglect .Definitions: .Neglect: Failure of the center, its team members or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Record review of Facility Investigation Template completed by Administrator documented the following: On 1/7/2024 at 8:10 pm a code 10 was called as resident was unable to be located. Staff completed a room to room audit to ensure all residents were safe and accounted for. At 8:25 pm resident was escorted back into center by Police Department officer. Investigation Summary: Review of the center's maintenance camera revealed the resident exited the center out an unlocked door in the rear of the center . Record review of Progress Notes Type: Behavior Charting, completed by Licensed Practical Nurse (LPN) #2, dated 01/01/2024 at 18:48 (6:48 PM) revealed Resident constantly trying to get out of building, she got into the kitchen and was headed out the back door before a staff member caught her. We are ensuring that she stays on this side of building however its hard to watch her 24/7. An additional entry by LPN #2 at 18:58 (6:58 PM) revealed DON (Director of Nursing) notified, ensured that kitchen doors were locked. Record review of Progress Note dated 01/04/2024 and signed by the Family Nurse Practitioner (FNP) on 01/05/2024 revealed .Chief Complaint/Reason for this Visit - Facility requested visit for not sleeping at night and wandering throughout the night .HPI (History of Present Illness) relating to this visit DNS (Director of Nursing Services Proper Name) reported that resident has insomnia during the night and wanders aimlessly throughout facility at night with exit seeking behaviors. Staff report resident wanders during day time hours but wandering increases late in the afternoon and continues through night time hours with exit seeking behavior increasing during night time hours as well .Cognitive Status: Forgetful, Dementia, Confused . On 01/09/24 at 8:45 PM, during an interview with LPN #1, revealed that she was working the night of 01/07/24 when Resident #1 left the facility without staff knowledge. LPN #1 stated that she had last seen Resident #1 that night around 7:50 PM walking down B-Hall. She revealed that Resident #1's cognitive status is not good due to dementia. She stated they could hold her hand and easily redirect her back to her room. LPN #1 revealed that Resident #1 had been seen exit seeking a lot lately and stated, They think she may have exited the kitchen. On 01/09/24 at 9:05 PM, an interview with the Administrator (ADM) revealed that Resident #1 had gotten out of the building again on 01/07/24 on the night shift. He revealed that according to interviews and statements taken by staff, Resident #1 was last seen around 7:55 PM and that there was about 20 to 25 minutes that Resident #1 was unaccounted for that night. The ADM revealed that he thought she left through the kitchen door this time. He revealed that the staff had been doing hourly checks since the last elopement incident on 12/14/23 and that this happened between the scheduled hourly visual checks. The ADM revealed that a Code 10 (elopement of a resident) was called around 8:10 PM. Resident #1 was last seen around 7:55 PM and was returned to the facility by a police officer around 8:25 PM or 8:30 PM. The ADM revealed that Maintenance came in that night and checked all of the windows and doors, checked all of the door alarms and wander guard bracelets and everything worked properly. The ADM revealed that the only way possible for her to get out was through the kitchen door. He revealed that the two doors that led from the dining room into the kitchen had locks on them from the inside of the kitchen and staff had to push the lock in and turn it for them to lock properly. He stated he wasn't aware that Resident #1 had gone back into the kitchen earlier that evening until he read the statements provided by the staff during the investigation of the elopement. The ADM indicated that this resident wanders a lot and according to what he was told, Resident #1 was last seen in the dining room around 7:25 PM on 01/07/2024. The ADM revealed that Resident #1 was placed on one on one (1:1) supervision after the incident until the new kitchen door locks were installed on 01/08/24 at 1:00 PM. He stated, The only thing we really changed were the kitchen doorknobs and put a pin lock on the doors so that everyone who entered had to have the code. On 01/09/24 at 10:05 PM, an interview with Certified Nursing Assistant (CNA) #1, revealed that she was working on the night of 01/07/24 when Resident #1 got out of the facility. She revealed that Resident #1 liked to wander at night and sometimes she would walk to the end of the hall, jiggle the door to see if it would open. CNA #1 revealed that it was hard to keep up with Resident #1 most of the time because she was constantly on the move. CNA #1 revealed that on 01/07/24 at around 7:35 PM, a kitchen staff member brought Resident #1 to her on the C/D hall and told her that Resident #1 had gotten into the kitchen again. CNA #1 revealed that she brought Resident #1 to the CNA she was assigned to for the night, and he took care of her. CNA #1 revealed that a little after 8 PM, Resident #1's CNA asked her if she had seen Resident #1. CNA #1 revealed that they looked down halls, resident rooms, and outside. CNA #1 revealed that a few minutes later, the police brought Resident #1 back to the facility. CNA #1 stated, I have no idea how she got out. On 01/10/24 at 10:10 AM, an interview with the Administrator (ADM) revealed that all windows and doors were checked by Maintenance, and everything worked properly. He stated there was still 20 minutes that Resident #1 was unaccounted for the night of 01/07/24. The ADM agreed that a lot could have happened to her in 20 minutes and stated, I'm just glad she was safe, it could have been really bad. On 01/10/24 at 10:20 AM, a phone interview with the Director of Nursing (DON), revealed that on Sunday night 01/07/24, the Administrator called and told her about Resident #1 getting out of the building again. She revealed that she was off, but came on to the facility. The DON revealed that Maintenance came in and checked all the doors, and she was confident that the kitchen door was the only door Resident #1 could have gotten out of. The DON revealed that Resident #1 had walked into the kitchen a couple of times that she knew of prior to this night because staff had mentioned it to her. The DON stated, This had happened during the day while we were there. The DON stated that she wasn't aware that Resident #1 had been brought out of the kitchen earlier the night of 01/07/24 until she arrived on that Sunday night around 9:00 PM. On 01/10/24 at 10:45 AM, an interview with Dietary Aide #1, revealed that she was working on the evening of 01/07/24 during the time that Resident #1 got out of the building. She revealed that at approximately 7:30 PM or a little after, she was bent down washing dishes in the washroom next to the kitchen door when she heard something. Dietary Aide #1 revealed that she saw that Resident #1 had come into the kitchen, had walked past her and was standing over by the stove and was walking towards the exit door which led to the outside of the building. Dietary Aide #1 revealed that she was in the kitchen by herself when this happened because Dietary Aide #2 had taken the trash out. Dietary Aide #1 revealed that she took Resident #1 by the hand and led her out of the kitchen and took her to CNA #1 who was working on the hall. Dietary Aide #1 revealed that about 30 minutes later, she came out of the kitchen to see that a CODE 10 was called and found out that Resident #1 was missing. This Dietary Aide #1 revealed that she was familiar with Resident #1 and that the resident walked constantly and was seen frequently at doors looking out. On 01/10/24 at 11:00 AM, an interview LPN #2 revealed that Resident #1 usually slept during the day until late afternoon or supper time and then walked the floors. LPN #2 stated, She stays busy, just does her thing. She also stated, We try to work together with the CNAs and do the best we can to keep our eyes on her but it's hard with her constantly on the move. She revealed that when Resident #1 walked the halls, she would push on the doors, then turn around and walk off if the doors wouldn't open. She revealed that Resident #1 was not combative and was easily redirected; but would often return to what she was doing. LPN #2 stated, Everyone knows that as soon as you redirect her, she goes right back. LPN #2 revealed that Resident #1 had dementia but said she was Smarter than you think, it's like she's watching and waiting. On 01/10/24 at 11:20 AM, an interview with the Administrator revealed that there were two older video cameras on the Maintenance Shop out behind the facility. He revealed that the cameras were 50 feet from the facility pointing back towards the back of the Nursing Home where the kitchen exit door was. The Administrator revealed that they played back the video camera footage, and it revealed Resident #1 exiting the kitchen door to the outside. The ADM stated, We do have evidence of her exiting the building and I know for sure that she went out the side kitchen door, not out the Emergency Exit door in the dining room. The ADM revealed that it was dietary not keeping the doors from the dining room into the kitchen locked properly that caused Resident #1 to get out. The ADM revealed that Maintenance had come in and changed the door locks on the doors which led from the dining room into the kitchen and had put in keypads that required a code to enter. The ADM stated, Now they don't have a choice but to keep the doors locked. The ADM revealed that he did not realize Resident #1 had gotten into the kitchen earlier the day of 01/07/24 until he was reading statements. The ADM revealed that the kitchen doors would lock but staff were not keeping them locked and stated, I do know that I've been on them about keeping the kitchen doors locked. On 01/10/24 at 11:55 AM, an interview with Dietary Aide #2, revealed that she was working on 01/07/24 in the kitchen. She revealed that she was outside taking the trash out and when she returned, was told by Dietary Aide #1, that Resident #1 had walked into the kitchen and was headed towards the exit door over by the stove. Dietary Aide #2 revealed that she got snacks together and when she passed out the snacks around 7:30 PM to A/B hall, she saw Resident #1 exiting a resident's room on that hall. She revealed that after 8:00 PM, a CODE 10 was called, and everyone went to look for her. Dietary Aide #2 revealed that Resident #1 came into the kitchen pretty often, but most of the time she just opened the door and closed it back without coming in. Dietary Aide #2 revealed that if Resident #1 opened the door to the kitchen, the staff would find a nurse or CNA to get her out of the kitchen. Dietary Aide #2 stated, If we didn't, she would just come right back. She revealed that Resident #1 had come into the kitchen a couple times while she had been at work but couldn't recall the dates. Dietary Aide #2 revealed that they always made sure the kitchen doors were locked before they left at night-time. She revealed that one door they had to manually lock when they were in the kitchen. Dietary Aide #2 revealed that Resident #1 must have gone into the kitchen while she (Dietary Aide #2) was passing out snacks and while Dietary Aide #1 was washing dishes for them not to have seen her. On 01/10/24 at 12:10 PM, a phone interview with the Police Officer who found the resident, revealed that on 01/07/24 around 8:00 PM, the Police Department had received a 911 call from a bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. The Officer revealed that he drove to the area and found that Resident #1 was walking in the middle of the street behind the Emergency Department at the local County Hospital which was a pretty good way from the nursing home. The Officer revealed that the resident had a shirt, jogging pants, and socks on. The Officer stated that Resident #1 was not wearing a coat or shoes. He stated that he stopped her, and the resident seemed to be confused. He asked her where she was going, and she told him to the nursing home. He revealed that she was hard to understand but Resident #1 told him she was going back to Proper Name of Facility. The officer revealed that he helped her into his car and drove her back to the facility. The Officer revealed that he released her to to LPN #3. Record review of the City of (Proper name of City) Police Department Incident Report revealed .Narrative .I was informed by (Proper Name) LPN #3 that this was not the first time that this has happened, that one of the doors in the building was not locked and does not have an alarm on it This incident report was completed by the Police Officer on 01/07/24. On 01/10/24 at 4:25 PM, a phone interview with LPN #3 revealed that she was working on 01/07/24, the night that Resident #1 got out of the facility. LPN #3 revealed that she had seen Resident #1 several times walking all around on A/B hall and E/F hall and staff members kept bringing her back to her room. LPN #3 revealed that Resident #1 was last seen just outside her room a little before 8:00 PM. She revealed that about 8:10 PM, she asked the CNA who was assigned to Resident #1 to go see if she was in her room and he found that she was not. LPN #3 revealed that she called a Code 10 and immediately started looking for her. She revealed that they looked on all halls, in all rooms and outside the building. LPN #3 revealed that she went to the front door about 8:25 PM and saw a police car drive up and then saw that he had Resident #1 in the back seat. She revealed that the police officer brought her to the door and stated, I believe I have someone who belongs to y'all and the officer released Resident #1 to them. LPN #3 revealed that Resident #1 had a pair of sweatpants on with a cuff at the bottom, had a long-sleeved shirt on, some gripper socks and had no coat or shoes on. She revealed that they immediately got her inside, checked her vital signs and did a head-to-toe assessment and there were no injuries noted. On 01/11/24 at 11:05 AM, an interview with LPN #2 revealed that on 01/01/24, Resident #1 had walked into the kitchen and was found to be on the left side of the stove walking towards the exit door when she was approached by a dietary aide and redirected back to the C/D hall. LPN #2 revealed that the kitchen doors should have been locked so that residents couldn't enter, and this situation should have been reinforced and monitored better so as to help prevent the elopement. She revealed that the door that goes to the outside of the building from the kitchen was unlocked. LPN #2 revealed that on 01/01/24 after supper, the staff members were in the kitchen pulling trays getting ready to wash dishes when one of the staff members in the kitchen saw Resident #1 heading straight for the exit door. LPN #2 revealed that she reported this to the DON who told her to make sure the kitchen doors were locked and to put a progress note (behavior) in about the incident and to make sure to cover herself in case the resident was to get out of the building again. LPN#2 revealed that this was the first and only time that this had happened on her shift that she was aware of. She revealed that Resident #1 seemed to have her days and nights mixed up and that her wandering seemed to be worse later in the evening. LPN #2 agreed that had this incident been addressed and taken care of back the first of the month when it happened and was reported to the DON it might have prevented Resident #1 from getting out of the facility on 01/07/2024. On 01/11/24 at 11:30 AM, an interview with Minimum Data Set (MDS) Coordinator, revealed that they had been having Quality Assurance and Performance Improvement (QAPI) Meetings every month with the Medical Director present. The MDS Coordinator revealed that Quality Assurance Performance Improvement (QAPI) was a functional tool that forced everyone to look at [NAME] if something had happened and a good way to follow up. She stated, It's a continual thing. The MDS Coordinator revealed that she was not aware of the wandering incident where Resident #1 was found inside the kitchen heading out the exit door on 01/01/2024. She revealed that this was not brought up in stand up or in QAPI meeting but then she had missed some. The MDS Coordinator stated, I didn't know about this incident and I should have. I must have missed some of this. The MDS Coordinator agreed that the facility neglected to handle this incident and it should have been reported, discussed, and taken care of. She revealed that it should have been care planned, interviews should have been completed, and they should have made sure that the incident was noted, and things were in place. The MDS Coordinator agreed that if the incident with Resident #1 had been taken care of on 01/01/24, it could have prevented the elopement incident on 01/07/24 which put the resident at risk of harm. The MDS Coordinator stated, Apparently we dropped the ball on this one. On 01/11/24 at 12:20 PM, an interview with the ADM revealed that he was not aware of the incident with Resident #1 walking into the kitchen and heading out the exit door which occurred on 01/01/24. He stated, I had no idea, no one told me that. The ADM revealed, I was told that the kitchen staff was not keeping the doors to the kitchen locked and we educated them on how to properly lock the doors. The ADM revealed that when this was brought to his attention, he was thinking more about safety with knives, hot steam tables, and infection control issues, not elopement concerns. He revealed that he wasn't sure why this wasn't brought up in their morning meetings and that if it had happened, they should have addressed it, corrected the situation then, and had measures in place. He stated, I was not aware and should have been notified. On 01/11/24 at 12:35 PM, a phone interview with the Director of Nursing Services (DON), revealed that she was made aware after she arrived at the facility on the night of 01/07/24, that Resident #1 had gone into the kitchen earlier in the evening prior to the elopement. The DON revealed that they always tried to keep an eye on Resident #1 and the staff had to bring her back to her room constantly. She revealed that the kitchen staff had been in-serviced on keeping the kitchen doors locked 24/7 with no exceptions. The DON revealed that she checked the kitchen doors when she was there, always making sure the doors to the kitchen were locked. The DON revealed that Resident #1 wandered all the time, and worse in the evenings. She revealed that the staff were constantly having to redirect her. She also revealed that when she walked the floors, someone was usually with Resident #1. The DON was asked what she knew about Resident #1 getting into the kitchen on 01/01/24 prior to the elopement on 01/07/24, she stated, LPN #2 didn't tell me until after the fact, but confirmed it was prior to the elopement on 01/07/24. The DON revealed that LPN #2 had called her and reported to her by phone because she was off work. She had told LPN #2 to chart a behavior note on Resident #1 in the computer. The DON revealed that she was off on 01/01/24, 01/02/24, and 01/03/24, and was not at work to bring it up and had not thought about it. The DON agreed that she should have reported this to other staff members even though she was off. She agreed the elopement on 01/07/24 might have been prevented had this been taken care of on 01/01/24. The DON confirmed that each morning at stand up meeting that a 24 hour report should be run to discuss any concerns from the last 24 hours in the facility and this was not done. On 01/11/24 at 1:00 PM, an interview with the ADM revealed that his goal was that Resident #1 and all one hundred twenty-one residents be kept safe. He revealed that he was ultimately responsible for everyone in the facility and his goal was to fix the problem and move on. The ADM revealed that after looking at video coverage, he knew how Resident #1 got out, he fixed the problem, and everything was secured. He revealed that he did not know about what happened on 01/01/24 and could not fix what he did not know because he was never made aware of it. Record review of the (Name of Local City) weather revealed on 01/07/24 at the time of the elopement that the temperature was 39 degrees Fahrenheit with clear skies. Record review of Resident #1's admission Record revealed the facility admitted Resident #1 on 04/14/2017. Her current diagnoses include Alzheimer's Disease, Need for Assistance with Personal Care, Dementia with unspecified severity with other behavioral disturbance, and Unspecified Psychosis not due to a substance or known physiological condition. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/2023 revealed under Section C0100 that a Brief Interview for Mental Status (BIMS) should not be conducted because the resident is rarely/never understood. C1000, Cognitive Skills for Daily Decision Making, revealed Resident #1's cognitive status was severely impaired. Section P0200 revealed a Wander/elopement alarm was used daily. Record review of Resident #1's Elopement Risk Assessment completed on 01/07/24 revealed that resident had a history of wandering or elopement. The facility implemented the following Removal Plan: On 1/7/2024 at approximately 8:10 pm the facility called a code 10 that Resident #1 was not found in her room, staff searched the entire building and upon going to look for resident outside an Officer with the local police department was pulling into facility parking lot with resident, resident was assisted back into the facility by nurse and Certified Nursing Assistant (CNA). The nursing staff last saw the resident at approximately 8:00 pm in the dining room and returned to facility at 8:25 pm on 1/7/2024. On January 11 at 3:19 PM the facility was verbally notified that Immediate Jeopardy (IJ) was identified for Federal tag 600 -Abuse, Federal tag 656- Care Plans, Federal tag 689- Failure to Prevent Accidents and Hazards, Federal tag 867 - QAPI (Quality Assurance Performance Improvement). The facility received IJ templates on January 11, 2024, at 3:19 PM. Immediate Corrective Actions for Resident #1: At 8:30 pm on 1/7/2024 the Executive Director and Director of Nursing (DON) begin official investigation of Resident #1 Elopement and determined the resident exited out of the door going through the kitchen. At 8:30 pm on 1/7/2024 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. Upon return to facility Resident # 1 was ambulating independently, awake, alert with usual state of cognition. Resident was examined by Licensed Practical Nurse (LPN) with no injuries noted. Resident was immediately taken to room and vitals and head to toe assessment obtained. Resident was smiling and had no complaints of pain noted. No signs of injury noted, no bruising, scratches, cuts, or bleeding noted blood pressure 135/72, pulse 75, respirations 18, temperature 96.8, blood oxygen saturation 92%. Resident changed b/p. 135/72, p. 75, r. 18, t. 96.8, sa02 92%. Resident changed for bed and CNA in room doing one on one care. Director of Nursing (DON) was notified at 8:27 pm. Upon her return to the center on 1/7/2024, the resident was examined by the staff nurse and noted to have no negative findings. She was placed on 1:1 supervision until 1 PM on 1/8/2024 after the door locks were replaced in the kitchen. After that she was placed on every 15-minute checks to assure her safety. The kitchen doors were monitored until locks were replaced at 1:00pm 1/8/2024. This close supervision continues as of 1/11/2024. Resident #1 will be placed on 15-minute checks until exit-seeking behavior ceases. On 1/7/2024 at 8:55 pm Medical Director (MD), Physician's Assistant (PA) and Nurse Practitioner (NP) was notified of Resident Elopement from facility. On 1/7/2024 maintenance staff arrived at 9:30 pm to assess all facility exit doors, doors were checked for proper functioning by maintenance staff. All doors and wander guard systems were functioning properly. On 1/7/2024 at 9:00 pm all residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. On 1/7/2024 at 9:00 pm, Director of Nursing (DON) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. On 1/7/2024 at 10:00 pm in-services was initiated by Director of Nursing (DON) to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 1/8/2024 with no staff allowed to work until in-service completed. At 10:00 pm on 1/7/2024 Director of Nursing (DON) attempted to notify Resident # 1 Responsible Representative (RR) of the resident elopement from facility with no answer message left for RR to return call. RR returned call at 8:08 AM on 1/8/2024 and was notified of incident. On 1/8/2024, the Administrator and the Director of Nursing (DON) immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 1/8/2024 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing via phone, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing (ADON), Infection Preventionist and Minimum Data Set Nurse (MDS) to discuss Resident #1's exit seeking behavior and all safeguards put in place to ensure safety of all residents. QA identified modification to resident #1's plan of care to include the addition of melatonin and snack at bedtime and involvement in daytime activities. At 2:46 pm on 1/8/2024, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. On 1/8/2024 at 11:30 pm maintenance staff initiated an Elopement Alarm Drill with all employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. On 1/8/2024, the maintenance assistant replaced the lock on the exterior door leaving the kitchen to avoid unsupervised residents leaving the center. On 1/8/2024, the Maintenance supervisor replaced the locks going into the kitchen with automatic door locks to assure that the kitchen doors will lock when they shut and to assure that unsupervised residents are not allowed into the kitchen. On 1/11/24, the psych nurse practitioner conducted a Telehealth visit to determine if medications needed to be adjusted. The nurse practitioner indicated she was pleasant and did not pose a risk to herself and others. On 1/11/2024, the Director of Clinical Education initiated education related to the importance of providing adequate supervision to resident to avoid accidents to including securing unsafe areas in the center. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. On 1/11/2024, the MDS Nurse conducted medical record reviews of all residents to identify which residents were interviewable verses those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interviewable. On 1/11/2024, The Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence of abuse or neglect. Assessments of these resident revealed no such evidence of abuse or neglect. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 1/11/24. On 1/11/2024, the Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced abuse or neglect. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was com[TRUNCATED]

