Diversicare Of Southaven

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate supervision and implement its elopement prevention system for a resident identified as an elopement and wandering risk. The resident was admitted with diagnoses including unspecified moderate dementia with behavioral disturbance and wandering, and had a BIMS score of 0, indicating severe cognitive impairment. On admission, the resident was assessed as being at risk for elopement, and documentation noted that a wander guard was in place. The facility’s clinical care system guidelines required that residents at risk for elopement have individualized interventions documented on the care plan and caregiver guide, a photograph taken, and their information placed in a central elopement information system, such as an elopement book at the nurse’s station or reception. On the day of the incident, nursing staff, including an LPN and CNAs, were aware that the resident wandered and was at risk for elopement and had last observed her walking the halls shortly after lunch. Around 1:00 PM, the LPN noticed the resident was no longer in the hallway and directed CNAs to check the resident’s room. When the resident was not found, the nurse initiated a missing resident code and staff began searching. Another resident reported seeing a lady in pink walking outside her window, prompting staff to search outside the building. The resident later confirmed in an interview that she had gone outside after following others because she did not want to be left alone when they left the table where she had been sitting. At the front entrance, the receptionist allowed a visitor to exit while a woman in pink followed the visitor out. The receptionist stated she was not aware that this individual was a resident and did not know she was at risk for wandering or elopement. She reported that there was an elopement book at the desk that should contain pictures and information on residents at risk, but she had not been notified about this resident and there was no information about her in the book. The receptionist also stated that the door alarm did not sound when she let the visitor and the woman in pink out, and that the alarm had been intermittently activating earlier in the day without residents present. Maintenance later reported that video footage showed the receptionist turning off the alarm after the visitor and the resident exited. The administrator confirmed that her review of the video showed the receptionist turning off the alarm and verified that the elopement book did not contain a picture or information regarding the resident’s elopement risk at the time of exit. The resident was determined to have exited the facility at approximately 1:08 PM and was located by staff about 0.4 miles away at 1:33 PM.