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Comprehensive Care Plan (Tag F0656)

Someone could have died · This affected 1 resident

Read full inspector narrative →

Based on interviews, record review, and facility policy review, the facility failed to implement effective comprehensive care plan interventions for Resident #1 who was at risk for elopement. Resident #1 was one (1) of three (3) wandering residents reviewed. Resident #1 was allowed to exit the facility on 01/07/24 unnoticed and unsupervised at an unknown time and was discovered to be missing from the facility at approximately 8:10 PM. On 01/07/24 at approximately 8:00 PM, the police department received a 911 call from an unknown bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. A local Police Officer was dispatched and found Resident #1 walking in the middle of the street approximately 1850 feet from the facility and she had no shoes and no coat on. The Police Officer assisted Resident #1 into the backseat of his car and took her to the facility where he discovered that the facility staff were looking for her. Resident #1 was last observed in the facility at 7:55 PM, a Code 10 (elopement) was called at 8:10 PM, and Resident #1 was returned to the facility at 8:25 PM. A head-to-toe assessment was completed immediately upon her return to the facility. Resident #1 was a wandering risk and had previously exited the facility on 12/14/23 and once again eloped from the facility without staff knowledge on 1/7/24. The facility's failure to provide supervision, implement a care plan to prevent an elopement for Resident #1 who was diagnosed with Alzheimer's and Dementia and sustain an effective Quality Assurance and Performance Improvement (QAPI) program. Resident #1 was allowed to leave the facility unnoticed and unsupervised until she was picked up by a local Police Officer in the middle of the street about 1850 feet away from the facility. The elopement placed Resident #1 and other residents who were at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) which began on 01/07/24 when Res #1 eloped from the facility unsupervised. The SA notified the facility's Administrator (ADM) of the IJ on 01/11/24 at 3:19 PM, and provided IJ templates to the ADM. The facility submitted an acceptable Removal Plan on 1/12/24, in which they alleged all corrective actions to remove the IJ were completed on 1/12/24, and the IJ removed on 1/13/24. The SA validated the Removal Plan on 1/22/24 and determined the IJ was removed on 1/13/24, prior to exit. Therefore, the scope and severity for 42 CFR (s): 483.21(b)(1)(i) - Comprehensive Care Plans (F656), and lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Record review of the facility policy titled, Comprehensive Care Plan effective May 1, 2012, revealed, .Practice Guidelines 1. The interdisciplinary care plan is implemented to guide health care center staff in the provision of necessary care and services to obtain and maintain the highest practicable physical, mental, and psychosocial well-being of the resident and promotion of the resident and family in planning care. Record review of Resident #1's Care Plan with revision date of 01/08/24 revealed Focus: I am at risk for elopement Not being able to make good safety decisions. I sometimes have behaviors which include wandering .Goal: My behavior will stop with staff intervention. Interventions: .Check function and placement of wander guard every shift. Help me maintain my favorite place to sit. I enjoy sitting in the dining room . Redirection such as taking her to activities or the area in hallway where she enjoys sitting . Resident currently has one on one staff supervision - date initiated: 01/08/24 .Wander guard: Visual check of resident Q (every) 2 hours. Record review of Facility Investigation Template completed by Administrator documented the following: On 1/7/2024 at 8:10 pm a code 10 was called as resident was unable to be located. Staff completed a room to room audit to ensure all residents were safe and accounted for. At 8:25 pm resident was escorted back into center by Police Department officer. Investigation Summary: Review of the center's maintenance camera revealed the resident exited the center out an unlocked door in the rear of the center Record review of Progress Notes created and completed by Licensed Practical Nurse (LPN) #2 revealed the following on 01/01/2024: At 18:48 Resident constantly trying to get out of building, she got into the kitchen and was headed out the back door before a staff member caught her. We are ensuring that she stays on this side of building however its hard to watch her 24/7. At 18:58 was documented, DON (Director of Nursing) notified, ensured that kitchen doors were locked. Progress notes were documented as Behavior Charting. An interview with Administrator on 01/09/24 at 9:05 PM, revealed that Resident #1 had gotten out of the building again on 01/07/24 on night shift. He revealed that according to interviews and statements taken by staff, Resident #1 was last seen around 7:55 PM and that there was about 20 to 25 minutes that Resident #1 was unaccounted for that night. ADM revealed that he thought she left through the kitchen door this time. He revealed that the staff had been doing hourly checks since the last incident on 12/14/23 and that this happened between the scheduled visual checks. Administrator confirmed that the care plan stated every 2 hour visual checks. A phone interview with Director of Nursing Services (DON) on 01/10/24 at 10:20 AM, revealed that on Sunday night 01/07/24, the Administrator called and told her that Resident #1 got out of the building again. The DON revealed that Resident #1 had walked into the kitchen a couple of times that she knew of prior to this night because staff had mentioned it to her. The DON stated, This had happened during the day while we were there. DON confirmed that they should have made staff aware of her exit seeking behavior through the kitchen doors but they failed to follow the care plan to prevent an elopement. An interview with the Assistant Director of Nursing (ADON) on 01/10/24 at 5:30 PM, revealed that the purpose of the comprehensive care plan was for the staff to be able to look at the resident as a whole, see what condition the resident was in and to look at any assistance the resident might need and to ensure the appropriate care was followed through. The ADON agreed that the facility failed to ensure that an effective care plan was followed through to prevent the resident from eloping from the facility. She confirmed that from interviews and review of the nurses notes that the resident needed more supervision at night and the care plan wasn't being followed. An interview with Minimum Data Set (MDS) Coordinator on 01/11/24 at 11:30 AM, revealed that she was not aware of the wandering incident where Resident #1 was found inside the kitchen heading out the exit door on 01/01/2024. She stated, I didn't know about this incident and should have. She agreed that this incident should have been reported, discussed, and taken care of. She revealed that it should have been care planned, interviews should have been completed, and they should have made sure that the incident was noted, and things were in place. The MDS Coordinator agreed that if the incident with Resident #1 had been taken care of on 01/01/24, it could have prevented the elopement incident on 01/07/24 which put the resident at risk of harm. The MDS Coordinator stated, Apparently we dropped the ball on this one. A phone interview with DON on 01/11/24 at 12:35 PM, revealed that she was made aware after she arrived at the facility on the night of 01/07/24, that Resident #1 had gone into the kitchen earlier in the evening prior to the elopement. DON revealed that they always tried to keep an eye on Resident #1 and the staff had to bring her back to her room constantly. She revealed that the kitchen staff had been in-serviced earlier this month on keeping the kitchen doors locked 24/7 with no exceptions. DON confirmed that Resident #1 wandered all the time, and it was worse in the evenings. DON confirmed that she knew about Resident #1 getting into the kitchen on 01/01/24 prior to the elopement on 01/07/24, and stated that was why they had completed the in-service to keep the kitchen doors locked. DON revealed that LPN #2 had called her and reported to her by phone and I told her to chart the behavior in the computer. DON revealed that she was off on 01/01/24, 01/02/24, and 01/03/24, and was not at work to bring it up in the stand up meeting and had not thought about it, but agreed that she should have reported this to other staff on the management team so it could have been addressed. DON agreed that the elopement on 01/07/24 might have been prevented had this been taken care of on 01/01/24 when it was reported to her. Record review of Resident #1's admission Record revealed admission date of 04/14/2017 and had the following diagnoses to include: Alzheimer's Disease, Need for Assistance with Personal Care, Dementia with unspecified severity with other behavioral disturbance, and Unspecified Psychosis not due to a substance or known physiological condition. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/27/2023 under Section C0100 revealed that the Brief Interview for Mental Status (BIMS) should not be conducted due to resident is rarely/never understood. Under C1000, Cognitive Skills for Daily Decision Making was documented that resident was severely impaired. The facility implemented the following Removal Plan: On 1/7/2024 at approximately 8:10 pm the facility called a code 10 that Resident #1 was not found in her room, staff searched the entire building and upon going to look for resident outside an Officer with the local police department was pulling into facility parking lot with resident, resident was assisted back into the facility by nurse and Certified Nursing Assistant (CNA). The nursing staff last saw the resident at approximately 8:00 pm in the dining room and returned to facility at 8:25 pm on 1/7/2024. On January 11 at 3:19 PM the facility was verbally notified that Immediate Jeopardy (IJ) was identified for Federal tag 600 -Abuse, Federal tag 656- Care Plans, Federal tag 689- Failure to Prevent Accidents and Hazards, Federal tag 867 - QAPI (Quality Assurance Performance Improvement). The facility received IJ templates on January 11, 2024, at 3:19 PM. Immediate Corrective Actions for Resident #1: At 8:30 pm on 1/7/2024 the Executive Director and Director of Nursing (DON) begin official investigation of Resident #1 Elopement and determined the resident exited out of the door going through the kitchen. At 8:30 pm on 1/7/2024 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. Upon return to facility Resident # 1 was ambulating independently, awake, alert with usual state of cognition. Resident was examined by Licensed Practical Nurse (LPN) with no injuries noted. Resident was immediately taken to room and vitals and head to toe assessment obtained. Resident was smiling and had no complaints of pain noted. No signs of injury noted, no bruising, scratches, cuts, or bleeding noted blood pressure 135/72, pulse 75, respirations 18, temperature 96.8, blood oxygen saturation 92%. Resident changed b/p. 135/72, p. 75, r. 18, t. 96.8, sa02 92%. Resident changed for bed and CNA in room doing one on one care. Director of Nursing (DON) was notified at 8:27pm. Upon her return to the center on 1/7/2024, the resident was examined by the staff nurse and noted to have no negative findings. She was placed on 1:1 supervision until 1 PM on 1/8/2024 after the door locks were replaced in the kitchen. After that she was placed on every 15-minute checks to assure her safety. The kitchen doors were monitored until locks were replaced at 1:00pm 1/8/2024. This close supervision continues as of 1/11/2024. Resident #1 will be placed on 15-minute checks until exit-seeking behavior ceases. On 1/7/2024 at 8:55 pm Medical Director (MD), Physician's Assistant (PA) and Nurse Practitioner (NP) was notified of Resident Elopement from facility. On 1/7/2024 maintenance staff arrived at 9:30 pm to assess all facility exit doors, doors were checked for proper functioning by maintenance staff. All doors and wander guard systems were functioning properly. On 1/7/2024 at 9:00 pm all residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. On 1/7/2024 at 9:00 pm, Director of Nursing (DON) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. On 1/7/2024 at 10:00 pm in-services was initiated by Director of Nursing (DON) to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 1/8/2024 with no staff allowed to work until in-service completed. At 10:00 pm on 1/7/2024 Director of Nursing (DON) attempted to notify Resident # 1 Responsible Representative (RR) of the resident elopement from facility with no answer message left for RR to return call. RR returned call at 8:08 AM on 1/8/2024 and was notified of incident. On 1/8/2024, the Administrator and the Director of Nursing (DON) immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 1/8/2024 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing via phone, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing (ADON), Infection Preventionist and Minimum Data Set Nurse (MDS) to discuss Resident #1's exit seeking behavior and all safeguards put in place to ensure safety of all residents. QA identified modification to resident #1's plan of care to include the addition of Elation and snack at bedtime and involvement in daytime activities. At 2:46 pm on 1/8/2024, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. On 1/8/2024 at 11:30 pm maintenance staff initiated an Elopement Alarm Drill with all employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. On 1/8/2024, the maintenance assistant replaced the lock on the exterior door leaving the kitchen to avoid unsupervised residents leaving the center. On 1/8/2024, the Maintenance supervisor replaced the locks going into the kitchen with automatic door locks to assure that the kitchen doors will lock when they shut and to assure that unsupervised residents are not allowed into the kitchen. On 1/11/24, the psych nurse practitioner conducted a Telehealth visit to determine if medications needed to be adjusted. The nurse practitioner indicated she was pleasant and did not pose a risk to herself and others. On 1/11/2024, the Director of Clinical Education initiated education related to the importance of providing adequate supervision to resident to avoid accidents to including securing unsafe areas in the center. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. On 1/11/2024, the MDS Nurse conducted medical record reviews of all residents to identify which residents were interviewable verses those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interviewable. On 1/11/2024, The Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or neglect. Assessments of these resident revealed no such evidence of abuse or neglect. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 1/11/24. On 1/11/2024, the Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager and interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced abuse or neglect. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 1/11/2024. On 1/11/2024, the Senior Director of Clinical Operations provided training for the Administrator, Director of Nursing (DON) the Assistant Director of Nursing (ADON) regarding abuse and neglect identification, protection, investigation. This action was completed on 1/11/2024. On 1/8/2024, the Director of Clinical Education initiated training on abuse and neglect to include identification of abuse and neglect, protections of residents, investigation, and reporting requirements. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. On 1/12/24, the Senior [NAME] President of Operations provided education to the Administrator regarding the expectation of following the facility Quality Assurance Policy and Procedure in having ADHOC meetings as needed when new concerns are identified to immediately discuss, and determine immediate action needed to correct/address the identified area of concern to prevent safety issues related to elopement and then to continue monthly meetings to review effectiveness of plans and adjust plans as needed to ensure sustained compliance. The Administrator educated the Quality Assurance Committee Members on 1/12/24. The Director of Nursing (DON) will be educated prior to next scheduled shift by the Administrator. Education initiated on 1/12/24 by the Director Clinical Education with all staff regarding the expectations to immediately report any identified deficient practice to the Administrator or Director of Nursing (DON) so that the deficient practice or new concern can be addressed through the facility Quality Assurance Performance Improvement Committee by initiation of a plan of correction to include education, systemic changes, and auditing to ensure correction and sustained compliance. Education included review of the Quality Assurance and Performance Improvement Policy. Staff that did not receive education on 1/12/24 will be educated prior to working next scheduled shift. An adhoc QAPI meeting addressing the finding was initiated and completed 1/12/24 with the attendance of the Administrator, Nurse Practitioner (NP), Human Resources Coordinator, Director of Rehab, Registered MDS Coordinator, Director of Clinical Education (Infection Preventionist), Director of Nursing via phone, Maintenance Director, Dietary Manager, Activity Director, and Health Information Manager and Medical Director via phone. All corrective actions were completed by 1/12/2024 and the facility alleges removal of the Immediate Jeopardy (IJ) 1/13/2024. The State Agency (SA) validated the facility's Removal Plan on 01/22/24. The SA validated through interviews and record review that at 8:30 pm on 1/7/2024 the Executive Director and Director of Nursing (DON) begin official investigation of Resident #1 Elopement and determined the resident exited out of the door going through the kitchen. The SA validated through interviews and record review that at 8:30 pm on 1/7/2024 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. The SA validated through interviews and record review that upon return to facility Resident # 1 was ambulating independently, awake, alert with usual state of cognition. Resident was examined by Licensed Practical Nurse (LPN) with no injuries noted. Resident was immediately taken to room and vitals and head to toe assessment obtained. Resident was smiling and had no complaints of pain noted. No signs of injury noted, no bruising, scratches, cuts, or bleeding noted blood pressure 135/72, pulse 75, respirations 18, temperature 96.8, blood oxygen saturation 92%. Resident changed b/p. 135/72, p. 75, r. 18, t. 96.8, sa02 92%. Resident changed for bed and CNA in room doing one on one care. Director of Nursing (DON) was notified at 8:27pm. The SA validated through interviews and record review that upon her return to the center on 1/7/2024, the resident was examined by the staff nurse and noted to have no negative findings. She was placed on 1:1 supervision until 1 PM on 1/8/2024 after the door locks were replaced in the kitchen. After that she was placed on every 15-minute checks to assure her safety. The kitchen doors were monitored until locks were replaced at 1:00pm 1/8/2024. This close supervision continues as of 1/11/2024. Resident #1 will be placed on 15-minute checks until exit-seeking behavior ceases. The SA validated through interviews and record review that on 1/7/2024 at 8:55 pm Medical Director (MD), Physician's Assistant (PA) and Nurse Practitioner (NP) was notified of Resident Elopement from facility. The SA validated through interviews and record review that on 1/7/2024 maintenance staff arrived at 9:30 pm to assess all facility exit doors, doors were checked for proper functioning by maintenance staff. All doors and wander guard systems were functioning properly. The SA validated through interviews and record review that on 1/7/2024 at 9:00 pm all residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. The SA validated through interviews and record review that on 1/7/2024 at 9:00 pm, Director of Nursing (DON) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. The SA validated through interviews and record review that on 1/7/2024 at 10:00 pm in-services was initiated by Director of Nursing (DON) to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 1/8/2024 with no staff allowed to work until in-service completed. The SA validated through interviews and record review that at 10:00 pm on 1/7/2024 Director of Nursing (DON) attempted to notify Resident # 1 Responsible Representative (RR) of the resident elopement from facility with no answer message left for RR to return call. RR returned call at 8:08 AM on 1/8/2024 and was notified of incident. The SA validated through interviews and record review that on 01/08/24, the Administrator and the Director of Nursing (DON) immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. The SA validated through interviews and record review that on 1/8/2024 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing via phone, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing (ADON), Infection Preventionist and Minimum Data Set Nurse (MDS) to discuss Resident #1's exit seeking behavior and all safeguards put in place to ensure safety of all residents. QA identified modification to resident #1's plan of care to include the addition of Elation and snack at bedtime and involvement in daytime activities. The SA validated through interviews and record review that at 2:46 pm on 1/8/2024, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. The SA validated through interviews and record review that on 1/8/2024 at 11:30 pm maintenance staff initiated an Elopement Alarm Drill with all employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. The SA validated through interviews and record review that on 1/8/2024, the maintenance assistant replaced the lock on the exterior door leaving the kitchen to avoid unsupervised residents leaving the center. The SA validated through observation, interviews and record review that on 1/8/2024, the Maintenance supervisor replaced the locks going into the kitchen with automatic door locks to assure that the kitchen doors will lock when they shut and to assure that unsupervised residents are not allowed into the kitchen. The SA validated through interviews and record review that on 1/11/24, the psych nurse practitioner conducted a Telehealth visit to determine if medications needed to be adjusted. The nurse practitioner indicated she was pleasant and did not pose a risk to herself and others. The SA validated through interviews and record review that on 1/11/2024, the Director of Clinical Education initiated education related to the importance of providing adequate supervision to resident to avoid accidents to including securing unsafe areas in the center. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. The SA validated through interviews and record review that on 1/11/2024, the MDS Nurse conducted medical record reviews of all residents to identify which residents were interviewable versus those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed versus those that were considered non interviewable. The SA validated through interviews and record review that on 1/11/2024, The Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or neglect. Assessments of these resident revealed no such evidence of abuse or neglect. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 1/11/24. The SA validated through interviews and record review that on 1/11/2024, the Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager and interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced abuse or neglect. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 1/11/2024. The SA validated through interviews and record review that on 1/11/2024, the Senior Director of Clinical Operations provided training for the Administrator, Director of Nursing (DON) the Assistant Director of Nursing (ADON) regarding abuse and neglect identification, protection, investigation. This action was completed on 1/11/2024. The SA validated through interviews and record review that on 1/8/2024, the Director of Clinical Education initiated training on abuse and neglect to include identification of abuse and neglect, protections of residents, investigation, and reporting requirements. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. The SA validated through interviews and record review that on 1/12/24, the Senior [NAME] President of Operations provided education to the Administrator regarding the expectation of following the facility Quality Assurance Policy and Procedure in having ADHOC meetings as needed when new concerns are identified to immediately discuss, and determine immediate action needed to correct/address the identified area of concern to prevent safety issues related to elopement and then to continue monthly meetings to review effectiveness of plans and adjust plans as needed to ensure sustained compliance. The Administrator educated the Quality Assurance Committee Members on 1/12/24. The Director of Nursing (DON) will be educated prior to next scheduled shift by the Administrator. The SA validated through interview and record review that Director of Nursing had been educated prior to her return to work. The SA validated through interviews and record review that education was initiated on 1/12/24 by the Director Clinical Education with all staff regarding the expectations to immediately report any identified deficient practice to the Administrator or Director of Nursing (DON) so that the deficient practice or new concern can be addressed through the facility Quality Assurance Performance Improvement Committee by initiation of a plan of correction to include education, systemic changes, and auditing to ensure correction and sustained compliance. Education included review of the Quality Assurance and Performance Improvement Policy. Staff that did not receive education on 1/12/24 will be educated prior to working next scheduled shift. The SA validated through interviews and record review that an adhoc QAPI meeting addressing the finding was initiated and completed 1/12/24 with the attendance of the Administrator, Nurse Practitioner (NP), Human Resources Coordinator, Director of Rehab, Registered MDS Coordinator, Director of Clinical Education (Infection Preventionist), Director of Nursing via phone, Maintenance Director, Dietary Manager, Activity Director, and Health Information Manager and Medical Director via phone. The SA validated through observation, interview, and record review that the facility removed the Immediate Jeopardy (IJ) on 01/12/24 and alleged compliance on 01/13/24.

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and facility policy review the facility failed to supervise and prevent the elopement of Resident #1 who left the faciity on [DATE] for the second time unnoticed and unsupervised. Resident #1 was one (1) of three (3) residents reviewed. Resident #1 was allowed to exit the facility on 01/07/24 unnoticed and unsupervised at an unknown time and was discovered to be missing from the facility at approximately 8:10 PM. On 01/07/24 at approximately 8:00 PM, the police department received a 911 call from an unknown bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. A local Police Officer was dispatched and found Resident #1 walking in the middle of the street approximately 1850 feet from the facility and she had no shoes and no coat on. The Police Officer assisted Resident #1 into the backseat of his car and took her to the facility where he discovered that the facility staff were looking for her. Resident #1 was last observed in the facility at 7:55 PM, a Code 10 (elopement) was called at 8:10 PM, and Resident #1 was returned to the facility at 8:25 PM. A head-to-toe assessment was completed immediately upon her return to the facility. Resident #1 was a wandering risk and had previously exited the facility on 12/14/23 and once again eloped from the facility without staff knowledge on 1/7/24. The facility's failure to provide supervision to prevent the second elopement for Resident #1 who was diagnosed with Alzheimer's and Dementia placed Resident #1 and other residents who were at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ), and Substandard Quality of Care (SQC) which began on 01/07/24 when Res #1 eloped from the facility unsupervised. The SA notified the facility's Administrator (ADM) of the IJ and SQC on 01/11/24 at 3:19 PM, and provided IJ templates to the ADM. The facility submitted an acceptable Removal Plan on 1/12/24, in which they alleged all corrective actions to remove the IJ were completed on 1/12/24, and the IJ removed on 1/13/24. The SA validated the Removal Plan on 1/22/24 and determined the IJ was removed on 1/13/24, prior to exit. Therefore, the scope and severity for 42 CFR 483.25 (d) (1) (2) - Accidents (F689) was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Record review of the facility policy Elopement dated April 2017, revealed Purpose To establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements . Record review of Facility Investigation Template completed by Administrator documented the following: On 1/7/2024 at 8:10 pm a code 10 was called as resident was unable to be located. Staff completed a room to room audit to ensure all residents were safe and accounted for. At 8:25 pm resident was escorted back into center by Police Department officer . Investigation Summary: Review of the center's maintenance camera revealed the resident exited the center out an unlocked door in the rear of the center . Record review of the City of (proper name) Police Department Incident Report revealed that the Police Officer responded to a call which was was received at 8:00 PM on 01/07/24 from a bystander. Police Officer responded to the area of [NAME] Lane and observed a confused, white female with no coat, sock footed who was walking in the middle of the street on hospital street. Police Officer approached Resident #1 and she told him that she was going back to the nursing home. Police Officer assisted Resident #1 into the back seat of his patrol car and transported her back to the facility. Police Officer was informed by LPN #3 that This was not the first time that this has happened, that one of the doors in the building was not locked and does not have an alarm on it . This Incident Report was completed by the Police Officer on 01/07/24. During an interview on 01/09/24 at 8:45 PM, with Licensed Practical Nurse (LPN) #1, revealed that she was working the night of 01/07/24 when Resident #1 got out of the building. She revealed that she had last seen Resident #1 that night around 7:50 PM walking down B-Hall. LPN #1 revealed that when the staff saw Resident #1 out walking around in the building, they redirected her back to her room. She revealed that Resident #1's cognition was not good, that she had dementia, but they could hold her hand and easily redirect her back to her room. This LPN revealed that a CODE 10 for elopement was called around 8:00 PM, all staff stopped what they were doing and went to look for her. LPN #1 revealed that right before 8:30 PM, Resident #1 was returned to the facility by the police. LPN #1 revealed that someone had called the police, reported that they had seen an elderly woman walking and the police brought her back to the facility. She stated Resident #1 had been seen exit seeking a lot lately and the door alarms went off when she walked near them. After this incident, they had someone watch all the doors until maintenance could get to the facility and check them out that night. Since the incident on 01/07/24, maintenance had put pin pads on the kitchen doors so the residents couldn't get in there. LPN #1 stated, They think she may have exited the kitchen. During an interview with Administrator on 01/09/24 at 9:05 PM, revealed that Resident #1 had gotten out of the building again on 01/07/24 on the night shift. He revealed that according to interviews and statements taken by staff, Resident #1 was last seen around 7:55 PM and that there was about 20 to 25 minutes that Resident #1 was unaccounted for that night. He thought she left through the kitchen door this time. The staff had been doing hourly checks since the last elopement incident on 12/14/23 and that this had happened between the scheduled visual checks. A Code 10 was called around 8:10 PM, Resident #1 was last seen around 7:55 PM and was returned to the facility by a police officer around 8:25 PM or 8:30 PM. He state he wasn't sure of all the details, but someone must have called the police or either he was patrolling and found her. ADM revealed that he was not sure of the exact location where she was picked up from either. Maintenance came in that night and checked all of the windows and doors, checked all of the door alarms and wander guard bracelets and everything worked properly. The only way possible for her to get out was through the kitchen door. He revealed that the two doors that led from the dining room into the kitchen had locks on them from the inside of the kitchen and staff had to push the lock in and turn it for them to lock properly. ADM confirmed that he wasn't aware that Resident #1 had gone back into the kitchen earlier that evening until he read the statements provided by the staff. ADM stated that this resident wanders a lot and according to what he was told, Resident #1 was last seen in the dining room around 7:25 PM. Resident was placed on 1 on 1 supervision after the incident until the new kitchen door locks were installed on 01/08/24 at 1:00 PM. He revealed that the exit doors on the hall doors would not release to open unless the fire alarm was pulled so she couldn't have gotten out there. He stated, The only thing we really changed were the kitchen doorknobs and put a pin lock on the doors so that everyone who entered had to have the code. During an interview on 01/09/24 at 9:55 PM, with Certified Nursing Assistant (CNA) #2, revealed that she was working on D-Hall on 01/07/24 on the night shift. She revealed that she saw Resident #1 that night between 7:30 PM and 8:00 PM coming out of the dining room walking towards the front door. CNA #2 revealed that the kitchen staff had brought her out of the kitchen to C-Wing, and the CNAs went and put her to bed. CNA #2 revealed that about 20 to 30 minutes later, she was missing, and they were looking for her. They checked all the rooms and halls, and she wasn't there, then around 8:25 PM, she saw that a police officer had pulled up and had Resident #1 in the backseat. The nurse opened the front door and let her back into the facility. CNA revealed that Resident #1 was brought in, was assessed, and had seemed to be fine, no skin issues and no injuries. During an interview on 01/09/24 at 10:05 PM, CNA #1 revealed that she was working on the night of 01/07/24 when Resident #1 got out of the facility. She stated that the resident liked to wander at night and sometimes she would walk to the end of the hall, jiggle the door to see if it would open. They would go get her by the hand and redirect her back. It was hard to keep up with Resident #1 most of the time because she was constantly on the move and that the staff worked together and tried to keep her in their sight. On 01/07/24 at around 7:35 PM, a kitchen staff member brought Resident #1 to her CNA on C/D hall and told her that Resident #1 had gotten into the kitchen. CNA #1 revealed that she brought Resident #1 to the CNA she was assigned to for the night, and he took care of her. CNA #1 revealed that a little after 8 PM, Resident #1's CNA asked her if she had seen Resident #1. CNA #1 revealed that they looked down halls, resident rooms, and outside. CNA #1 revealed that a few minutes later, the police brought Resident #1 back to the facility and stated, I have no idea how she got out. During an interview on 01/10/24 at 10:10 PM, the Administrator (ADM) revealed that he was glad that the codes on the doors checked out and worked properly and that everything else checked out, but there was still 20 minutes that Resident #1 was unaccounted for, and he agreed that a lot could have happened to her in 20 minutes. The ADM stated, I'm just glad she was safe, it could have been real bad. During an interview by phone on 01/10/24 at 10:20 AM, with Director of Nursing Services (DON), revealed that on Sunday night 01/07/24, the Administrator called and told her about Resident #1 getting out of the building again. She revealed that she was off; but came on to the facility. She walked around with maintenance, started interviews, took statements, and had all the wander guard bracelets checked and they were all working properly. She then completed elopement assessments on every resident in the building and updated care plans. She stated that maintenance came in and checked all the doors, and she was confident that the kitchen door was the only one she could have gotten out of. The DON revealed that Resident #1 had walked into the kitchen a couple of times that she knew of prior to this night because staff had told her about it. The DON stated, This had happened during the day while we were there. The DON stated that she wasn't aware that Resident #1 had been brought out of the kitchen earlier the night of 01/07/24 until she arrived on that Sunday night around 9:00 PM, but that she did know the resident had been in the kitchen days prior and was attempting to go out the exit door. During an interview on 01/10/24 at 10:45 AM, with Dietary Aide #1 revealed that she was working on the evening of 01/07/24 during the time that Resident #1 got out of the building. She revealed that at approximately 7:30 PM or a little after, she was bent down washing dishes in the washroom next to the kitchen door when she heard something. Dietary Aide #1 revealed that she saw that Resident #1 had come into the kitchen, had walked past her, and was over by the stove walking towards the exit door which led to the outside of the building. This dietary aide revealed that she walked constantly and was seen frequently at doors looking out. Dietary Aide #1 revealed that she was working in the kitchen by herself when this happened because Dietary Aide #2 had taken the trash out. She got Resident #1 by the hand and led her out of the kitchen and took her to CNA #1 who was working out on the hall. About 30 minutes later, she came out of the kitchen to see what a CODE 10 was that was called and found out that Resident #1 was missing. She revealed that Dietary Aide #2 worked in the kitchen with her that evening and had passed the snacks out on the night of 01/07/24. Dietary Aide #1 revealed that Resident #1 walked constantly and was seen frequently at doors looking out. During an interview on 01/10/24 at 11:00 AM, LPN #2 revealed that Resident #1 usually slept during the day until late afternoon or supper time and then walked the floors. LPN #2 stated, She stays busy, just does her thing. She and the CNAs tag teamed to try and keep an eye on her. She stated, We try to work together with the CNAs and do the best we can to keep our eyes on her but it's hard with her constantly on the move. She revealed that when Resident #1 walked the halls, she would push on the doors, then turn around and walk off if they wouldn't open. Resident #1 was not combative and was easily redirected; but would often return to what she was doing. LPN #2 stated, Everyone knows that as soon as you redirect her, she goes right back. LPN #2 revealed that Resident #1 had dementia but said she was smarter than you think, it's like she's watching and waiting. LPN #2 revealed that they had to work together as best they could to keep their eyes on her. During an interview on 01/10/24 at 11:20 AM, the Administrator (ADM) revealed that there were two older video cameras on the Maintenance Shop out behind the facility. He revealed that he knew they were out there but didn't know if they worked or not. The cameras were 50 feet from the facility pointing back towards the back of the Nursing Home where the kitchen exit door was. They played back the video camera footage, and it showed Resident #1 exiting the kitchen door to the outside. ADM stated, We do have evidence of her exiting the building and I know for sure that she went out the side kitchen door, not out the Emergency Exit in the dining room. ADM revealed that it was dietary not keeping the doors from the dining room into the kitchen locked properly that caused Resident #1 to get out. He revealed that the camera footage showed her getting out at 7:55 PM and that she was out of camera view when she turned left at about 8:05 PM. He revealed that it showed that she walked across the back parking lot back to the left, basically, followed the concrete road around. The Administrator revealed that they replaced the kitchen door locks, removed the flex locks, and replaced them with locks that required a code to enter. The ADM stated, Now they don't have an option but to keep the doors locked. Administrator stated that he did not realize Resident #1 had gotten into the kitchen earlier the day of 01/07/24 or on 01/01/24 until he was reading statements. ADM revealed that the kitchen doors would lock but staff were not keeping them locked. ADM stated, I do know that I've been on them about keeping the kitchen doors locked and confirmed they had completed an in-service earlier this month to keep the kitchen doors locked so residents could not enter the kitchen. During an interview on 01/10/24 at 11:55 AM, Dietary Aide #2, revealed she was working on 01/07/24 in the kitchen. She revealed she was outside taking the trash out and when she returned, was told by Dietary Aide #1, that Resident #1 had walked into the kitchen and was headed towards the exit door over by the stove. Dietary Aide #2 revealed that she got snacks together and when she passed out the snacks around 7:30 PM to A/B hall, she saw Resident #1 exiting a resident's room on that hall. She revealed that after 8:00 PM, a CODE 10 was called, and everyone went to look for her. Dietary Aide #2 revealed that Resident #1 had come back to the kitchen pretty often; but most of the time she just opened the door and closed it back without coming in. Dietary Aide #2 revealed that if Resident #1 opened the door, the kitchen staff would get her out of the kitchen and find a nurse or CNA to get her. Dietary Aide #2 stated, If we don't, she would just come back. She revealed that Resident #1 had come into the kitchen a couple times while she had been at work but couldn't recall the dates. Dietary Aide #2 revealed that they always made sure the kitchen doors were locked before they left at night-time. She revealed that one door they had to manually lock when they were in the kitchen. Dietary Aide #2 revealed that Resident #1 had to have gone into the kitchen while she (Dietary Aide #2) was passing out snacks and while Dietary Aide #1 was washing dishes for them not to have seen her. During an interview on 01/10/24 at 12:10 PM, via telephone with the Police Officer revealed that on 01/07/24 around 8:00 PM, the local Police Department received a 911 call from a bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. Police Officer revealed that he drove to the area and found that Resident #1 was walking in the middle of the street behind the Emergency Department at the County Hospital which was a pretty good way from the nursing home. The resident had a shirt, jogging pants, and socks on. Resident #1 was not wearing a coat or shoes. He revealed that he stopped her, and this resident seemed to be confused. He asked her where she was going, and she told him to the nursing home. He revealed that Resident #1 was hard to understand but told him she was going back to (Proper Name of Facility). He helped her into his car and drove her back to the facility. When he pulled into the parking lot, he did notice that some of staff were in personal vehicles headed out to look for her. The Police Officer revealed that he released her to LPN #3. During an interview on 01/10/24 at 4:25 PM, via phone with LPN #3 revealed that she was working on 01/07/24, the night that Resident #1 got out of the facility. LPN #3 revealed that she had seen Resident #1 several times walking all around on A/B hall and E/F hall and staff members kept bringing her back to her room. Resident #1 was last seen just outside her room a little before 8:00 PM. She revealed that about 8:10 PM, she asked the CNA who was assigned to Resident #1 to go see if the resident was in her room and he found that she was not. LPN #3 revealed that she called a Code 10 and immediately started looking for her. They looked on all halls, in all rooms and outside the building. She went to the front door about 8:25 PM and saw a police car drive up and then saw that he had Resident #1 in the back seat. She revealed that there were a couple staff who had gotten in their cars to go look for her when they saw the police officer drive up with Resident #1. The police officer brought her to the door and stated, I believe I have someone who belongs to y'all and the officer released Resident #1 to them. LPN #3 revealed that Resident #1 had a pair of sweatpants on with a cuff at the bottom, had a long-sleeved shirt on, some gripper socks and had no coat or shoes on. They immediately got her inside, checked her vital signs and did a head-to-toe assessment and there were no injuries noted. LPN #3 revealed that they put her on one-on-one supervision and had someone in the room with her to always have eyes on her. She revealed that Resident #1 went to bed as soon as they got her checked out. LPN #3 revealed that she couldn't see how they could do any better with monitoring this resident. Record review of the Name of local city weather on 01/07/24 revealed that the temperature at the time of the elopement was 39 degrees Fahrenheit with clear skies. Record review of Resident #1's admission Record revealed admission date of 04/14/2017 and had the following diagnoses to include: Alzheimer's Disease, Need for Assistance with Personal Care, Dementia with unspecified severity with other behavioral disturbance, and Unspecified Psychosis. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/27/2023 under Section C revealed a Brief Interview for Mental Status (BIMS) should not be conducted because resident is rarely/never understood. Under C1000, Cognitive Skills for Daily Decision Making was documented that resident was severely impaired. Section P0200 revealed a Wander/Elopement Alarm was used daily. Record review of Resident #1's Elopement Risk Assessment completed on 01/07/24 revealed that resident had history of wandering or elopement. The facility implemented the following Removal Plan: On 1/7/2024 at approximately 8:10 pm the facility called a code 10 that Resident #1 was not found in her room, staff searched the entire building and upon going to look for resident outside an Officer with the local police department was pulling into facility parking lot with resident, resident was assisted back into the facility by nurse and Certified Nursing Assistant (CNA). The nursing staff last saw the resident at approximately 8:00 pm in the dining room and returned to facility at 8:25 pm on 1/7/2024. On January 11 at 3:19 PM the facility was verbally notified that Immediate Jeopardy (IJ) was identified for Federal tag 600 -Abuse, Federal tag 656- Care Plans, Federal tag 689- Failure to Prevent Accidents and Hazards, Federal tag 867 - QAPI (Quality Assurance Performance Improvement). The facility received IJ templates on January 11, 2024, at 3:19 PM. Immediate Corrective Actions for Resident #1: At 8:30 pm on 1/7/2024 the Executive Director and Director of Nursing (DON) begin official investigation of Resident #1 Elopement and determined the resident exited out of the door going through the kitchen. At 8:30 pm on 1/7/2024 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. Upon return to facility Resident # 1 was ambulating independently, awake, alert with usual state of cognition. Resident was examined by Licensed Practical Nurse (LPN) with no injuries noted. Resident was immediately taken to room and vitals and head to toe assessment obtained. Resident was smiling and had no complaints of pain noted. No signs of injury noted, no bruising, scratches, cuts, or bleeding noted blood pressure 135/72, pulse 75, respirations 18, temperature 96.8, blood oxygen saturation 92%. Resident changed b/p. 135/72, p. 75, r. 18, t. 96.8, sa02 92%. Resident changed for bed and CNA in room doing one on one care. Director of Nursing (DON) was notified at 8:27 pm. Upon her return to the center on 1/7/2024, the resident was examined by the staff nurse and noted to have no negative findings. She was placed on 1:1 supervision until 1 PM on 1/8/2024 after the door locks were replaced in the kitchen. After that she was placed on every 15-minute checks to assure her safety. The kitchen doors were monitored until locks were replaced at 1:00pm 1/8/2024. This close supervision continues as of 1/11/2024. Resident #1 will be placed on 15-minute checks until exit-seeking behavior ceases. On 1/7/2024 at 8:55 pm Medical Director (MD), Physician's Assistant (PA) and Nurse Practitioner (NP) was notified of Resident Elopement from facility. On 1/7/2024 maintenance staff arrived at 9:30 pm to assess all facility exit doors, doors were checked for proper functioning by maintenance staff. All doors and wander guard systems were functioning properly. On 1/7/2024 at 9:00 pm all residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. On 1/7/2024 at 9:00 pm, Director of Nursing (DON) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. On 1/7/2024 at 10:00 pm in-services was initiated by Director of Nursing (DON) to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 1/8/2024 with no staff allowed to work until in-service completed. At 10:00 pm on 1/7/2024 Director of Nursing (DON) attempted to notify Resident # 1 Responsible Representative (RR) of the resident elopement from facility with no answer message left for RR to return call. RR returned call at 8:08 AM on 1/8/2024 and was notified of incident. On 1/8/2024, the Administrator and the Director of Nursing (DON) immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 1/8/2024 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing via phone, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing (ADON), Infection Preventionist and Minimum Data Set Nurse (MDS) to discuss Resident #1s exit seeking behavior and all safeguards put in place to ensure safety of all residents. QA identified modification to resident #1's plan of care to include the addition of melatonin and snack at bedtime and involvement in daytime activities. At 2:46 pm on 1/8/2024, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. On 1/8/2024 at 11:30 pm maintenance staff initiated an Elopement Alarm Drill with all employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. On 1/8/2024, the maintenance assistant replaced the lock on the exterior door leaving the kitchen to avoid unsupervised residents leaving the center. On 1/8/2024, the Maintenance supervisor replaced the locks going into the kitchen with automatic door locks to assure that the kitchen doors will lock when they shut and to assure that unsupervised residents are not allowed into the kitchen. On 1/11/24, the psych nurse practitioner conducted a Telehealth visit to determine if medications needed to be adjusted. The nurse practitioner indicated she was pleasant and did not pose a risk to herself and others. On 1/11/2024, the Director of Clinical Education initiated education related to the importance of providing adequate supervision to resident to avoid accidents to including securing unsafe areas in the center. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. On 1/11/2024, the MDS Nurse conducted medical record reviews of all residents to identify which residents were interviewable versus those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed versus those that were considered non interviewable. On 1/11/2024, The Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or neglect. Assessments of these resident revealed no such evidence of abuse or neglect. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 1/11/24. On 1/11/2024, the Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager and interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced abuse or neglect. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 1/11/2024. On 1/11/2024, the Senior Director of Clinical Operations provided training for the Administrator, Director of Nursing (DON) the Assistant Director of Nursing (ADON) regarding abuse and neglect identification, protection, investigation. This action was completed on 1/11/2024. On 1/8/2024, the Director of Clinical Education initiated training on abuse and neglect to include identification of abuse and neglect, protections of residents, investigation, and reporting requirements. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. On 1/12/24, the Senior [NAME] President of Operations provided education to the Administrator regarding the expectation of following the facility Quality Assurance Policy and Procedure in having ADHOC meetings as needed when new concerns are identified to immediately discuss, and determine immediate action needed to correct/address the identified area of concern to prevent safety issues related to elopement and then to continue monthly meetings to review effectiveness of plans and adjust plans as needed to ensure sustained compliance. The Administrator educated the Quality Assurance Committee Members on 1/12/24. The Director of Nursing (DON) will be educated prior to next scheduled shift by the Administrator. Education initiated on 1/12/24 by the Director Clinical Education with all staff regarding the expectations to immediately report any identified deficient practice to the Administrator or Director of Nursing (DON) so that the deficient practice or new concern can be addressed through the facility Quality Assurance Performance Improvement Committee by initiation of a plan of correction to include education, systemic changes, and auditing to ensure correction and sustained compliance. Education included review of the Quality Assurance and Performance Improvement Policy. Staff that did not receive education on 1/12/24 will be educated prior to working next scheduled shift. An adhoc QAPI meeting addressing the finding was initiated and completed 1/12/24 with the attendance of the Administrator, Nurse Practitioner (NP), Human Resources Coordinator, Director of Rehab, Registered MDS Coordinator, Director of Clinical Education (Infection Preventionist), Director of Nursing via phone, Maintenance Director, Dietary Manager, Activity Director, and Health Information Manager and Medical Director via phone. All corrective actions were completed by 1/12/2024 and the facility alleges removal of the Immediate Jeopardy (IJ) 1/13/2024. The State Agency (SA) validated the facility's Removal Plan on 01/22/24. The SA validated through interviews and record review that at 8:30 pm on 1/7/2024 the Executive Director and Director of Nursing (DON) begin official investigation of Resident #1 Elopement and determined the resident exited out of the door going through the kitchen. The SA validated through interviews and record review that at 8:30 pm on 1/7/2024 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. The SA validated through interviews and record review that upon return to facility Resident # 1 was ambulating independently, awake, alert with usual state of cognition. Resident was examined by Licensed Practical Nurse (LPN) with no injuries noted. Resident was immediately taken to room and vitals and head to toe assessment obtained. Resident was smiling and had no complaints of pain noted. No signs of injury noted, no bruising, scratches, cuts, or bleeding noted blood pressure 135/72, pulse 75, respirations 18, temperature 96.8, blood oxygen saturation 92%. Resident changed b/p. 135/72, p. 75, r. 18, t. 96.8, sa02 92%. Resident changed for bed and CNA in room doing one on one care. Director of Nursing (DON) was notified at 8:27 pm. The SA validated through interviews and record review that upon her return to the center on 1/7/2024, the resident was examined by the staff nurse and noted to have no negative findings. She was placed on 1:1 supervision until 1 PM on 1/8/2024 after the door locks were replaced in the kitchen. After that she was placed on every 15-minute checks to assure her safety. The kitchen doors were monitored until locks were replaced at 1:00pm 1/8/2024. Th[TRUNCATED]