Removal Plan

• Implemented the elopement guideline.
• Completed an immediate room-to-room audit of all residents to assure all were safe.
• Returned Resident #1 safely to her room.
• Checked Resident #1’s wander guard for functionality upon return and confirmed it was functioning as designed.
• Performed a full body audit/assessment of Resident #1 immediately upon return with no negative findings.
• Placed Resident #1 on 1:1 supervision pending psychiatric consultation.
• Placed a request for psychiatric consultation for Resident #1.
• Planned that following removal of 1:1 supervision, Resident #1 would have visual observations every 30 minutes for 24 hours and continued as needed.
• Reviewed and updated Resident #1’s plan of care to reflect elopement risk.
• Checked all doors for proper function and operation and confirmed all doors were functioning properly.
• Notified the Medical Director.
• Notified Resident #1’s resident representative.
• Completed a 100% audit of all residents identified for elopement risk to ensure placement and functioning of the wander guard system.
• Completed an audit of elopement books on all units and at reception to ensure pictures and care plans were present for all at-risk residents.
• Completed elopement drills on all shifts.
• Educated the Receptionist on elopement guidance with emphasis on prompt response and investigation of alarm activation.
• Placed the Receptionist on administrative leave.
• Initiated an in-service with nursing staff regarding elopement guidelines, including completion of risk assessments, care plan updates, and elopement book updates.
• Initiated additional staff education on elopement guidelines and abuse and neglect.
• Provided education to Social Services regarding elopement guideline oversight.
• Returned (DNS) to educate staff and monitor effectiveness.
• Educated House Supervisors and Managers on Duty regarding elopement book accuracy.
• Ensured no staff member will be permitted to work without completing education.
• Conducted a QAPI meeting to address root cause and corrective action.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that ordered medications were available and administered as prescribed for one resident on the night of admission. The facility’s Medication Availability form, identified by the Nurse Consultant as the protocol for missing medications, directs staff to check the Emergency Medication Kit (E Kit), call the pharmacy for an estimated delivery time, notify a supervisor, and, if the delay is greater than four hours, call the physician for a plan to address the situation. Record review of the electronic Medication Administration Record (eMAR) for January 2026 showed that on the night of admission, the resident had physician orders for terazosin 1 mg at HS for essential hypertension, dabigatran 150 mg twice daily at HS for paroxysmal atrial fibrillation, and morphine sulfate 30 mg twice daily for pain related to rheumatoid arthritis. All three medications were documented with code 7 (Other/See Progress Notes), indicating they were not administered as ordered. Progress notes dated that night at 11:48 PM contained only the entry "awaiting medications" with no further documentation that the medications were obtained or given in accordance with the facility’s protocol. Interview with an LPN confirmed that, for new admissions, medication orders are transmitted to the pharmacy and that if medications are not available, staff may obtain them from the E Kit or contact the pharmacy, including backup or emergency pharmacy, to secure the medications. The LPN stated that failure to administer the resident’s prescribed medications could result in adverse outcomes. Review of the eMAR and interview with the DON confirmed that the three ordered medications were not administered and that staff did not follow the facility’s protocol for obtaining unavailable medications. Admission records showed the resident was admitted with essential hypertension, paroxysmal atrial fibrillation, and rheumatoid arthritis, requiring ongoing physician-ordered medication management.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from neglect by not adhering to the prescribed transfer method as outlined in the resident's care plan. The incident involved a Certified Nursing Assistant (CNA) who transferred the resident using a stand-pivot method instead of the required total lift with a medium yellow sling, as specified in the resident's Kardex. This improper transfer method led to the resident being lowered to the floor after expressing discomfort, which was initially assessed by a Registered Nurse (RN) with no apparent injury noted. Within 48 hours of the incident, the resident exhibited swelling and tenderness in the right knee, prompting further medical evaluation. An X-ray revealed a fracture above the previous joint replacement device, leading to the resident's transfer to the emergency room for further treatment. The facility's investigation confirmed that the CNA did not check the Kardex for updated transfer instructions, which contributed to the improper handling of the resident. The resident, who had been admitted to the facility with a diagnosis of dementia and required maximal assistance for transfers, suffered an acute comminuted periprosthetic fracture of the distal femoral metaphysis. The CNA admitted to not checking the Kardex for the resident's current transfer needs, despite being instructed to do so during orientation. This oversight resulted in the resident's injury and subsequent hospitalization.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement a resident's care plan when a Certified Nursing Assistant (CNA) transferred a resident using an incorrect method, leading to an injury. The resident, who had a history of dementia and impaired range of motion in the lower extremities, required a total lift with a medium yellow sling and assistance from two staff members for transfers, as outlined in their care plan. However, on the evening of the incident, CNA #1 used a stand-pivot transfer method instead of the required lift, resulting in the resident being eased to the floor after expressing pain. Initially, no injury was noted, but within 48 hours, swelling and a fracture were identified, necessitating further medical evaluation and treatment. Interviews with facility staff revealed that the Kardex, which details the care plan interventions, was not consulted by CNA #1 before the transfer. The facility's policy mandates that CNAs check the Kardex at the beginning of each shift to ensure compliance with care plans. Despite this, CNA #1 admitted to not following the care plan, leading to the resident's injury. The facility's administrator confirmed that the care plan interventions automatically populate the Kardex for CNAs to follow, emphasizing the expectation for staff to adhere to these guidelines.

Penalty

Fine: $19,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately submit staffing data into the Payroll-Based Journal (PBJ) system for the first quarter of 2025. The deficiency was identified through staff interviews, record reviews, and analysis of the PBJ staffing data report. The facility's policy on PBJ entry submission was not revised, and it was found that excessively low weekend staffing data was submitted for the specified quarter. Interviews with the Regional Human Resource and Human Resources personnel revealed that the facility's payroll system automatically transferred late clock-ins and shifts crossing midnight to the next shift, which was not manually corrected. This led to discrepancies in the reported staffing data. The Administrator confirmed that the facility had not experienced low staffing and that an on-call person was available on weekends to meet the required patient per day (PPD) staffing levels. However, the payroll system, which had been in use for about a year, had unresolved issues that affected the accuracy of the reported hours. The Administrator acknowledged that the workforce manager's schedule and the human resources report did not align, resulting in incorrect hour capture. This discrepancy in the payroll system contributed to the inaccurate submission of staffing data in the PBJ system.