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

QAPI Program (Tag F0867)

Someone could have died · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and facility policy review the facility failed to monitor and implement a Quality Assurance (QA) program that prevented an elopement for Resident #1 who had previously eloped from the facility on 12/14/23 and continued to seek an exit from the building for one (1) of three (3) residents reviewed. Resident #1. Resident #1 was allowed to exit the facility on 01/07/24 unnoticed and unsupervised at an unknown time and was discovered to be missing from the facility at approximately 8:10 PM. On 01/07/24 at approximately 8:00 PM, the police department received a 911 call from an unknown bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. A local Police Officer was dispatched and found Resident #1 walking in the middle of the street approximately 1850 feet from the facility and she had no shoes and no coat on. The Police Officer assisted Resident #1 into the backseat of his car and took her to the facility where he discovered that the facility staff were looking for her. Resident #1 was last observed in the facility at 7:55 PM, a Code 10 (elopement) was called at 8:10 PM, and Resident #1 was returned to the facility at 8:25 PM. Resident #1 was a wandering risk and had previously exited the facility on 12/14/23 and once again eloped from the facility without staff knowledge on 1/7/24. The facility's failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) program. Resident #1 was allowed to leave the facility unnoticed and unsupervised until she was picked up by a local Police Officer in the middle of the street about 1850 feet away from the facility. The elopement placed Resident #1 and other residents who were at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) which began on 01/07/24 when Res #1 eloped from the facility unsupervised. The SA notified the facility's Administrator (ADM) of the IJ on 01/11/24 at 3:19 PM, and provided IJ templates to the ADM. The facility submitted an acceptable Removal Plan on 1/12/24, in which they alleged all corrective actions to remove the IJ were completed on 1/12/24, and the IJ removed on 1/13/24. The SA validated the Removal Plan on 1/22/24 and determined the IJ was removed on 1/13/24, prior to exit. Therefore, the scope and severity 42 CFR (s): 483.75(d)(1)- QAPI/QAA Improvement Activities (F867) was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Record review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) dated February 2017 revealed Purpose: QAPI is a data driven, proactive approach to improving the quality of life, care and services in our centers. The activities of QAPI involve team members at all levels of the organization to identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor the effectiveness of our interventions. QAPI is consistent with our Service Standard: We continually strive to improve personal and company performance. In an interview with the Administrator on 01/09/24 at 9:05 PM, revealed that Resident #1 had gotten out of the building again on 01/07/24 on night shift. He stated, The only thing we really changed were the kitchen doorknobs and put a pin lock on the doors so that everyone who entered had to have the code. He revealed that the QAPI team along with the Medical Director were all notified at 8:55 PM on 01/07/24 and they had a QAPI meeting on Monday morning, 01/08/24. In an interview with the Minimum Data Set (MDS) Coordinator on 01/11/24 at 11:30 AM, revealed that they had been having Quality Assurance and Performance Improvement (QAPI) Meetings every month with the Medical Director present and that they had an Emergency QAPI Meeting on 01/08/24 after Resident #1 eloped. The MDS Coordinator revealed that QAPI was a functional tool that forced everyone to look at [NAME] if something had happened and a good way to follow up. She stated, It's a continual thing. The MDS Coordinator revealed that they looked at alert notes, falls, active infection, all skilled residents, admissions, discharges, nursing concerns, therapy, acute problems, and really, anything going on. The MDS Coordinator revealed that she was not aware of the wandering incident where Resident #1 was found inside the kitchen heading out the exit door on 01/01/2024. She revealed that this was not brought up in stand up or in QAPI meeting but then she had missed some. The MDS Coordinator stated, I didn't know about this incident and should have. I must have missed some of this. The MDS Coordinator agreed that this incident should have been reported, discussed, and taken care of. She revealed that it should have been care planned, interviews should have been completed, and they should have made sure that the incident was noted, and things were in place. The MDS Coordinator agreed that if the incident with Resident #1 had been taken care of on 01/01/24, it could have prevented the elopement incident on 01/07/24 which put the resident at risk of harm. The MDS Coordinator stated, Apparently we dropped the ball on this one. In a phone interview with the Director of Nursing Services (DON), on 01/11/24 at 12:35 PM, the DON was asked why at the QA meetings or the stand up meetings that the resident attempting to leave the facility prior through the unlocked door in the kitchen had not been talked about or addressed and she stated that she was off work on 01/01/24-01/03/24. She stated that when the LPN called her she just told the nurse to document the behavior in the nurse's notes and stated I wasn't at work to bring it up and had not thought about it anymore. The DON agreed that she should have reported this and agreed that the elopement on 01/07/24 might have been prevented had this been taken care of on 01/01/24 and discussed in the stand up meetings or the QA meetings. Record review of Progress Notes created and completed by LPN #2 revealed the following on 01/01/2024: At 18:48 Resident constantly trying to get out of building, she got into the kitchen and was headed out the back door before a staff member caught her. We are ensuring that she stays on this side of building however its hard to watch her 24/7. At 18:58 was documented, DON (Director of Nursing) notified, ensured that kitchen doors were locked. Progress notes were documented as Behavior Charting. In an interview with the Assistant Director of Nursing Service (ADON) on 01/10/24 at 5:30 PM, the ADON agreed that the facility failed to ensure that an effective monitoring system was in place throughout the facility to prevent the resident from getting out of the facility again. The ADON confirmed that they should be monitoring this resident more closely and talking about her in the meetings because she has eloped from the facility prior. In an interview with ADM on 01/11/24 at 12:20 PM, revealed that he was not aware of the incident with Resident #1 walking into the kitchen and heading out the exit door which occurred on 01/01/24. He stated, I had no idea, no one told me that. He revealed that he wasn't sure why this wasn't brought up in their morning meetings and that if it had happened, they should have addressed it, corrected the situation then, and had measures in place. He stated, I was not aware and should have been notified. The facility implemented the following Removal Plan: On 1/7/2024 at approximately 8:10 pm the facility called a code 10 that Resident #1 was not found in her room, staff searched the entire building and upon going to look for resident outside an Officer with the local police department was pulling into facility parking lot with resident, resident was assisted back into the facility by nurse and Certified Nursing Assistant (CNA). The nursing staff last saw the resident at approximately 8:00 pm in the dining room and returned to facility at 8:25 pm on 1/7/2024. On January 11 at 3:19 PM the facility was verbally notified that Immediate Jeopardy (IJ) was identified for Federal tag 600 -Abuse, Federal tag 656- Care Plans, Federal tag 689- Failure to Prevent Accidents and Hazards, Federal tag 867 - QAPI (Quality Assurance Performance Improvement). The facility received IJ templates on January 11, 2024, at 3:19 PM. Immediate Actions: At 8:30 pm on 1/7/2024 the Executive Director and Director of Nursing (DON) begin official investigation of Resident #1 Elopement and determined the resident exited out of the door going through the kitchen. At 8:30 pm on 1/7/2024 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. Upon return to facility Resident # 1 was ambulating independently, awake, alert with usual state of cognition. Resident was examined by Licensed Practical Nurse (LPN) with no injuries noted. Resident was immediately taken to room and vitals and head to toe assessment obtained. Resident was smiling and had no complaints of pain noted. No signs of injury noted, no bruising, scratches, cuts, or bleeding noted blood pressure 135/72, pulse 75, respirations 18, temperature 96.8, blood oxygen saturation 92%. Resident changed b/p. 135/72, p. 75, r. 18, t. 96.8, sa02 92%. Resident changed for bed and CNA in room doing one on one care. Director of Nursing (DON) was notified at 8:27 pm. Upon her return to the center on 1/7/2024, the resident was examined by the staff nurse and noted to have no negative findings. She was placed on 1:1 supervision until 1 PM on 1/8/2024 after the door locks were replaced in the kitchen. After that she was placed on every 15-minute checks to assure her safety. The kitchen doors were monitored until locks were replaced at 1:00pm 1/8/2024. This close supervision continues as of 1/11/2024. Resident #1 will be placed on 15-minute checks until exit-seeking behavior ceases. On 1/7/2024 at 8:55 pm Medical Director (MD), Physician's Assistant (PA) and Nurse Practitioner (NP) was notified of Resident Elopement from facility. On 1/7/2024 maintenance staff arrived at 9:30 pm to assess all facility exit doors, doors were checked for proper functioning by maintenance staff. All doors and wander guard systems were functioning properly. On 1/7/2024 at 9:00 pm all residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. On 1/7/2024 at 9:00 pm, Director of Nursing (DON) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. On 1/7/2024 at 10:00 pm in-services was initiated by Director of Nursing (DON) to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 1/8/2024 with no staff allowed to work until in-service completed. At 10:00 pm on 1/7/2024 Director of Nursing (DON) attempted to notify Resident # 1 Responsible Representative (RR) of the resident elopement from facility with no answer message left for RR to return call. RR returned call at 8:08 AM on 1/8/2024 and was notified of incident. On 1/8/2024, the Administrator and the Director of Nursing (DON) immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 1/8/2024 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing via phone, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing (ADON), Infection Preventionist and Minimum Data Set Nurse (MDS) to discuss Resident #1's exit seeking behavior and all safeguards put in place to ensure safety of all residents. QA identified modification to resident #1's plan of care to include the addition of Elation and snack at bedtime and involvement in daytime activities. At 2:46 pm on 1/8/2024, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. On 1/8/2024 at 11:30 pm maintenance staff initiated an Elopement Alarm Drill with all employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. On 1/8/2024, the maintenance assistant replaced the lock on the exterior door leaving the kitchen to avoid unsupervised residents leaving the center. On 1/8/2024, the Maintenance supervisor replaced the locks going into the kitchen with automatic door locks to assure that the kitchen doors will lock when they shut and to assure that unsupervised residents are not allowed into the kitchen. On 1/11/24, the psych nurse practitioner conducted a Telehealth visit to determine if medications needed to be adjusted. The nurse practitioner indicated she was pleasant and did not pose a risk to herself and others. On 1/11/2024, the Director of Clinical Education initiated education related to the importance of providing adequate supervision to resident to avoid accidents to including securing unsafe areas in the center. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. On 1/11/2024, the MDS Nurse conducted medical record reviews of all residents to identify which residents were interviewable verses those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interviewable. On 1/11/2024, The Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or neglect. Assessments of these resident revealed no such evidence of abuse or neglect. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 1/11/24. On 1/11/2024, the Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager and interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced abuse or neglect. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 1/11/2024. On 1/11/2024, the Senior Director of Clinical Operations provided training for the Administrator, Director of Nursing (DON) the Assistant Director of Nursing (ADON) regarding abuse and neglect identification, protection, investigation. This action was completed on 1/11/2024. On 1/8/2024, the Director of Clinical Education initiated training on abuse and neglect to include identification of abuse and neglect, protections of residents, investigation, and reporting requirements. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. On 1/12/24, the Senior [NAME] President of Operations provided education to the Administrator regarding the expectation of following the facility Quality Assurance Policy and Procedure in having ADHOC meetings as needed when new concerns are identified to immediately discuss, and determine immediate action needed to correct/address the identified area of concern to prevent safety issues related to elopement and then to continue monthly meetings to review effectiveness of plans and adjust plans as needed to ensure sustained compliance. The Administrator educated the Quality Assurance Committee Members on 1/12/24. The Director of Nursing (DON) will be educated prior to next scheduled shift by the Administrator. Education initiated on 1/12/24 by the Director Clinical Education with all staff regarding the expectations to immediately report any identified deficient practice to the Administrator or Director of Nursing (DON) so that the deficient practice or new concern can be addressed through the facility Quality Assurance Performance Improvement Committee by initiation of a plan of correction to include education, systemic changes, and auditing to ensure correction and sustained compliance. Education included review of the Quality Assurance and Performance Improvement Policy. Staff that did not receive education on 1/12/24 will be educated prior to working next scheduled shift. An adhoc QAPI meeting addressing the finding was initiated and completed 1/12/24 with the attendance of the Administrator, Nurse Practitioner (NP), Human Resources Coordinator, Director of Rehab, Registered MDS Coordinator, Director of Clinical Education (Infection Preventionist), Director of Nursing via phone, Maintenance Director, Dietary Manager, Activity Director, and Health Information Manager and Medical Director via phone. All corrective actions were completed by 1/12/2024 and the facility alleges removal of the Immediate Jeopardy (IJ) 1/13/2024. The State Agency (SA) validated the facility's Removal Plan on 01/22/24. The SA validated through interviews and record review that at 8:30 pm on 1/7/2024 the Executive Director and Director of Nursing (DON) begin official investigation of Resident #1 Elopement and determined the resident exited out of the door going through the kitchen. The SA validated through interviews and record review that at 8:30 pm on 1/7/2024 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. The SA validated through interviews and record review that upon return to facility Resident # 1 was ambulating independently, awake, alert with usual state of cognition. Resident was examined by Licensed Practical Nurse (LPN) with no injuries noted. Resident was immediately taken to room and vitals and head to toe assessment obtained. Resident was smiling and had no complaints of pain noted. No signs of injury noted, no bruising, scratches, cuts, or bleeding noted blood pressure 135/72, pulse 75, respirations 18, temperature 96.8, blood oxygen saturation 92%. Resident changed b/p. 135/72, p. 75, r. 18, t. 96.8, sa02 92%. Resident changed for bed and CNA in room doing one on one care. Director of Nursing (DON) was notified at 8:27 pm. The SA validated through interviews and record review that upon her return to the center on 1/7/2024, the resident was examined by the staff nurse and noted to have no negative findings. She was placed on 1:1 supervision until 1 PM on 1/8/2024 after the door locks were replaced in the kitchen. After that she was placed on every 15-minute checks to assure her safety. The kitchen doors were monitored until locks were replaced at 1:00pm 1/8/2024. This close supervision continues as of 1/11/2024. Resident #1 will be placed on 15-minute checks until exit-seeking behavior ceases. The SA validated through interviews and record review that on 1/7/2024 at 8:55 pm Medical Director (MD), Physician's Assistant (PA) and Nurse Practitioner (NP) was notified of Resident Elopement from facility. The SA validated through interviews and record review that on 1/7/2024 maintenance staff arrived at 9:30 pm to assess all facility exit doors, doors were checked for proper functioning by maintenance staff. All doors and wander guard systems were functioning properly. The SA validated through interviews and record review that on 1/7/2024 at 9:00 pm all residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. The SA validated through interviews and record review that on 1/7/2024 at 9:00 pm, Director of Nursing (DON) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. The SA validated through interviews and record review that on 1/7/2024 at 10:00 pm in-services was initiated by Director of Nursing (DON) to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 1/8/2024 with no staff allowed to work until in-service completed. The SA validated through interviews and record review that at 10:00 pm on 1/7/2024 Director of Nursing (DON) attempted to notify Resident # 1 Responsible Representative (RR) of the resident elopement from facility with no answer message left for RR to return call. RR returned call at 8:08 AM on 1/8/2024 and was notified of incident. The SA validated through interviews and record review that on 1/8/2024, the Administrator and the Director of Nursing (DON) immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. The SA validated through interviews and record review that on 1/8/2024 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing via phone, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing (ADON), Infection Preventionist and Minimum Data Set Nurse (MDS) to discuss Resident #1's exit seeking behavior and all safeguards put in place to ensure safety of all residents. QA identified modification to resident #1's plan of care to include the addition of Elation and snack at bedtime and involvement in daytime activities. The SA validated through interviews and record review that at 2:46 pm on 1/8/2024, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. The SA validated through interviews and record review that on 1/8/2024 at 11:30 pm maintenance staff initiated an Elopement Alarm Drill with all employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. The SA validated through interviews and record review that on 1/8/2024, the maintenance assistant replaced the lock on the exterior door leaving the kitchen to avoid unsupervised residents leaving the center. The SA validated through observation, interviews and record review that on 1/8/2024, the Maintenance supervisor replaced the locks going into the kitchen with automatic door locks to assure that the kitchen doors will lock when they shut and to assure that unsupervised residents are not allowed into the kitchen. The SA validated through interviews and record review that on 1/11/24, the psych nurse practitioner conducted a Telehealth visit to determine if medications needed to be adjusted. The nurse practitioner indicated she was pleasant and did not pose a risk to herself and others. The SA validated through interviews and record review that on 1/11/2024, the Director of Clinical Education initiated education related to the importance of providing adequate supervision to resident to avoid accidents to including securing unsafe areas in the center. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. The SA validated through interviews and record review that on 1/11/2024, the MDS Nurse conducted medical record reviews of all residents to identify which residents were interviewable versus those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed versus those that were considered non interviewable. The SA validated through interviews and record review that on 1/11/2024, The Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or neglect. Assessments of these resident revealed no such evidence of abuse or neglect. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 1/11/24. The SA validated through interviews and record review that on 1/11/2024, the Assistant Director of Nursing (ADON), Minimum Data Set Nurses (MDS) and Unit Manager and interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced abuse or neglect. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 1/11/2024. The SA validated through interviews and record review that on 1/11/2024, the Senior Director of Clinical Operations provided training for the Administrator, Director of Nursing (DON) the Assistant Director of Nursing (ADON) regarding abuse and neglect identification, protection, investigation. This action was completed on 1/11/2024. The SA validated through interviews and record review that on 1/8/2024, the Director of Clinical Education initiated training on abuse and neglect to include identification of abuse and neglect, protections of residents, investigation, and reporting requirements. This training will continue until all staff are trained. Employees will not be allowed to work until they have received this training. The SA validated through interviews and record review that on 1/12/24, the Senior [NAME] President of Operations provided education to the Administrator regarding the expectation of following the facility Quality Assurance Policy and Procedure in having ADHOC meetings as needed when new concerns are identified to immediately discuss, and determine immediate action needed to correct/address the identified area of concern to prevent safety issues related to elopement and then to continue monthly meetings to review effectiveness of plans and adjust plans as needed to ensure sustained compliance. The Administrator educated the Quality Assurance Committee Members on 1/12/24. The Director of Nursing (DON) will be educated prior to next scheduled shift by the Administrator. The SA validated through interview and record review that Director of Nursing had been educated prior to her return to work. The SA validated through interviews and record review that education was initiated on 1/12/24 by the Director Clinical Education with all staff regarding the expectations to immediately report any identified deficient practice to the Administrator or Director of Nursing (DON) so that the deficient practice or new concern can be addressed through the facility Quality Assurance Performance Improvement Committee by initiation of a plan of correction to include education, systemic changes, and auditing to ensure correction and sustained compliance. Education included review of the Quality Assurance and Performance Improvement Policy. Staff that did not receive education on 1/12/24 will be educated prior to working next scheduled shift. The SA validated through interviews and record review that an adhoc QAPI meeting addressing the finding was initiated and completed 1/12/24 with the attendance of the Administrator, Nurse Practitioner (NP), Human Resources Coordinator, Director of Rehab, Registered MDS Coordinator, Director of Clinical Education (Infection Preventionist), Director of Nursing via phone, Maintenance Director, Dietary Manager, Activity Director, and Health Information Manager and Medical Director via phone. The SA validated through observation, interview, and record review that the facility removed the Immediate Jeopardy (IJ) on 01/12/24 and alleged compliance on 01/13/24.