Penalty

Fine: $19,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the safe storage and locking of hazardous cleaning chemicals on two of the three housekeeping carts observed during the survey. On one occasion, an unattended housekeeping cart on the west hall was found unlocked, containing hazardous chemicals such as Crew Bathroom Disinfectant Cleaner, Virex Plus One-step disinfectant cleaner & deodorant, and Crew clinging Toilet bowl cleaner. Housekeeper #5 confirmed the cart was not locked and mentioned that the locking mechanism was broken, with previous attempts to secure it using tape. She acknowledged the importance of locking the cart to prevent residents from accessing the dangerous chemicals. In another instance, the rehabilitation hall housekeeping cart was locked, but chemicals were stored outside the cart within residents' reach. Housekeeper #4 admitted to storing the chemicals outside because he did not have a key to unlock the cart, having worked at the facility for about a month. The Housekeeping Supervisor was unaware of the issues with the west housekeeping cart and had forgotten to provide Housekeeper #4 with a key. The Administrator was also unaware of these issues, expecting to be notified if there were problems with the cart locks or if additional keys were needed. The Safety Data Sheets for the chemicals indicated potential hazards, including severe skin burns and eye damage, emphasizing the need for secure storage.

Penalty

Fine: $19,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement proper infection prevention and control practices, as evidenced by several deficiencies observed during the survey. For Resident #4, the Treatment Nurse and a Certified Nursing Assistant did not wear gowns while providing wound care, despite the Enhanced Barrier Precautions (EBP) signage on the door indicating the need for such protective equipment. Both staff members acknowledged their oversight, attributing it to the absence of personal protective equipment at the door. The Infection Control Nurse confirmed that EBP should be followed during wound care to prevent infection spread. Similarly, for Resident #118, a Certified Nursing Assistant did not wear a gown while performing Foley catheter care, despite the EBP sign on the resident's door. The CNA admitted to the oversight and acknowledged the importance of wearing a gown to reduce the risk of bacterial transmission. The Infection Preventionist and Director of Nursing both confirmed that failing to use EBP during catheter care increased the risk of infection spread. For Resident #125, the facility failed to provide biohazard containers for the disposal of contaminated personal protective equipment, despite the resident being on contact precautions for Clostridium Difficile infection. The housekeeping staff used cleaning products that were not effective against C. diff spores, as confirmed by the Housekeeping Supervisor. The Infection Preventionist admitted to not notifying the housekeeping department about the specific precautions needed for Resident #125, which contributed to the improper handling of the resident's clothing and trash, potentially spreading the infection.

Penalty

Fine: $19,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that resident call lights were within reach, limiting the ability of two residents to request assistance as needed. For Resident #32, the call light was observed wrapped around the side rail of the bed and out of reach. During an interview, the resident expressed difficulty in using the call light due to its inaccessibility. Staff members, including a CNA and an RN, confirmed the call light's position and acknowledged the oversight, with the CNA admitting to forgetting to reposition it after leaving the room. Resident #32, who is cognitively intact with a BIMS score of 15, has diagnoses including blindness in the right eye and end-stage renal disease. Resident #42's call light was found inside a closed drawer, making it inaccessible while the resident was asleep. Subsequent observations revealed the call light hanging down the side of the nightstand and later on the floor, consistently out of reach. A CNA confirmed the call light's inaccessibility throughout the morning and acknowledged the expectation for it to be within reach. The Director of Nurses emphasized the importance of call light accessibility for resident safety and care. Resident #42 has diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side.

Penalty

Fine: $19,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe, clean, and homelike environment for several residents, as evidenced by multiple maintenance and housekeeping issues that were not addressed in a timely manner. Resident #14's room had a broken headboard with jagged edges, which was reported by the resident but not repaired, posing a potential safety hazard. Similarly, Resident #70's room had mice droppings in the dresser drawers, which were reported but not cleaned, raising health concerns. Resident #79's room had a hole in the wall with a vent cover hanging out, which was not identified or addressed by staff, creating a potential hazard. Resident #17's room had towels on the floor due to a leaking air conditioner, and a window with a gap exposing outside elements, which were not repaired despite being reported. Resident #32's bed remote control had exposed wires, posing a risk of shock, but this issue was not reported to maintenance. Resident #71's mattress was sagging and peeling, and the bed was not functioning, affecting the resident's comfort and positioning, yet these issues were not addressed by maintenance. Resident #87's room had multiple issues, including a broken bed rail, an oxygen concentrator covered in powdery substance, and boxes of supplies on the floor, which were not reported or addressed. Resident #93's overbed light was broken, preventing the resident from turning it off, and this was not repaired despite being reported. Resident #95's room had stained curtains and clutter from boxes on the floor, creating a fall risk, but these issues were not resolved. The facility's failure to address these maintenance and housekeeping issues compromised the safety and comfort of the residents.

Penalty

Fine: $19,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement appropriate care plans for several residents, leading to deficiencies in their care. Resident #12, who had a self-care deficit due to a cerebral vascular accident with left hemiplegia, was observed with poor oral hygiene, as a thick white substance was adhered to his gums. Despite the care plan specifying daily oral care, the resident's teeth were neglected, as confirmed by a CNA and the Director of Nurses (DON). This neglect indicates that the care plan was not followed, resulting in inadequate grooming for the resident. Resident #111, who had an ADL self-care performance deficit related to dementia and Parkinson's disease, was found with long, jagged fingernails with a brown substance underneath. Despite the care plan's directive for daily nail care, the resident's nails were not attended to, as confirmed by the DON. Similarly, Resident #118, who required assistance with personal hygiene due to weakness and impaired cognition, was observed with long, unclean fingernails. The DON confirmed that the care plan for personal hygiene was not implemented, leading to the resident not receiving the necessary care. Resident #32, who had end-stage renal disease, was on a 1-liter fluid restriction as per his care plan. However, the facility failed to monitor and document his fluid intake accurately, resulting in the resident exceeding the fluid limit on multiple days. An LPN admitted to not verifying the fluid intake from meal trays, and the DON acknowledged the oversight. The MDS Nurse confirmed that the failure to monitor and document the fluid restriction was a failure to implement the care plan, which was intended to prevent complications associated with impaired renal function.

Penalty

Fine: $19,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate activities of daily living (ADL) care for three residents who were dependent on staff assistance. Resident #12 was observed with a thick white substance on their teeth, indicating a lack of oral hygiene care. Despite having a hospice aide visit twice a week, the responsibility for daily oral care was acknowledged by the staff, including a CNA and an RN, who admitted that the resident's oral care had been neglected. The Director of Nurses confirmed that all residents should receive proper grooming, including oral care. Resident #111, a diabetic, had long, jagged fingernails with a brown substance underneath, and expressed dissatisfaction with their condition. The resident stated that the nurse was responsible for cutting their nails, but it was unclear when this would occur. A CNA confirmed the need to notify nurses about the resident's nail care, which had not been done. Similarly, Resident #118 had long, jagged fingernails with a dark brown substance underneath, and expressed a dislike for their length. An RN confirmed the need for nail care, noting the potential risk of skin breakdown or infection. The DON acknowledged that Resident #118 was dependent on staff for personal care and should have received nail care.

Penalty

Fine: $19,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to secure electronic health records, resulting in a breach of privacy for two residents. On the [NAME] unit, a computer on a medication cart was left unattended with the Electronic Medication Administration Record (EMAR) of Resident #86 visible on the screen. This occurred when LPN #1 stepped away from the cart to assist another resident, leaving the screen open and accessible to anyone passing by. The visible information included the resident's name, medications, and room number. LPN #1 acknowledged the oversight and confirmed that the EMAR should have been closed to protect the resident's private health information. Similarly, on the same day, another incident occurred on the [NAME] Hall where Resident #104's EMAR was left visible on an unattended medication cart. LPN #1 admitted to leaving the cart unattended with the resident's information displayed, acknowledging that this was a violation of privacy. The Director of Nursing confirmed that resident information should not be left visible on unattended computers, recognizing this as a privacy issue. Both residents' admission records were reviewed, confirming their residency at the facility.

Penalty

Fine: $19,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a medication cart was locked and medications were secured during one of the four survey days. According to the facility's policy titled 'Medication Storage,' it is the responsibility of the facility to keep the medication cart locked and secure at all times when not in use. On March 18, 2025, at 11:44 AM, an observation revealed that the medication cart in the [NAME] Wing was left unattended and unlocked by the door of room W-18. A medication cup containing six pills was found sitting on top of the cart, and two visitors walked by the unattended cart. At 11:50 AM, an LPN returned to the cart and confirmed that she had left it unlocked with medications exposed. She admitted that she had stepped away from the cart to assist in moving a bed, acknowledging that she should have secured the medications or completed her task without leaving the cart unattended. The medications in the cup were identified as Lasix, Amiodarone, Protonix, Eliquis, Tamsulosin, and Midodrine. The Director of Nurses confirmed that the facility's expectation and policy require all medication carts to be locked and medications to be kept secure when unattended, aligning with nursing standards of practice.