Dec 2023 2 deficiencies 2 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Comprehensive Care Plan (Tag F0656)

Someone could have died · This affected 1 resident

Read full inspector narrative →

Based on interviews, record review, and facility policy review, the facility failed to implement the plan of care for Resident #1 who was at risk for elopement. Resident #1 was one (1) of three (3) residents reviewed. The facility failed to provide supervision to prevent the elopement of Resident #1, who was a wandering risk. Resident #1 had a Care Plan that documented that she was at risk for elopement. Facility #1 did not provide the supervision as outlined in the care plan to Resident #1 to prevent her from eloping. Resident #1 left the facility unnoticed and unsupervised at an unknown time and was discovered by the staff at another nursing home (Facility #2) approximately 380 yards from the facility. Facility #2 let the resident inside their nursing home and contacted Facility #1 at 9:04 PM to see if they had a resident missing and they discovered that it was Resident #1 and went to pick her up and return her to the facility. Resident #1 was last observed on 12/14/23 at 8:15 PM, prior to the elopement. Resident #1 was transported back to Facility #1, where a head-to-toe assessment was completed and there were no noted injuries or complaints of pain or discomfort. During the investigation on 12/19/23 the SA identified an Immediate Jeopardy (IJ) which began on 12/14/23 when Res #1 eloped from Facility #1 unsupervised and was identified at: 42 CFR (s): 483.21(b)(1) - Comprehensive Care Plans (F656) Scope and Severity J. The elopement placed Resident #1 and other residents at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or death. The SA notified the facility's Administrator of the IJ on 12/19/23 at 2:40 PM and provided the Administrator with the IJ templates. Based on the facility's implementation of corrective actions on 12/14/23 through 12/15/23, the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on 12/16/23, prior to the SA's entrance on 12/19/23. Findings Include: Review of the facility policy Comprehensive Care Plan, effective date May 1, 2012, revealed, The interdisciplinary care plan is implemented to guide health care center staff in the provision of necessary care and services to obtain and maintain the highest practicable physical, mental, and psychosocial well-being of the resident and promotion of the resident and family in planning care . Record review of Resident #1's Care Plan revealed, Focus: I am at risk for elopement, Not being able to make good safety decisions, I sometimes have Restlessness, agitation and increased confusion .Interventions: .Check function of Wanderguard every shift, Check placement of Wanderguard every shift . Redirection such as taking her to activities or the area in hallway where she enjoys sitting. Wander guard: Visual check of resident Q2 (every two) hours and chart location Record review of the facility investigation revealed that Resident #1 was allowed to exit Facility #1 on 12/14/23 unnoticed and unsupervised at an unknown time and was discovered by the staff at another nursing home, Facility #2, which was 380 yards away from Facility #1. The staff of Facility #2 heard someone trying to enter their facility by jerking on the door. Facility #2 let Resident #1 inside their building and contacted Facility #1 to see if they had a missing resident and they discovered it was Resident #1 and the staff from Facility #1 went to pick her up and returned her back to the facility. Resident #1 was last observed in Facility #1 at 8:15 PM and the call was received from Facility #2 at 9:04 PM informing them that this said resident was in their building. On 12/19/23 at 9:00 AM, an interview with Administrator (ADM), revealed that on 12/14/23, Resident #1 left Facility #1 unsupervised and unnoticed and she walked over to Facility #2. ADM revealed that there were statements from staff members taken saying no door alarms went off. He revealed that it was reported to him that Resident #1 was last seen standing at the C/D nursing station around 8:15 PM on 12/14/23. ADM revealed that it was also reported to him that at 9:04 PM on 12/14/23, Licensed Practical Nurse (LPN) #1 received a call from Facility #2 reporting that Resident #1 was at their facility and that her Wander Guard had set the alarm system off and they had her safe inside the building. ADM revealed that LPN #1 and Certified Nursing Assistant (CNA) #1, both from Facility #1 went to Facility #2 and picked the resident up and brought her back. He revealed that on 12/14/23, there was about forty-five minutes that resident was unaccounted for. ADM stated that he hated it and that they couldn't prevent everything from happening; but they tried really hard. ADM stated, It's our mess up and we are trying to minimize the damage and not let it happen again. He revealed that he knew as soon as it happened what it would be, and he confirmed understanding that the facility failed to implement the care plan effectively to prevent a resident with dementia who required a wander guard from leaving the facility. ADM revealed that the breakdown was the system at the door, maintenance had discovered that the antenna on the left side of the door was not working properly and was not picking up on the wander guards; therefore, not triggering the alarm to go off. He revealed that they did not have a camera system and they could only speculate that the resident had exited out the front door. He revealed that the alarm should have triggered it, but the staff members revealed that the alarm never went off to indicate a problem. He confirmed that the staff members changed out the resident's wander guard bracelet when she returned to the facility just to be safe. Record review of Resident #1's admission Record revealed an admission date of 04/14/2017 with diagnoses including Alzheimer's Disease, Need for Assistance with Personal Care, Dementia, and Unspecified psychosis. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/2023 revealed in Section C Item 0100 that the Brief Interview for Mental Status (BIMS) should not be conducted due to the resident is rarely/never understood. Item C1000 Cognitive Skills for Daily Decision Making was documented as severely impaired. Section P Item 0200 revealed that a Wander/Elopement Alarm was used daily. The facility implemented the following Corrective Action Plan prior to the State Agency's (SA) entrance on 12/19/23: On 12/14/23 at 9:23 PM, Resident #1 was assisted back into Facility #1 with easy redirection, one on one monitoring was initiated, Physician and Resident Responsible Party were notified. Resident #1 was assessed by nursing staff, elopement risk assessment performed, care plans, and elopement book were updated to reflect elopement risk and monitoring. Staff completed a room-to-room audit of all residents to assure them all were safe and accounted for. All residents with Code Alert Bracelets were checked for functionality and positioning. All doors and windows were checked for proper function and operation. ADM began an investigation to determine how this resident went outside and assessed each resident for potential risk for elopement. In-Services on Elopement guidelines, Abuse, Neglect, prevention of accidents and supervision of residents. Elopement drills were conducted on all three shifts beginning 12/15/23, then weekly was initiated. Care plans were updated for Wander Guard bracelets to be checked every shift rather than once a day. Initiated door checks daily. It was determined that Resident #1 was last seen by Facility #1 staff on 12/14/23 at 8:15 PM and was notified of resident being inside Facility #2 at 9:04 PM. On 12/14/23 the facility was notified by Facility #2 at 9:04pm that Resident #1 was trying to enter their facility. The nursing staff last saw the resident at 8:15 pm at C/D wing nurses' station. It was determined that Resident # 1 was last seen by facility staff at 8:15 pm and returned to facility at 9:23 pm on 12/14/23. On December 19 at 2:40 PM the facility was verbally notified that Immediate Jeopardy (IJ) was identified for Federal tag 656- Care Plans and Federal tag 689- Failure to Prevent Accidents and Hazards. The facility received IJ templates on December 19, 2023, at 2:40 PM. Immediate Actions: At 9:30 pm on 12/14/23 Executive Director notified Resident # 1 Responsible Representative of the resident elopement from facility. At 9:45 pm on 12/14/23 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. Upon return to facility Resident # 1 was assessed by Licensed Practical Nurse (LPN) with no injuries noted. On 12/14/23 all doors were monitored throughout the night until maintenance staff arrived on 12/15/2023 at 8:00 am to assess all facility exit doors, doors were checked for proper functioning by Maintenance Assistant and PRN Maintenance personnel. It was discovered that a bad antenna could have caused the door not to alarm when resident exited the facility. A new antenna was immediately put in place and troubleshooting was completed with the vendor via phone to ensure proper functioning. On 12/15/23 at 8:30 am residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. At 9:23 pm on 12/14/2023 the Executive Director and Director of Nursing begin official investigation of Resident #1 Elopement. On 12/14/23 at 11:00pm in-services was initiated by Director of Nursing to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 12/15/2023 with no staff allowed to work until in-service completed. On 12/15/23 at 9:00 am, Infection Preventionist Registered Nurse (RN) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. On 12/15/23 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing, Director of Clinical Education and Minimum Data Set Nurse (MDS). At 2:57 pm on 12/15/23, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. On 12/15/23 at 3:20 pm Maintenance Assistance initiated an Elopement Alarm Drill with employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. All corrective actions were completed on 12/15/23 and the facility alleges removal of the Immediate Jeopardy (IJ) on 12/16/2023. The State Agency (SA) validated the facility's Past Non-Compliance (PNC) Corrective Action Plan on 12/19/23: The SA validated through interviews and record review that on 12/14/23 at 9:30 PM Executive Director notified Resident #1 Responsible Representative of the resident elopement from facility. The SA validated through interview and record review that on 12/14/23 at 9:45 PM the facility completed a 100% head count of all other residents to ensure they were accounted for. The SA validated through interview and record review that on 12/14/23 upon return to facility Resident #1 was assessed by Licensed Practical Nurse (LPN) with no injuries noted. The SA validated through interviews and record review that on 12/14/23 all doors were monitored throughout the night until maintenance staff arrived on 12/15/23 at 8:00 AM to assess all facility exit doors, doors were checked for proper functioning by Maintenance Department. It was discovered that a bad antenna could have caused the door not to alarm when resident exited the facility. A new antenna was immediately put in place and troubleshooting was completed with the vendor via phone to ensure proper functioning. The SA validated through interviews and record reviews that on 12/15/23 residents with risk of elopements were reevaluated and updated to ensure all residents at risk had appropriate interventions in place. The SA validated through interviews and record review that on 12/14/23 at 9:23 PM, the Executive Director and Director of Nursing began official investigation of Resident #1 elopement. The SA validated through interview and record review that on 12/14/23 at 11:00 PM that In-Services were initiated by Director of Nursing to include all staff on Elopement Policy and Procedures, Abuse-Neglect, In-Services were completed by 12/15/23. The SA validated through interview and record review that on 12/15/23 Infection Preventionist Registered Nurse checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. The SA validated through interview and record review that on 12/15/23 at 9:30 AM, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing, Director of Clinical Education and Minimum Data Set Nurse (MDS). The SA validated through interview and record review that on 12/15/23 at 2:57 PM, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Director of Nursing. The SA validated that on 12/15/23 at 3:20 PM Maintenance Assistant initiated an Elopement Alarm Drill with employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. The SA validated through observations, record reviews, and facility policy reviews that all corrective actions were completed on 12/15/23 and the facility alleges removal of the Immediate Jeopardy (IJ) on 12/16/2023.

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

Read full inspector narrative →

Based on staff interviews, record review and facility policy review the facility failed to supervise and prevent the elopement of Resident #1, who was assessed as an elopement risk and left Facility #1 through an unarmed door on 12/14/23 unnoticed. Resident #1 was one (1) of three (3) residents reviewed. The facility failed to provide supervision to prevent the elopement of Resident #1, who was a wandering risk. Res #1 walked 380 yards away from Facility #1 to Facility #2 and was discovered by staff at Facility #2 as Res #1 was attempting to get inside their building. Resident #1 left Facility #1 unnoticed and unsupervised at an unknown time. Facility #2 allowed the resident inside their nursing home and contacted Facility #1 at 9:04 PM to see if they had any resident missing and they discovered that it was Resident #1 and went to pick her up and return her to the facility. Resident #1 was last observed on 12/14/23 at 8:15 PM prior to the elopement. Resident #1 was transported back to Facility #1, where a head to toe assessment was completed and there were no noted injuries or complaints of pain or discomfort. During the investigation on 12/19/23 the State Agency (SA) identified an Immediate Jeopardy (IJ), and Substandard Quality of Care (SQC) which existed on 12/14/23 when Res #1 eloped from Facility #1 unsupervised. IJ and SQC existed at: 42 CFR (s): 483.25 (d) (1) (2) - Free of Accidents/Supervision/Devices (689) - Scope and Severity J. The elopement placed Resident #1 and other residents at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or death. The SA notified the facility's Administrator of the IJ and SQC on 12/19/23 at 2:40 PM and provided the Administrator with the IJ templates. Based on the facility's implementation of corrective actions on 12/14/23 through 12/15/23, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 12/16/23, prior to the SA's entrance on 12/19/23. Findings include: Review of the facility policy titled Elopement dated April 2017, revealed, Purpose: To establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements . Record review of the facility investigation revealed that Resident #1 was allowed to exit Facility #1 on 12/14/23 unnoticed and unsupervised at an unknown time and was discovered by the staff at another nursing home, Facility #2, which was 380 yards away from Facility #1. The staff of Facility #2 heard someone trying to enter their facility by jerking on the door. Facility #2 let Resident #1 inside their building and contacted Facility #1 to see if they had a missing resident and they discovered it was Resident #1 and the staff from Facility #1 went to pick her up and returned her back to the facility. Resident #1 was last observed in Facility #1 at 8:15 PM and the call was received from Facility #2 at 9:04 PM informing them that this said resident was in their building. An interview with the Administrator (ADM) on 12/19/23 at 9:00 AM, revealed that on 12/14/23, Resident #1 left Facility #1 unsupervised and unnoticed and she walked over to Facility #2. The ADM revealed that there were statements from staff members taken saying no door alarms went off. He revealed that it was reported to him that Resident #1 was last seen standing at the C/D Nursing Station around 8:15 PM on 12/14/23. He revealed that it was also reported to him that at 9:04 PM on 12/14/23, Licensed Practical Nurse (LPN) #1 received a call from Facility #2 reporting that Resident #1 was at their facility and that her Wander Guard had set the alarm system off and they had her safe inside the building. ADM revealed that LPN #1 and Certified Nursing Assistant (CNA) #1, both from Facility #1 went to Facility #2 and picked the resident up and brought her back. He revealed that on 12/14/23, there was about forty-five minutes that resident was unaccounted for. ADM revealed that he hated it and that they couldn't prevent everything from happening; but tried really hard. The ADM stated, It's our mess up and we are trying to minimize the damage and not let it happen again. He revealed that the breakdown was the system at the door, maintenance had discovered that the antenna on the left side of the door was not working properly and was not picking up on the wander guards; therefore, not triggering the alarm to go off. He revealed that they did not have a camera system and they could only speculate that the resident had exited out the front door. He revealed that the alarm should have triggered it, but the staff members revealed that the alarm never went off to indicate a problem. He revealed that the staff members changed out the resident's wander guard bracelet when she returned to the facility just to be safe. On 12/19/23 at 10:00 AM, a phone interview with CNA #1 revealed that she was working the night of 12/14/23 and had last observed Resident #1 around 8:00 PM trying to enter the dining room beside the C/D nurse's station. CNA #1 revealed that at 9:04 PM, a call was received from Facility #2 that they had a resident come into their facility and her name was (proper name) as stated by Resident #1 and she, CNA #1 went with LPN #1 to pick Resident #1 up. CNA #1 revealed that they arrived at Facility #2 to get Resident #1 at 9:13 PM and arrived back at Facility #1 with her at 9:23 PM. CNA #1 revealed that Facility #1's door alarms never went off as they were supposed to when a resident with a wander guard went through the door. CNA #1 recalled what Resident #1 was wearing that night and revealed that she had on a pair of gray sweatpants, a long-sleeved top, she was wearing socks, and no shoes. She revealed it was pretty chilly outside that night. On 12/19/23 at 10:30 AM, an interview with the Maintenance Supervisor revealed that the expiration dates on all wander guards were checked monthly. He revealed that he made rounds and checked to make sure all doors were secure every morning and on a weekly basis, he checked the doors with a wander guard to make sure they were working properly. The Maintenance Supervisor revealed that when a resident with a wander guard bracelet was within 5 feet of the door, the keypad, which required a special code, would not work. The Maintenance Supervisor revealed that it would lock down the system so as not to allow anyone to get out. He stated, We take this serious and realize that anything could have happened. The Maintenance Supervisor also revealed that if the door was opened and a resident with a wander guard walked up, the alarm would go off to alert staff members. The Maintenance Supervisor revealed that the alarm system on the doors were checked first thing on the morning of 12/15/23 and it was determined that there was an internal malfunction with the antenna located on the left door which would not activate the alarm system. The Maintenance Supervisor revealed that normally the antenna would pick up the signal from the wander bracelet if a resident tried to exit the doors and the door alarm would go off. He revealed that they put a new antenna on the door, and everything was working fine now. The Maintenance Supervisor measured the distance from Facility #1 to Facility #2 which was 1,140 feet which equaled 380 yards resident walked on the night of 12/14/23. On 12/19/23 at 11:00 AM, a phone interview with LPN #1 revealed that she was working on the night of 12/14/23 and had last observed Resident #1 standing at the C/D Nursing Desk at 8:15 PM. LPN #1 revealed that this resident walked up and down the halls all the time; but would usually walk up to the windows, look outside, turn around and walk the other way. She revealed that Resident #1 had never been noticed to try and get out of the doors. She revealed that at 9:04 PM, Facility #2 called and asked if they had a resident missing by the name of Proper Name. She revealed that she and CNA #1 got into her car and went to Facility #2 and brought Resident #1 back to Facility #1. LPN #1 revealed that Resident #1 was in no distress and her vital signs were all normal. LPN #1 revealed that when they returned to Facility #1, she called and reported the incident to the Administrator and to the Director of Nursing. LPN #1 revealed that Resident #1 had Dementia and mumbled speech frequently. She also revealed that she had never witnessed Resident #1 pushing on the doors or trying to leave the facility. LPN #1 revealed that the door alarms never went off at Facility #1 to alert them that she had gotten out. On 12/19/23 at 11:30 AM, an interview with Director of Nursing, revealed that LPN #1 had called and reported the elopement around 9:30 PM to her. The DON revealed they did a full body audit on Resident #1, watched all doors and initiated one on one care for Resident #1. Resident #1's son was notified as well. DON stated that Resident #1 always walked and mumbled. She stated, Everyone just knows to watch her, she's constantly on the move. DON revealed that Resident #1 was on hourly checks already as a latest intervention updated on her Care Plan. DON revealed that it was reported to her that Resident #1 went to the old part of Facility #2 that wasn't used anymore which was A straight shot from here. She revealed that Resident #1's wander guard bracelet had set off Facility #2's alarm system when she tried to get their door open; but had not set off the alarm at Facility #1 where she left from. DON revealed that the next morning, maintenance came in, investigated the door situation, and found that the antenna on the left side of the entrance door wasn't working properly, replaced it, and turned up the sensitivity. She revealed that on the night of 12/14/23, that Resident #1 had been on hourly checks and the nurse had not missed any of them. She revealed that the incident happened between her scheduled checks and that the staff members never knew she was out of the building until Facility #2 called them. She revealed that they also called for an on-site inspection of the door alarm system by the company and they expected them to be there December 27, 2023. She revealed that she reported the incident to the State Agency and to the Attorney General's Office, initiated an immediate investigation, In-services on abuse, neglect, elopement. She revealed that they had been conducting monthly elopement drills; but, after this incident, more frequently. She revealed that Maintenance Department was checking doors weekly. DON revealed that Nurses checked all wander guard bracelet function and location every shift and document on the Medication Administration Record (MAR). Record review of Progress Notes dated 12/10/23 at 7:35 AM was documented that resident was alert with some confusion, had slurred speech at times but can be understood sometimes. Resident #1 ambulates throughout the facility with redirection and supervision. Record review of the weather in (proper name of city) on 12/14/23 documented that the temperature at the time of the elopement was 52 degrees Fahrenheit, clear skies and no rain. Record review of the admission Record revealed the facility admitted Resident #1 on 04/14/2017 with diagnoses of Alzheimer's Disease, Need for Assistance with Personal Care, Dementia, and Unspecified psychosis. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/2023 revealed Section C0100 that the Brief Interview for Mental Status (BIMS) should not be conducted due to resident is rarely/never understood. Under C1000 Cognitive Skills for Daily Decision Making was documented that resident was severely impaired. Section P0200 revealed that a Wander/Elopement Alarm was used daily. The facility implemented the following Corrective Action Plan prior to the State Agency's (SA) entrance on 12/19/23: On 12/14/23 at 9:23 PM, Resident #1 was assisted back into Facility #1 with easy redirection, one on one monitoring was initiated, Physician and Resident Responsible Party were notified. Resident #1 was assessed by nursing staff, elopement risk assessment performed, care plans, and elopement book were updated to reflect elopement risk and monitoring. Staff completed a room-to-room audit of all residents to assure them all were safe and accounted for. All residents with Code Alert Bracelets were checked for functionality and positioning. All doors and windows were checked for proper function and operation. ADM began an investigation to determine how this resident went outside and assessed each resident for potential risk for elopement. In-Services on Elopement guidelines, Abuse, Neglect, prevention of accidents and supervision of residents. Elopement drills were conducted on all three shifts beginning 12/15/23, then weekly was initiated. Care plans were updated for Wander Guard bracelets to be checked every shift rather than once a day. Initiated door checks daily. It was determined that Resident #1 was last seen by Facility #1 staff on 12/14/23 at 8:15 PM and was notified of resident being inside Facility #2 at 9:04 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 12/19/23 at 2:20 PM. On 12/14/23 the facility was notified by Long Term Care Facility #2 at 9:04 pm that Resident #1 was trying to enter their facility. The nursing staff last saw the resident at 8:15 pm at C/D wing nurses' station. It was determined that Resident # 1 was last seen by facility staff at 8:15 pm and returned to facility at 9:23 pm on 12/14/23. On December 19 at 2:40 PM the facility was verbally notified that Immediate Jeopardy (IJ) was identified for Federal tag 656- Care Plans and Federal tag 689- Failure to Prevent Accidents and Hazards. The facility received IJ templates on December 19, 2023, at 2:40 PM. Immediate Actions: At 9:30 pm on 12/14/23 Executive Director notified Resident # 1 Responsible Representative of the resident elopement from facility. At 9:45 pm on 12/14/23 the facility completed a 100% head count of all other residents to ensure they were accounted for. All residents were found to be in the facility. Upon return to facility Resident # 1 was assessed by Licensed Practical Nurse (LPN) with no injuries noted. On 12/14/23 all doors were monitored throughout the night until maintenance staff arrived on 12/15/2023 at 8:00 am to assess all facility exit doors, doors were checked for proper functioning by Maintenance Assistant and PRN Maintenance personnel. It was discovered that a bad antenna could have caused the door not to alarm when resident exited the facility. A new antenna was immediately put in place and troubleshooting was completed with the vendor via phone to ensure proper functioning. On 12/15/23 at 8:30 am residents with risk of elopements were reevaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings. At 9:23 pm on 12/14/2023 the Executive Director and Director of Nursing begin official investigation of Resident #1 Elopement. On 12/14/23 at 11:00pm in-services was initiated by Director of Nursing to include all staff on Elopement Policy and Procedures and Abuse-Neglect, in-services to be completed by 12/15/2023 with no staff allowed to work until in-service completed. On 12/15/23 at 9:00 am, Infection Preventionist Registered Nurse (RN) checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. On 12/15/23 at 9:30 am, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing, Director of Clinical Education and Minimum Data Set Nurse (MDS). At 2:57 pm on 12/15/23, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Executive Director. On 12/15/23 at 3:20 pm Maintenance Assistance initiated an Elopement Alarm Drill with employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. All corrective actions were completed on 12/15/23 and the facility alleges removal of the Immediate Jeopardy (IJ) on 12/16/2023. The State Agency (SA) validated the facility's Past Non-Compliance (PNC) Removal Plan/Corrective Action on 12/19/23: The SA validated through interviews and record review that on 12/14/23 at 9:30 PM Executive Director notified Resident #1 Responsible Representative of the resident elopement from facility. The SA validated through interview and record review that on 12/14/23 at 9:45 PM the facility completed a 100% head count of all other residents to ensure they were accounted for. The SA validated through interview and record review that on 12/14/23 upon return to facility Resident #1 was assessed by Licensed Practical Nurse (LPN) with no injuries noted. The SA validated through interviews and record review that on 12/14/23 all doors were monitored throughout the night until maintenance staff arrived on 12/15/23 at 8:00 AM to assess all facility exit doors, doors were checked for proper functioning by Maintenance Department. It was discovered that a bad antenna could have caused the door not to alarm when resident exited the facility. A new antenna was immediately put in place and troubleshooting was completed with the vendor via phone to ensure proper functioning. The SA validated through interviews and record reviews that on 12/15/23 residents with risk of elopements were reevaluated and updated to ensure all residents at risk had appropriate interventions in place. The SA validated through interviews and record review that on 12/14/23 at 9:23 PM, the Executive Director and Director of Nursing began official investigation of Resident #1 elopement. The SA validated through interview and record review that on 12/14/23 at 11:00 PM that In-Services were initiated by Director of Nursing to include all staff on Elopement Policy and Procedures, Abuse-Neglect, In-Services were completed by 12/15/23. The SA validated through interview and record review that on 12/15/23 Infection Preventionist Registered Nurse checked all residents at risk for elopement wander-guard bracelet for placement and function with no negative findings. The SA validated through interview and record review that on 12/15/23 at 9:30 AM, a Quality Assurance (QA) meeting was held with the Medical Director via phone, Director of Nursing, Administrator, Nurse Practitioner (NP), Social Services, Director of Care Coordinator, Assistant Director of Nursing, Director of Clinical Education and Minimum Data Set Nurse (MDS). The SA validated through interview and record review that on 12/15/23 at 2:57 PM, the Mississippi State Department of Health (MSDH) was notified of the elopement with the resident by Director of Nursing. The SA validated that on 12/15/23 at 3:20 PM Maintenance Assistant initiated an Elopement Alarm Drill with employees across all shifts, to include 7a-3p, 3p-11p, 11p-7a shift employees. The SA validated through observations, record reviews, and facility policy reviews that all corrective actions were completed on 12/15/23 and the facility alleges removal of the Immediate Jeopardy (IJ) on 12/16/2023.