Penalty

Fine: $19,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate documentation and proper physician orders for the care of a resident with a Peripherally Inserted Central Catheter (PICC). During an observation, a Registered Nurse (RN) flushed the resident's PICC line and started an antibiotic infusion without a physician's order to do so. The resident's Electronic Medication Administration Record (EMAR) did not contain an order for flushing the PICC or changing the dressing, which was confirmed by another RN and the Director of Nursing. The resident was admitted with a medical diagnosis that included aftercare following the explantation of a knee joint prosthesis.

Penalty

Fine: $19,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective pest control program, as evidenced by the presence of mice droppings in a resident's dresser drawers. The issue was first noticed by the resident's husband and subsequently reported to the staff. Upon inspection, a Certified Nurse Assistant confirmed the presence of numerous black substances resembling mice droppings in multiple drawers. This finding was corroborated by a Registered Nurse, who expressed concern about potential contamination of the resident's clothing with feces and bacteria. The facility's policy on pest control, effective since September 1, 2014, was not effectively implemented in this instance. The Maintenance Supervisor acknowledged receiving a work order regarding the issue, which was reported on March 15, 2025. The resident involved was cognitively intact, as indicated by a Brief Interview for Mental Status score of 15, and had been admitted with a diagnosis of Occlusion and Stenosis of an Unspecified Vertebral Artery. The presence of mice droppings in the resident's personal space posed a potential health hazard, as confirmed by the facility's Administrator.

Penalty

Fine: $19,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately monitor and document fluid intake for a resident receiving dialysis, leading to a deficiency. The resident, diagnosed with End-Stage Renal Disease, had a physician's order for a one-liter fluid restriction per day. However, a review of the resident's Electronic Medication Administration Record (eMAR) revealed that the resident exceeded this fluid intake on multiple days. The Licensed Practical Nurse (LPN) responsible for documenting the fluid intake admitted to only recording the fluids she administered during her shift and was unaware of the total daily intake, leading to uncertainty about adherence to the fluid restriction. Further interviews with the Director of Nursing (DON) and a Nurse Practitioner (NP) confirmed the inconsistency and inaccuracy in the documentation of the resident's fluid intake. Both acknowledged the difficulty in determining whether the resident adhered to the fluid restriction due to unclear documentation. The DON was uncertain if the fluid provided with meals was included in the recorded intake, and the NP agreed that the failure to accurately monitor fluid intake could worsen the resident's medical condition.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident received treatment and services in accordance with professional standards of practice by not changing the negative pressure wound therapy (NPWT) system dressing as ordered. The resident had an order for the wound vac dressing to be changed every Monday and Thursday or as needed for drainage/dislodgement. However, the dressing was not changed from 4/1/2024 to 4/10/2024, resulting in the foam from the dressing adhering to the wound bed. This was confirmed by the resident's representative, the wound care nurse practitioner, and the facility's registered nurse, who all noted the lack of documentation and the physical state of the wound upon assessment. The resident's wound vac dressing was last changed on 3/25/2024, and it was not changed again until 4/10/2024, despite the order. The wound care nurse practitioner had to debride the wound to remove the adhered foam fragments, but not all fragments could be removed. The facility's administrator acknowledged that the dressing should have been changed as ordered. The failure to follow the prescribed treatment schedule led to complications in the resident's wound care, as evidenced by the adhered foam and the need for debridement.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement an elopement/wandering risk plan of care for a resident who had a documented history of wandering and elopement attempts prior to his admission. Despite being identified as a wanderer and wearing a wander guard since admission, the resident was able to exit the facility unsupervised and undetected by staff. The resident was missing for approximately ten to twenty minutes before being found off the facility grounds by the police and returned by a staff member. The facility's failure to provide adequate supervision and ensure the proper functioning of the wander guard system led to this incident. The resident's care plan, initiated upon admission, included interventions such as checking the placement and function of the wander guard every shift and redirecting the resident from doors. However, the Medication Administration Record (MAR) revealed multiple instances where the wander guard was not checked as required. Interviews with facility staff confirmed that the kitchen door was not properly shut, allowing the resident to leave undetected. The Assistant Director of Nursing (ADON) and the MDS/Care Plan nurse acknowledged the deficiencies in the care plan and the failure to monitor the wander guard effectively. The resident was admitted with diagnoses including senile degeneration of the brain, dementia, muscle weakness, unsteadiness on feet, abnormalities of gait or mobility, lack of coordination, and cognitive communication deficit. Despite these conditions, the facility did not adequately address the resident's elopement risk, leading to the incident. The facility's policies on care plans and elopement risk were not followed, resulting in a serious lapse in resident safety and supervision.