Aug 2023 8 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, and record review the facility failed to provide the correct size sling for a resident who needed to be transferred with a total lift (Resident #26) and to provide easy access to a resident's personal restroom (Resident #99) for two (2) of 121 residents reviewed for accommodations during the survey. Findings include: Review of the typed statement signed by the Administrator on facility letterhead, undated, revealed, (Proper name of facility) does not have an Accommodation of needs Policy. Resident #26 An observation and interview on 08/29/23 at 12:22 PM, revealed Resident #26 lying in bed and stated that sometimes she doesn't get out of bed, because the staff tell her that they only have one sling in the building that will fit her, and it is being used for another resident. An interview on 8/30/23 at 10:55 AM, with Certified Nurse Assistant (CNA) #1 and CNA #2 revealed that Resident #26 required a total lift using a blue sling, but they were about to use that sling on another resident that had to get up for therapy. They both confirmed there was only one blue sling in the facility, and it must be sent to laundry to be washed between residents. CNAs were asked if they would be able to have the sling laundered in order to get Resident #26 out of bed today and they both confirmed they would not. An interview on 8/30/23 at 11:20 AM, with Laundry Staff #1 revealed that staff usually come to get the slings they need in the mornings and bring them back sometime during the day for them to be washed for the next day. She revealed they would be washed in the afternoon before laundry leaves at 2:00 PM and if not, they will be early in the morning the next day. She confirmed that she does not recall ever being asked to quickly wash a sling in order for the staff to use it on another resident. She revealed she does not know how many blue slings the facility has but there is none currently in laundry to be cleaned. An interview and record review on 8/30/23 at 1:46 PM, with the Director of Nurses (DON) revealed she thought the facility had two blue slings, but the resident usually refuses to get up. Record review of Resident #26's most recent lift evaluation revealed a blue sling should be used when transferring the resident out of the bed. An interview on 8/30/23 at 2:30 PM, with Resident #26 with Licensed Practical Nurse (LPN) #2, CNA #1 and CNA #2 present, the resident stated that she would get up out of the bed more, but she wants the correct sling used, and the staff tell her that they only have one and it is being used for another resident. LPN #2, CNA #1, and CNA #2 confirmed that the facility only has one blue sling. An interview on 8/30/23 at 2:45 PM, with Registered Nurse (RN) #1 supervisor confirmed that as far as she knew the facility only had one blue sling. An interview on 8/31/23 at 12:45 PM, with the Administrator confirmed that if they had more than one resident that needed the same size sling then it was probably best to have more than one sling in that size. He stated he had not been made aware that they only had one blue sling in the facility, or he could have already ordered another one. He revealed he understood that they were trying to get the residents that needed the blue sling up on alternate days. Record review of Resident #26's Lift Transfer Evaluation (Hoyer) dated 8/21/23 revealed the resident required a Hoyer Total Lift with an extra-large (XL) sling size which is blue for transfers. Record review of Resident #26's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Combined Systolic (Congestive) And Diastolic Congestive Heart Failure and Body Mass Index (BMI) 70 or Greater - Adult. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/24/23 revealed in Section C a Brief Interview for Mental Status (BIMS) Score of 15, which indicated the resident is cognitively intact. Resident #99 On 08/30/23 at 1:45 PM, an observation and interview in Resident #99's room revealed that there were two red hazardous waste containers stacked inside the bathroom door to the right in the corner in front of the resident's sink. Resident #99 revealed that he has had both legs amputated below the knee and had a hard time transferring onto the toilet when he needed to have a bowel movement. He stated, I have to lift myself out of the wheelchair, transfer onto the commode and get turned around. He revealed that there wasn't much room in his bathroom and revealed that he could not get to the sink to wash his hands, shave himself or to wash off like he liked to do because of the red containers stacked in there just inside the bathroom door. He said I like to do things myself and don't like to call for help. He revealed that he had asked for the red containers to be removed from the bathroom, but they had not done it yet. It was also observed that a bed-side commode was against the wall with a specimen hat inserted into the top of the commode. Resident revealed that he couldn't use that and didn't know why it didn't have the bucket under it like it was supposed to. An interview with 08/30/23 at 2:30 PM, with the Administrator, revealed that he did not know why the red biohazard containers were stored in the bathroom nor who placed them there. He revealed that they should not have been stored in a way that would block the resident's use of his bathroom. Record review of Resident #99's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses to include: Need for Assistance with Personal Care, Acquired Absence of Right Leg Above Knee, and Acquired Absence of Left Leg Above Knee. Record review of the MDS with an ARD of 06/20/2023 revealed in Section C, a BIMS score of 09 which indicated Resident #99 had moderate cognitive deficits.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, staff and resident interviews and facility policy review, the facility failed to ensure a resident resided in a clean comfortable homelike environment for one (1) of thirty residents reviewed. Resident #99 Findings include: Record review of undated Facility Policy on 5-Step Daily Room Cleaning revealed .the proper cleaning method to sanitize a patient room or any area in a healthcare facility. Under 5-Step Patient Room Cleaning Procedure, the facility policy revealed, 1. Empty Trash . 2. Horizontal Surfaces . 3. Spot Clean Walls . 4. Dust Mop . 5. Damp Mop . On 08/29/23 at 3:30 PM, an observation of Resident #99's room revealed sticky brown substance scattered on the floor of his private room, along with trash debris to include napkins, medication cups and gloves. There was also an empty pizza box on the floor lying next to the wall on the left side of his room. It was also observed that there were three urinals open and hanging on the top drawer of the nightstand to the left of Resident's bed. There was 750 milliliters (ml) of amber urine in the first urinal, 350 ml amber urine in the second urinal and the third urinal was empty. On 08/30/23 at 12:05 PM, an observation in Resident #99's room revealed three urinals hanging on the partially opened top drawer of the nightstand. The first urinal closest to the bed held 750 ml of amber urine inside and the second urinal held 350 ml amber urine. An interview at the same time with Certified Nursing Assistant (CNA) #4 as she entered Resident #99's room revealed that the resident was gone for a doctor's appointment. CNA#4 observed the urinals hanging on the nightstand and revealed that she needed to come back in and dispose of the urine. On 08/30/23 at 1:45 PM, an observation and interview with Resident #99 in his room revealed three urinals on the nightstand next to his bed. The first urinal had 900 ml of amber urine and the second had about 350 ml of amber urine inside. This SA also observed a sticky brown substance on the floor throughout resident's room and an empty pizza box on the floor lying next to the wall on the left side of his room. Trash and debris was also noted on the floor of the resident's room to include napkins, medication cups and gloves. The resident revealed that he feels like the staff don't come in very often because of the sign on the door (isolation sign) and that his room had not been cleaned today or yesterday (08/29/23 or 08/30/23). On 08/30/23 at 1:50 PM, the Director of Nursing (DON) entered Resident #99's room with the State Agency (SA) and stated, This room is disgusting. She also revealed that this room didn't look like it had been cleaned yesterday and had not been cleaned yet today. She confirmed that the CNAs should be making frequent rounds and pouring the urine out of the urinals as soon as he used it. On 08/30/23 at 1:55 PM, an interview with CNA #4, revealed that she had not been in Resident #99's room this morning because he had been gone for a doctor's appointment and stated that the urinals must have been left from the night shift because he was gone this morning and she needed to get back in here and empty them. On 08/30/23 at 2:00 PM, an interview with Housekeeping, revealed that all rooms were cleaned every day and that she cleaned the isolation rooms at the end of the day to help prevent spread of infection. Housekeeping revealed that she normally worked 7:30 AM to 2:30 PM and that she left about 3:20 PM yesterday, 08/29/23. She also revealed that Resident #99's family was in his room visiting while she was trying to clean and sweep the room, so she wasn't in there long yesterday. On 08/30/23 at 2:10 PM, an interview with the Housekeeping Supervisor, revealed that he teaches the housekeeping staff to clean the isolation rooms last and also revealed that maybe they needed to start getting Resident #99's room cleaned twice a day because stuff seemed to accumulate in his room. Record review of (Proper name of cleaning services) Daily Work Routine form dated 08/29/23 documented that Housekeeper had cleaned Resident Rooms using 5 and 7 Step Method which included to Pull Trash, Horizontal Surfaces, Vertical Surfaces Dust Mop, and Damp Mop. Record review revealed that Housekeeper had marked that these tasks were completed for Resident #99's room on 8/29/23 at 12:00 PM. Record review of Resident #99's admission Record revealed admit date of 06/13/2023 with the following diagnoses to include: Encounter for Orthopedic Aftercare Following Surgical Amputation, Klebsiella Pneumoniae as The Cause Of Diseases Classified Elsewhere, Pain in Right Leg, Difficulty in Walking, Cognitive Communication Deficit, Need for Assistance with Personal Care, Acquired Absence of Right Leg Above Knee, Acquired Absence of Left Leg Above Knee. Record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/20/2023 revealed under Section C, a Brief Interview for Mental Status (BIMS) score of 09 which indicated Resident #99 had moderate cognitive deficits.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on staff interviews and record review, the facility failed to ensure a resident admitted to the facility had an accurate Pre-admission Screen (PAS) to ensure the resident was appropriate for nursing home placement for one (1) of two (2) residents reviewed for Pre-admission Screening and Resident Review (PASARR). Resident #1 Findings include: Record review of facility statement on letterhead, undated, revealed, (Proper name of facility) follows state guidelines for PASSAR. Record review of Administrative Census revealed Resident #1 was admitted to the facility for skilled services on 9/9/19 and changed to non-skilled services on 10/19/19. Record review of PAS Application for Long Term Care dated 10/14/19, revealed the answer of no to the question of Person has a diagnosis of a major mental illness? and to the question of Person has a recent history of a major mental illness? revealed an answer of no. Record review of Resident #1's admission Record revealed the resident was admitted to the facility originally on 2/2/2016. The most recent admission date was 5/14/20. Diagnoses included Schizophrenia (2/11/19), Depression (7/26/22), and Dementia (10/1/22). During an interview on 8/31/23 at 8:30 AM, the Social Service Director revealed she was the person responsible for ensuring the accurate completion of the PAS. She confirmed the resident was diagnosed with Schizophrenia on 2/11/19, and on her Pre-admission Screen dated 10/14/19, this diagnosis was not listed. She confirmed the facility failed to submit an accurate Pre-admission Screening application with the major mental illness diagnosis of Schizophrenia listed, therefore, the Level II was not done. She stated an accurate screening application is needed to ensure a resident is appropriate for nursing home placement. During an interview on 8/31/23 at 9:45 AM, the Director of Nursing (DON) confirmed Resident #1 had a diagnosis of Schizophrenia dated 2/11/19, and on her PAS dated 10/14/19, this diagnosis was not listed. She confirmed that due to the inaccurate application, a Level II was not done, and the screen was to be filled out accurately to ensure the resident is appropriate for nursing home placement and the facility failed to do this. Record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/5/23, revealed the resident with a Brief Interview for Mental Status (BIMS) score of 11 indicating the resident was mildly cognitively impaired.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review and facility policy review the facility failed to develop and implement comprehensive care plans related to nail care for Resident #61 and #68 and failed to develop a smoking care plan for Resident #77 for three (3) of 33 care plans reviewed. Findings Include: Record review of the facility policy titled, Comprehensive Care Plan, dated 05/01/12, revealed, .Practice Guidelines:1. The Interdisciplinary care plan is implemented to guide health care center staff in necessary care and services to obtain the highest practicable physical, mental and psychosocial well-being of the resident .3. Interdisciplinary team communicates mental and psychosocial problems, needs, and concerns to the care planning team for inclusion in the overall plan of care . Resident #61 On 08/29/23 at 10:29 AM, during an observation and interview, revealed Resident #61 toenails were long and thick, approximately 1/2 past the end of the resident's toes. An interview with the resident stated that he needs his toenails trimmed. During an interview and observation on 8/30/23 at 1:35 PM, with the Treatment Nurse revealed someone just came and got her to go look at Resident #61's toenails and see if she could trim them. She stated that she had not been told about the resident's toenails needing trimmed before today and confirmed that the toenails were long and needed to be trimmed. An interview on 8/31/23 at 12:52 PM, with the Director of Nurses (DON) confirmed that Resident #61 had a care plan regarding nail care PRN (As Needed), and it was not being implemented. She revealed the purpose of the care plan is to ensure the resident's get their care provided that they need. Record review of Resident #61's care plan revealed Focus: (Proper name of Resident) has a physical functioning deficit .Interventions . Nail Care as needed (PRN) . Record review of Resident # 61's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified Resident #68 During an observation and interview with Resident # 68 on 08/29/23 at 10:55 AM, revealed excessively long toenails that measured one-half (1/2) inch in length from the tip of the toes on both feet. An observation and interview with the DON on 8/30/23 at 11:15 AM, confirmed that Resident # 68 had long toenails. Record review of Resident # 68's care plans revealed Focus: I have a physical functioning deficit .Interventions: Nail care PRN (as needed) . An interview with the Minimum Data Set (MDS) Nurse on 8/31/23 at 12:30 PM, revealed that the purpose of the care plan was to identify the resident's needs and goals along with preferences to provide the necessary care. She confirmed that the facility did not follow the care plan for as needed (PRN) nail care for Resident # 68. An interview on 8/31/23 at 12:45 PM, with Licensed Practical Nurse (LPN) # 4 revealed that the purpose of the care plan was to be able to know everything about the resident to provide the needed care. She confirmed that the facility did not follow Resident # 68's care plan for as needed nail care. An interview on 8/31/23 at 12:56 PM, with the Assistant Director of Nurses (ADON) confirmed that Resident # 68's care plan was not followed for nail care. Record review of the admission Record revealed Resident # 68 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus and Peripheral Vascular Disease. Resident #77 During an observation and interview on 08/30/23 at 9:33 AM, observed Resident #77 awake, lying in his bed. Observed a pack of cigarettes and a lighter laying on the bed side table in his room. Resident #77 stated his name and confirmed that those are his cigarettes and lighter and that he goes outside to smoke. Interview with the Assistant Director of Nursing (ADON) on 08/30/23 at 9:40 AM, confirmed that the cigarettes and lighter should not be in the resident's room and stated, He is our resident that goes out to the road to smoke and he left yesterday to go out to the store with someone and I bet he bought those cigarettes then. But he usually does keep his cigarettes in his room I think because he smokes independently and goes outside when he wants to. The ADON confirmed that she could see how that could be a safety issue with him keeping his lighter and cigarettes with him in his room. She confirmed that this resident walks across the road to smoke because they are a smoke free facility. He knew that when he was admitted so because he is cognitive he said he would just sign himself out on pass and go across the road to smoke, so that is what he does. So, when he does that he just keeps his cigarettes. Record review of the resident's medical record revealed there was not a smoking care developed for Resident #77. Interview with the Director of Nursing (DON) on 08/30/23 at 2:00 PM, stated Surely he has a care plan, let me check. The DON confirmed at 5:00 PM on 08/30/23 that she had reviewed the resident's medical record and that there was not a smoking care plan for this resident and that when she was looking that they had not completed a smoking assessment on the resident either. She confirmed that a completed smoking assessment would have triggered a care plan to be developed. She stated, When he first came here he was very sick and has improved, but honestly I didn't know he was a smoker until recently, probably in the last month and we just missed doing a smoking assessment for him and also completing a smoking care plan. Record review revealed that the resident was admitted to the facility on [DATE] with diagnoses that included Paranoid Schizophrenia, Heart Failure and Need for Assistance with Personal Care.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review and facility policy review the facility failed to provide the necessary nail care for a resident as evidenced by long, thick, overgrown toe nails for two (2) of thirty residents on sample. Resident #61 and Resident #68. Findings Include: Record review of a typed statement on facility letterhead, undated, and signed by the Administrator revealed, (Formal Name of Facility) does not have a general ADL (Activities of Daily Living) Policy. Record review of a typed statement on facility letterhead and signed by the facility Administrator revealed, (Formal Name of Facility) adopted Clinical Nursing Skills and Techniques, [NAME] and [NAME] as a supplementary policy and procedure care guide. Category: Clinical. Effective Date: Jan (January) 2023 Resident #61 An observation and interview on 08/29/23 at 10:29 AM, revealed Resident #61 toenails were long and thick, approximately 1/2 inch past the end of the resident's toes. An interview with the resident stated that he needs his toenails trimmed. An interview and observation on 8/30/23 at 1:15 PM, with Certified Nurse Assistant (CNA) #5 confirmed that Resident #61's toenails were too long and needed to be trimmed. She stated the resident is a diabetic and a Registered Nurse (RN) would be responsible for doing this resident's nails. An interview and observation on 8/30/23 at 1:35 PM, with the Treatment Nurse revealed someone just came and got her to go look at Resident #61's toenails and see if she could trim them. She stated that she had not been told about the resident's toenails needing trimmed before today. She confirmed that Resident #61 toenails were long and needed to be trimmed. An observation revealed the Treatment nurse trimmed the resident's toenails. An interview on 8/30/23 at 1:46 PM, with the Director of Nurses (DON) confirmed that Resident #61 was a diabetic and needed his toenails trimmed. She confirmed that the nurse doing the weekly skin audits should have notified the treatment nurse about the need for nail care. She revealed the treatment nurse, or the RN can trim their nails if they are not too thick, and it should have been done. An interview on 8/31/23 at 12:30 PM, with RN #1 confirmed that Resident #61's toenails were thick and long and that should have been communicated to the treatment nurse to do nail care or she should have done it herself. She stated that any staff member that noticed the resident's toenails are long should notify the RN for nail care on a diabetic resident. She revealed the purpose of nail care is to prevent infection and to prevent them from scratching themselves and diabetics have slow wound healing. Record review of Resident # 61's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified Record review of Resident #61's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/3/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15 which indicates the resident is cognitively intact and in Section G that the resident was totally dependent for bathing. Resident #68 An observation and interview with Resident # 68 on 08/29/23 at 10:55 AM, revealed excessively long toenails that measured one-half (1/2) inch in length from the tip of the toes on both feet. The resident stated, The doctor was here a couple of months ago, but didn't cut mine. The resident revealed he was unable to wear socks and was afraid that he may cut himself or someone else. An observation and interview on 8/30/23 at 11:05 AM, with RN # 1 confirmed that Resident # 68 had long toenails on both feet. She revealed that the treatment nurse was responsible for cutting the resident's toenails because he was a diabetic. She revealed that the Podiatrist just came to the facility a couple of weeks ago, but was unable to see the resident because he had too many residents on the list to be seen. RN #1 confirmed that the resident could scratch or injure himself due to the length of his nails. An observation and interview with the Director of Nursing (DON) on 8/30/23 at 11:15 AM, confirmed that Resident # 68 had long toenails. She acknowledged that he could potentially scratch or cut himself. Record review of the admission Record revealed Resident # 68 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus and Peripheral Vascular Disease. Record review of the MDS with an ARD of 7/25/23 revealed under section C a BIMS of 15 which indicated Resident # 68 was cognitively intact.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview and facility policy review, the facility failed to supervise and complete a smoking assessment for one (1) of three (3) residents who smoked. Resident #77. Findings Include: Record review of facility policy titled, Safe Smoking, dated 11/01/16, revealed, Purpose .2. To assess the ability to smoke and determine any measures needed to protect residents from possible self-inflicted injury during smoking. Procedure 1. Any resident who identified themselves as desiring to smoke will be assessed for safety related to smoking. This assessment will be reviewed and updated with any change of condition . On 08/30/23 at 9:33 AM, during an observation and interview, observed Resident #77 awake, lying in his bed. Observed a pack of cigarettes and a lighter laying on the bed side table in his room. Resident #77 stated his name and confirmed that those are his cigarettes and lighter and that he goes outside to smoke. An interview with the Assistant Director of Nursing (ADON) on 08/30/23 at 9:40 AM, confirmed that the cigarettes and lighter should not be in the resident's room and stated, He is our resident that goes out to the road to smoke and he left yesterday to go out to the store with someone and I bet he bought those cigarettes then. But he usually does keep his cigarettes in his room I think because he smokes independently and goes outside whenever he wants to. The ADON confirmed that she could see how that could be a safety issue with him keeping his lighter and cigarettes with him in his room and confirmed that the resident walks across the road to smoke. She stated they are a smoke free facility so he knew that when he was admitted and because he is cognitive she stated that the resident told them that he would just sign himself out on pass and go across the road to smoke, so that is what he does. The ADON revealed, So, I guess when he does that he just keeps his cigarettes and lighter with him. An interview on 08/30/23 at 2:15 PM, with the Administrator stated, We are considered a smoke free building, meaning that when new residents are admitted that they know they cannot smoke on the premises and this resident was admitted knowing that he couldn't smoke here on the facility premises so since he is cognitive and alert and signs himself out and walks across the street to be off the premises to smoke. Record review of the resident's medical record revealed there was not a smoking assessment completed for Resident #77. An interview with the Director of Nursing (DON) at 5:00 PM on 08/30/23, confirmed that she had reviewed the residents medical record and that they had not completed a smoking assessment on the resident on admission to the facility. She stated, When he first came here he was very sick and has improved, but honestly I didn't know he was a smoker until recently, probably in the last month, and we just missed doing a smoking assessment on him. He has a friend that comes by, and he goes out with him and he started bringing back cigarettes and smoking. Record review of the admission Record revealed that the resident was admitted to the facility on [DATE] with diagnoses that included Paranoid Schizophrenia, Heart Failure and Need for Assistance with Personal Care. Record review of the Minimum Data Set with an Assessment Reference Date (ARD) of 06/29/23, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident is fully cognitively intact.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review the facility failed to label and date eye drops on one (1) of five (5) medication carts observed during medication administration for C Hall medication cart. Findings Include: Record review of Facility Policy, dated 04/22, titled Medication Storage, revealed, It is the policy .that medication storage complies with state and federal laws and regulations . Expired, contaminated, or deteriorated medications are immediately removed from stock and disposed of according to procedures for medication destruction and reordered from the pharmacy if a current order exists. An observation on [DATE] at 8:40 AM, during medication pass with Licensed Practical Nurse (LPN) #5, revealed the eye drops for Resident #10 were not dated on the bottle or box. The date the eye drops were filled from the pharmacy was [DATE]. An interview on [DATE] at 8:44 AM, with LPN #5 stated that eye drops were good for 60 days before having to be discarded. LPN #5 confirmed that the eye drops had no open date on the box or the bottle and that if the eye drops were filled on [DATE] that they should have been discarded on [DATE]. An interview on [DATE] at 9:00 AM, with the Director of Nursing (DON) confirmed that eye drops should be discarded 60 days after the fill date and that a date should be placed on the bottle when they are opened.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on observation, staff interviews and facility policy review, the facility failed to label food items in the refrigerator and freezer and failed to maintain a clean ice maker for one (1) of three (3) kitchen tours. Findings Include: Record review of the facility policy titled food storage with an effective date of 11/01/17 revealed under, Policy: It is the policy of this center to store, prepare and serve food that is stored in accordance with federal, state, and local sanitary codes. Also revealed under, Policy Interpretation and Implementation . 5. Foods will be labeled as to content and dated . Record review of the facility policy titled Ice Machines with an effective date of 9/01/14 revealed Purpose: To maintain dietary refrigeration equipment to preserve food at safe regulated temperatures. The temperatures at which foods are stored can affect their appearance, taste, nutrient content and most importantly their safety . Monthly Preventative Maintenance . Sanitize interior of ice machine per manufacturer's instructions. Clean out and sanitize the ice bin . Record review of the kitchen ice machine manufacturer's guidelines for cleaning and maintenance revealed under, 1. Cleaning Procedure: 1) Dilute 16 fl. (fluid) oz. (ounce) (473 ml) (milliliters) of Hoshizaki Scale Away with 3 gal. (gallon) (11 I) (liters) of warm water. Also revealed under, 2. Sanitizing Procedure-Following Cleaning Procedure: 1) Dilute a 5.25% sodium hypochlorite solution (chlorine bleach) with warm water. (Add 1.5 fl. (fluid) oz. (ounce) (44 ml) (milliliters) of sanitizer to 3 gal. (gallons) (11 I)(liters) of water.) . An observation of the kitchen ice machine with the Dietary Manager (DM) on 8/29/23 at 10:21 AM, revealed a black substance adhering to the inside of the entire ice machine door. The DM confirmed the black substance inside the ice maker door, and she revealed she was not sure what the black substance could be. She revealed that the ice machine was emptied routinely and cleaned by the maintenance department, but she was unsure how often or the last time it was cleaned. She revealed that the black substance could make the residents or staff sick. An observation of the kitchen stand-up refrigerator with the DM on 8/29/23 at 10:28 AM, confirmed four (4) unlabeled/undated sandwiches wrapped up in clear plastic wrap. The DM revealed the sandwiches were peanut butter, and she revealed she was unsure when they were placed in the refrigerator. An observation of a large clear bag with whitish colored meat that was unlabeled/undated. The DM identified the item in the bag as turkey breast and revealed she was unsure how long it had been in the refrigerator. Observed 12 small burgundy bowls with a whitish/tan chunky substance inside and covered with clear plastic wrap that was unlabeled/undated. The DM revealed the substance was pineapple tidbits and confirmed that the staff should have dated it. The DM confirmed that by not dating the food inside the refrigerator, the staff would not know how long the food had been stored or when it should be thrown away. The DM revealed she was throwing away all the unlabeled foods for safety and acknowledged that the residents could possibly get sick. An observation of the kitchen freezer with the DM on 8/29/23 at 10:40 AM, revealed an open 32-ounce bag of whole kernel corn with less than one-half (1/2) the bag remaining that was undated. The DM confirmed that the corn should have been labeled when it was opened. The DM also confirmed a clear plastic bag that was opened and undated with six (6) frozen chicken breasts. She confirmed that all things placed inside the freezer should be labeled and dated. An interview with the DM on 8/30/23 at 1:30 PM, confirmed that the dietary staff had not been cleaning the ice machine and revealed the only cleaning the ice machine received was by the maintenance department. An interview with the Maintenance Supervisor on 8/30/23 at 1:45 PM, revealed that he did routine cleaning on the ice machine every 3 months. He revealed he cleaned the coils, descaled, delimed, emptied the ice and flushed the ice machine with clean water. He confirmed that he did not clean the inside of the ice machine door as part of his cleaning routine. He confirmed that the kitchen staff were responsible for cleaning the inside of the ice machine door, and he stated, That should be wiped down daily. He confirmed that the black substance on the inside of the ice maker door could potentially make someone sick. Record review of the Ice Machine Quarterly Cleaning Schedule revealed the last date of cleaning was documented on 6/14/23. An interview with the Administrator (ADM) on 8/30/23 at 1:54 PM, with the DM in attendance, confirmed that the Dietary Department was not cleaning the ice machine. The ADM revealed that the black substance that had built up on the inside of the ice machine door could cause staff or residents to become sick. An interview with the Administrator on 8/30/23 at 2:04 PM, confirmed that all food items placed inside the refrigerator and freezer should be labeled with a date of opening and acknowledged that the residents could become sick from outdated food.

Nov 2021 4 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observations, staff interviews and facility policy review the facility failed to provide residents with a safe environment, as evidenced by, a can of chemical disinfectant spray found unsecured on an open linen cart for one (1) of four (4) days of survey. Findings include: Review of the facility policy titled, Internal Hazardous Materials Incident, no date, revealed, Overview: Several hazardous chemical materials are stored and used within the center every day within several areas and departments. Examples include, but are not limited to: .Nursing: Alcohols, disinfectants, and hazardous drugs . Preventing Accidental Exposure, Spills, and Releases .All chemicals stored within resident care areas will be secured in locked cabinets when not in use . An observation on 11/7/2021 at 3:00 PM, revealed a can of chemical disinfectant spray on the clean linen cart on D hall. An interview on 11/7/21 at 3:02 PM, with Registered Nurse (RN) #3 revealed the disinfectant spray should not be on the clean linen cart. RN #3 removed the can. She stated that the staff knows that the spray is not supposed to be on the cart. An interview on 11/7/21 at 3:15 PM, with Certified Nursing Assistant (CNA) #3 confirmed the chemical spray should not be on the linen cart. She stated that a resident could possibly get it and hurt themselves or make them sick. CNA #3 stated that the can was there (on the open linen cart) when she came to the floor and she should have removed it then. An interview on 11/10/21 at 10:20 AM, with the Director of Nursing (DON), revealed that she did not know how the chemical disinfectant spray got on the linen cart unless, it was due to their recent COVID positive resident, and somebody put it on there to spray themselves. She confirmed that the disinfectant spray should not have been on the linen cart. The DON stated that the chemical could be harmful if a resident got it.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and record review, the facility failed to store nebulizer tubing in a manner to prevent the possible spread of infection and failed to date oxygen tubing for three (3) of eight (8) residents with oxygen and nebulizer equipment. Resident #45, Resident #46 and Resident #70. Findings include: Resident #46 An observation on 11/07/2021 at 3:25 PM, of Resident #46 revealed oxygen (O2) at two point five (2.5) Liters per minute/ by nasal cannula (LPM/BNC) with the aqua pack (water bottle) dated 11/6/21. The O2 Tubing was not dated. A nebulizer machine was on the bedside table with tubing and mask attached. The mask was laying on top of the nebulizer and it was not in a zip lock bag. There was no plastic bag observed near the nebulizer or O2 concentrator to prevent the spread of infection. Record review of the admission Record for Resident #46 revealed she was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Morbid Obesity, Heart Failure, unspecified and Unspecified Atrial Fibrillation. Record review of Resident #46's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/28/21, revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. Record review of Resident #46's Clinical Physician Orders, last review date 11/1/21, revealed Oxygen concentrator every shift for (shortness of breath) SOB, acute respiratory. distress, SaO2 (oxygen saturation) < 90% May infuse 2-4 LPM BNC, revision date 09/27/21. Ipratropium-Albuterol Solution 0.5-2.5 three (3) MG/3ML, 3 ml inhale orally via nebulizer every four (4) hours as needed for SOB related to Chronic Obstructive Pulmonary Disease unsupervised self-administration dated 05/11/21. Change oxygen tubing and humidifier bottle weekly. Clean any external filters with soap/water, every night shift every Fri. Change nebulizer mask and tubing every three (3) days, every night shift every 3 day(s) dated 4/7/2021. Resident #70 An observation on 11/07/2021 at 4:30 PM, of Resident #70's room revealed no Aqua Pack (water bottle) attached to the O2 concentrator and the O2 tubing was not dated. Record review of Resident #70's Order Summary Report revealed an order dated 08/13/21 for oxygen concentrator every day and evening shift , may infuse at 5 LPM BNC during wake hours. Resident #45 On 11/07/21 at 05:17 PM, an observation revealed Resident #45 had no date on the O2 tubing. A nebulizer mask with tubing attached but not to the machine was laying on the bedside table near the nebulizer machine. Record review of Resident #45's Order Summary Report revealed an order dated 10/10/2020 for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML one (1) vial inhale orally every six (6) hours as needed for SOB/decreased SAO2 related to Chronic Obstructive Pulmonary Disease, unsupervised self-administration and an order dated 9/27/21 for Oxygen concentrator as needed for SOB/respiratory distress may infuse 2-4 LPM BNC. On 11/09/2021 at 2:10 PM, an interview with the Director of Nurses (DON) revealed it was the standard in the facility to change O2 tubing and water bottles weekly. Usually the order is to be changed on Friday night and they date the water bottle but not the oxygen tubing. The nebulizer tubing and mask are changed every three days and they date the mask. We store mask and cannulas in plastic bags when not in use. The DON confirmed that the nebulizer mask and the oxygen cannulas should have been stored in plastic bags. On 11/10/2021 at 9:00 AM, an interview with the DON revealed when asked what could happen if the O2 tubing itself was not changed but the water bottle got changed, she replied that it could cause bacteria growth or make the resident sick. When asked for a policy for changing and dating O2 tubing the DON denied that the facility had a policy that spoke to dating of the oxygen tubing and stated we go by the physician orders and chart it on the medication administration record.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, staff interview and facility policy review the facility failed to secure the medication cart on hallway C and hallway D while away from the medication cart during medication administration for three (3) of nine (9) medication administration opportunities on halls B, C, and D. Findings include: Review of policy titled, 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles with an effective date 12/01/07 revealed APPLICABILITY This Policy 5.3 sets for the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles. PROCEDURE . 3. (3.3) Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. On 11/8/2021 at 4:16 PM, an observation of Registered Nurse (RN #1) revealed the nurse left the cart unlocked and unattended in the hallway while giving the medications and performing a finger stick blood glucose test in a residents room. On 11/8/2021 at 4:28 PM, an observation of RN #1 revealed the nurse prepared the insulin dose for a resident and left the medication cart unlocked and unattended in the hallway while administering the insulin in a residents room. On 11/8/2021 at 4:37 PM, an observation of Licensed Practical Nurse (LPN) #2 prepared an insulin dose for a resident and left the medication cart unlocked and unattended in the hallway while administering the insulin in a residents room. 0 11/08/2021 at 4:45 PM, an interview with RN #1 revealed that when she walks away from a medication cart the computer and the medication cart should be locked and that she had failed to lock her medication cart both times that she entered the residents room. On 11/8/2021 at 5:00 PM, an interview with LPN #2 revealed she always tries to lock her medication cart before walking away, but that she had noticed she left it unlocked when she came back to the medication cart and she stated, It must have been my nerves that I forgot to lock my cart. On 11/9/2021 at 2:15 PM an interview with the Director of Nurses (DON) revealed the medication carts should always be locked when the nurse walks away from the cart, a wandering resident could get in an unlocked cart.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Record review of the facility policy titled, Equipment and Department Cleaning/Maintenance Policy with an effective date April 2020 revealed under POLICY Equipment is to be cleaned and maintained according to manufacturer's instructions. POLICY INTERPRETATION AND IMPLEMENTATION Each piece of equipment used for patient/resident care is to be cleaned with center approved surface disinfectant before and after each patient use. This includes, but not limited to: wheelchairs, blood pressure cuffs, glucometers, temperature probes, lifts, all therapy equipment, shower chairs, bedside table, and scales .Each piece of equipment should be cleaned with disinfectant wipe on (Formal Name of Facility) formulary or product that is purchased from an approved list of EPA registered disinfectants. The manufacturer's instructions should be reviewed carefully for dry time after cleaning and before next use .Equipment should not be used between patients without being appropriately disinfected .The ice scoop is to not be left in the ice while not being used and should be cleaned daily in the dish machine . Record review of the Maintenance instructions for the Assure Platinum blood glucose [NAME] ,page 47, revealed Cleaning and Disinfecting Guidelines ., Option 1: Cleaning and disinfecting can be completed by using a commercially available EPA (Environmental Protection Agency)-registered disinfectant detergent or germicide wipe Option 2: With all the recommended meter cleaning and disinfecting method, it is critical that the meter be completely dry before testing a resident's glucose level. Please follow the disinfectant product label instructions to ensure proper drying time . On 11/8/2021 at 11:38 AM, an observation of Licensed Practical Nurse (LPN) #1 cleaned the glucometer after performing a fingerstick for Resident #31 revealed she cleaned her hands with hand gel, opened her medication cart and got out a sani-cloth from a purple top container and preceded to wipe the glucometer. LPN #1 wiped the glucometer for 30 seconds and then set it on a tissue on the medication cart to air dry. On 11/8/ 2021 at 11:40 AM, an interview with LPN #1 revealed the nurses use sani-cloth purple top disinfectant wipes to clean the glucometers between each use. The State Agency (SA) asked what the kill time for the disinfectant wipe was and LPN#1 reported the kill time is two (2) minutes. The SA asked LPN #1 if she cleaned the glucometer for two minutes and she confirmed that she did not clean the glucometer for two minutes. LPN #1 then picked up the disinfectant wipe container and read the instructions and confirmed that the glucometer needed to stay wet for two minutes in order to kill viruses and bacteria. On 11/8/2021 at 4:16 PM, an observation of Registered Nurse (RN) #1 revealed the nurse after checking a residents blood sugar cleaned the glucometer using a purple top Sani Cloth wipe and wiped the glucometer for less than a minute and allowed it to air dry. On 11/8/2021 at 4:28 PM, an observation of RN #1 revealed the nurse after checking resident #57's blood sugar brought the glucometer out of the resident's room, sat it on the medication cart without utilizing a barrier, retrieved a sanitizer wipe out of the purple top Sani Cloth container and wiped the glucometer for 18 seconds and then laid the glucometer down on a tissue to air dry. RN #1 did not disinfect the top of the medication cart after placing the glucometer back in her medication cart. She confirmed she should have wiped the top of the medication cart. On 11/08/2021 at 4:45 PM, an interview with RN #1 revealed she used the purple top sani cloth to clean glucometers most of the time. When asked what the facility policy was for cleaning/disinfecting multiple resident use equipment such as glucometers, blood pressure cuffs, stethoscope, or pulse oximeters she replied she did not know the policy, but she always wiped them off with the purple top sanitizer wipes. The SA asked RN #1 to read the instructions on the purple top Sani Cloth disinfectant wipes, then asked what was the contact time for sani cloth to disinfect and RN #1 replied two minutes and she confirmed that she did not leave it wet for two minutes. On 11/8/2021 at 4:12 PM, an observation was made of Certified Nurses Assistant (CNA) #1 exiting out of Resident #95's room with an empty ice scoop in his hand and he then placed the ice scoop in the ice cart in the hallway. On 11/8/2021 at 4:37 PM, an observation of LPN #2 performed a finger stick blood glucose for Resident #6 and brought the glucometer back to the medication cart and sat the glucometer on top of the medication cart, washed her hands and placed a sani cloth over the top and sides of glucometer and did not wrap to the back of glucometer and allowed it to remain wet for two minutes. On 11/8/2021 at 5:00 PM, an interview with LPN #2 revealed she normally wraps the glucometer with the sani-cloth all the way around the glucometer after cleaning the surface and confirmed that she failed to do that while cleaning the glucometer after she checked the blood glucose.She confirmed that her failure to appropriately clean the glucometer could spread infection. On 11/8/2021 at 5:10 PM, an interview with CNA #1 revealed that he goes into a residents room, removes their lid to the residents ice cup, uses hand gel to disinfect his hands and then comes to the ice cart scoops ice in the ice scoop and then takes it into the room to fill the ice cup and then returns the ice scoop to the ice cart. The SA asked if CNA #1 disinfects the ice scoop before returning to ice cart and he replied that no one has ever told him that was a problem. CNA #1 reported that the RN supervisor told him to pass ice this way. On 11/9/2021 at 2:15 PM, an interview with the Director of Nurses (DON) revealed the CNA's pass ice every shift, they are not supposed to take the ice scoop into the residents rooms. The SA asked what should be done to any equipment that goes from room to room, resident to resident she replied that such equipment would be disinfected between each resident use. On 11/09/2021 at 3:30 PM, an interview with RN #2 who is the Supervisor for 3 to 11 shift revealed that CNA #1 came to her and asked if he should take the cup out of the room to pass ice and she told him that she did not take the cup out of the room because she didn't want to risk transferring bacteria and she left the conversation at that with CNA #1. She reported to SA that when she passes ice, she would fill a disposable cup with ice at the ice cart and take it into the room to pour it in the resident's ice cup. When asked did she instruct CNA #1 in the way she passed ice and she replied, I did not. Based on observation, staff interviews, record review and facility policy reviews the facility failed to prevent the possible spread of infection as evidenced by failure to conduct hand hygiene during meal tray distribution, properly clean and sanitize a medication cart, an ice scoop and glucometers on four (4) of (4) hallways. Residents number #63, #77, #92,,#95, and #98 and two (2) residents observed during medication pass. Findings Include: Record review of a facility policy titled, Handwashing/Hand Hygiene, with an effective date March 2020 revealed POLICY This center considers hand hygiene the primary means to prevent the spread of infection. POLICY INTERPRETATION AND IMPLEMENTATION . 2. All team members shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other team members, residents, and visitors .5. Use an alcohol-based hand rub or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents Observation of evening meal on 11/07/21 at 5:25 PM, observed Certified Nursing Assistant (CNA) #4 on hallway A distributing the meal trays to the resident's in their rooms. CNA #4 set up a meal tray for Resident #98 and exited the room without using hand hygiene. CNA #4 then went to the food cart and removed the meal tray for Resident #77 and went into the room and set her meal tray up . CNA #4 then removed the dome lid from the tray and opened up resident's silverware and went to resident's dresser to retrieve a straw for the resident. CNA #4 touched the straw with her bare hands and placed in into the resident's drink glass. CNA #4 then exited the resident's room without using hand sanitizer or washing hands and went back to the food cart and retrieved the food tray for Resident #92, then walked into his room and placed his tray on his over the bed tray table and exited his room without using hand hygiene. CNA #4 then returned to the meal cart and obtained a food tray for Resident #63 and placed the tray down on the resident's over the bed tray table, walked to the window to close the window blinds for the resident and exited the room without any hand hygiene or hand sanitizer. CNA #4 then returned to the food cart and took another tray and the State Agency (SA) stopped the CNA and interviewed her regarding infection control and conducting hand hygiene after touching items on the food tray and in the resident's room without washing her hands or using hand sanitizer. The CNA stated that she had washed her hands earlier and that she had forgotten to use hand sanitizer or to wash her hands and confirmed that she should have after she exited each residents room before retrieving a meal tray for another resident. She stated that her failure to provide hand hygiene could possibly lead to the spread of infection. CNA #4 confirmed that the facility had provided in-services and that she knew better and just forgotten to clean her hands. Interview with the Director of Nursing (DON) on 11/10/21 at 2:50PM, confirmed that all of the staff are in-serviced constantly on hand hygiene and the importance of using hand sanitizer or washing their hands after contact with the residents to prevent the spread of infection from one resident to another. Record review of in-service dated 03/01/21 and signed by CNA #4 revealed that Handwashing is done before and after each resident contact. Sanitizer can be used instead of soap and water when hands are lightly soiled without visible debris on hand. Hands are rubbed together until completely dry.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 41% turnover. Below Mississippi's 48% average. Good staff retention means consistent care.

Concerns

• Multiple safety concerns identified: 6 life-threatening violation(s), 2 harm violation(s), $72,793 in fines. Review inspection reports carefully.
• 33 deficiencies on record, including 6 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $72,793 in fines. Extremely high, among the most fined facilities in Mississippi. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has 6 Immediate Jeopardy findings. Serious concerns require careful evaluation.

Email me this report

About This Facility

What is Diversicare Of Ripley's CMS Rating?

CMS assigns DIVERSICARE OF RIPLEY an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Mississippi, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Diversicare Of Ripley Staffed?

CMS rates DIVERSICARE OF RIPLEY's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 41%, compared to the Mississippi average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Diversicare Of Ripley?

State health inspectors documented 33 deficiencies at DIVERSICARE OF RIPLEY during 2021 to 2025. These included: 6 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 25 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Diversicare Of Ripley?

DIVERSICARE OF RIPLEY is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by DIVERSICARE HEALTHCARE, a chain that manages multiple nursing homes. With 140 certified beds and approximately 116 residents (about 83% occupancy), it is a mid-sized facility located in RIPLEY, Mississippi.

How Does Diversicare Of Ripley Compare to Other Mississippi Nursing Homes?

Compared to the 100 nursing homes in Mississippi, DIVERSICARE OF RIPLEY's overall rating (1 stars) is below the state average of 2.6, staff turnover (41%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Diversicare Of Ripley?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.

Is Diversicare Of Ripley Safe?

Based on CMS inspection data, DIVERSICARE OF RIPLEY has documented safety concerns. Inspectors have issued 6 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Mississippi. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Diversicare Of Ripley Stick Around?

DIVERSICARE OF RIPLEY has a staff turnover rate of 41%, which is about average for Mississippi nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Diversicare Of Ripley Ever Fined?

DIVERSICARE OF RIPLEY has been fined $72,793 across 5 penalty actions. This is above the Mississippi average of $33,807. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Diversicare Of Ripley on Any Federal Watch List?

DIVERSICARE OF RIPLEY is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 140
Avg. Residents: 116
Occupancy: 82.9%
Ownership: For profit - Corporation
Chain: DIVERSICARE HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
6 Immediate Jeopardy citations: -72
2 Actual Harm citations: -10
33 Deficiencies: -10
Fines ($72,793): -10
Final Score: 0/100

Nearby Alternatives

TIPPAH COUNTY NURSING HOME 3-star REST HAVEN HEALTH AND REHABILI... 1-star

View all in RIPLEY →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 255102