Removal Plan

• Resident #1 was assisted back to the facility via facility staff personal vehicle and thoroughly assessed by RN #1 with no adverse injuries/incidents found.
• RN #1 contacted the RR, the Medical Director, the facility Administrator, the facility ADON, and placed Resident #1 on one to one close observation by facility staff.
• The elopement risk assessment was updated for Resident #1 and the care plan was revised.
• The elopement book kept at the nursing station was reviewed and updated.
• Facility staff conducted room to room audits of all residents in the building to ensure safety.
• The facility conducted a Quality Assurance meeting with the Medical Director in attendance via telephone.
• Elopement drills were conducted on all three shifts.
• All residents with wander guard bracelets were checked for functionality and positioning on each shift.
• The ADM and the ADON began in-services of all staff on elopement protocol, wander guard monitoring, and Abuse and Neglect.
• All doors and windows were checked for proper functioning and operation.
• ADM began an investigation to determine how Resident #1 eloped.
• ADM called the incident in to the Mississippi State Department of Health office.
• Resident #1 was placed on one to one close observation immediately upon his return to the facility and remained on one to one by staff until his transfer.
• A staff member was placed at the front door to monitor the entrance and exits of the building 24/7 until the new wander guard alarm system was installed.
• No staff were allowed to work until they were in-serviced on elopements, Abuse/Neglect, and monitoring of wander guard systems.
• RN#1 notified the ADM, the ADON, the Maintenance Director, the RR, and the MD via telephone of the elopement of Resident #1.
• A 100% head count of all residents was conducted to ensure they were all accounted for.
• All doors were monitored by staff 24/7 until the wander guard system was found fully functioning and new punch pad systems were installed on the kitchen doors.
• Four residents with risks of elopement were reevaluated and updated to ensure all residents at risk for elopement had appropriate interventions in place.
• RN #1 and the ADM began officially investigating and obtaining statements for the Elopement of Resident #1.
• Staff in-services were initiated by RN #1, the ADON, and the ADM to include all staff on Elopement Protocols, Wander Guard checks, and Abuse/Neglect.
• A QA meeting was held via telephone with the MD, the ADON, ADM, MDS/Care Plan Nurses, Maintenance Director, Dietary Manager, Social Worker, and the QA/Infection Control Nurse.
• The Maintenance Director checked the functioning of the wander guard alarm/security system and found that the alarm was functioning properly.
• New punch pads and alarms and locks were installed on the kitchen doors.
• The ADM contacted the SA and the MS Attorney General's Office to report the elopement of Resident #1.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision to prevent a resident, identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised. The resident was missing for approximately ten to twenty minutes before being discovered at an apartment complex parking lot, talking to the police. The resident was returned to the facility by a staff member and was found to be uninjured and in no distress. The incident occurred because the kitchen door was not properly closed and locked, allowing the resident to leave undetected as the wander guard alarm did not sound. The resident had been identified upon admission as a wanderer and had a wander guard alarm placed on his ankle. However, the kitchen area did not have a wander guard alarm system, and no staff were assigned to that area late at night. The facility's policy on missing residents and elopement was not effectively implemented, as the door's malfunction allowed the resident to exit the facility without triggering the alarm or alerting the staff. Interviews with various staff members, including the Administrator, Assistant Director of Nursing, Certified Nursing Assistants, and the Maintenance Director, confirmed that the kitchen door was not properly shut, which allowed the resident to leave the facility undetected. The resident's care plan and elopement risk assessment had identified him as a wanderer, but the failure to secure the kitchen door and the lack of staff monitoring in that area led to the resident's unsupervised exit from the facility.

Removal Plan

• Resident #1 was assisted back to the facility via facility staff personal vehicle and thoroughly assessed head to toe by RN #1 with no adverse injuries/incidents found.
• RN #1 contacted the Resident Representative, the Medical Director, the facility Administrator, the facility ADON, and placed Resident #1 on one to one close observation by facility staff.
• The elopement risk assessment was updated for Resident #1 and the care plan was revised.
• The elopement book kept at the nursing station was reviewed and updated.
• Facility staff conducted room to room audits of all residents in the building to ensure safety.
• The facility conducted a Quality Assurance meeting with the Medical Director in attendance via telephone.
• Elopement drills were conducted on all three shifts.
• All residents with wander guard bracelets were checked for functionality and positioning on each shift.
• The ADM and the ADON began in-services of all staff on elopement protocol, wander guard monitoring, and Abuse and Neglect.
• All doors and windows were checked for proper functioning and operation.
• ADM began an investigation to determine how Resident #1 eloped.
• ADM called the incident in to the Mississippi State Department of Health office.
• Resident #1 was placed on one to one close observation immediately upon his return to the facility and remained on one to one by staff until his transfer.
• A staff member was placed at the front door to monitor the entrance and exits of the building 24/7 until the new wander guard alarm system was installed.
• No staff were allowed to work until they were in-serviced on elopements, Abuse/Neglect, and monitoring of wander guard systems.
• RN#1 notified the ADM, the ADON, the Maintenance Director, the RR, and the MD via telephone of the elopement of Resident #1.
• The facility staff conducted a 100% head count of all residents to ensure they were all accounted for.
• All doors were monitored by staff 24/7 until the wander guard system was found fully functioning and new punch pad systems were installed on the kitchen doors.
• Four residents with risks of elopement were reevaluated and updated to ensure all residents at risk for elopement had appropriate interventions in place.
• RN #1 and the ADM began officially investigating and obtaining statements for the Elopement of Resident #1.
• Staff in-services were initiated by RN #1, the ADON, and the ADM to include all staff on Elopement Protocols, Wander Guard checks, and Abuse/Neglect with no staff allowed to work until in-services were completed.
• A QA meeting was held via telephone with the MD, the ADON, ADM, MDS/Care Plan Nurses, Maintenance Director, Dietary Manager, Social Worker, and the QA/Infection Control Nurse.
• The Maintenance Director checked the functioning of the wander guard alarm/security system and found that the alarm was functioning properly and the alarm was sounding.
• The vendor installed new punch pads and alarms and locks to the kitchen doors.
• The ADM contacted the SA and the MS Attorney General's Office to report the elopement of Resident #1.

Penalty

Fine: $36,335

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe, clean, and homelike environment as evidenced by multiple deficiencies observed by surveyors. The East Wing hall had damaged floors with buckled, unsecured vinyl flooring, indentations, and peeling laminate, posing a hazard to residents, staff, and visitors. Additionally, the floors in the [NAME] wing hall were dirty with discarded paper, dried liquid stains, and food crumbs. The facility also failed to provide clean linens, as observed in the case of Resident #2, who was found lying in bed without sheets or a full blanket in cold weather conditions. The linen closets on the [NAME] Wing and East Wing were found to be empty, and the laundry room was backed up with dirty laundry due to only one working washer. The Administrator and staff confirmed the lack of clean linens and the ongoing issues with the laundry equipment. The facility's shower room on the [NAME] Wing had been broken for about two months, resulting in residents receiving bed baths instead of showers. Housekeeping and maintenance issues were also prevalent, with observations of unclean resident rooms, including dried brown substances and food crumbs on the floors. Housekeeping staff failed to adequately clean these areas, and there were reports of foul-smelling garbage piling up in the biohazard room on the East Wing. The Environmental Manager and housekeeping staff acknowledged the deficiencies and the need for better cleanliness and garbage disposal practices. Interviews with staff and residents revealed ongoing concerns about the cleanliness and safety of the facility. Maintenance staff confirmed multiple water leaks and inadequate repairs to the East Wing floors, which remained unlevel and hazardous. The Administrator and Director of Nursing acknowledged the deficiencies and the need for improvements in laundry, housekeeping, and maintenance practices. The facility's failure to address these issues in a timely manner resulted in an unsafe and uncomfortable environment for the residents.

Penalty

Fine: $36,335

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a resident with adequate bedding and protection from cold temperatures. An observation revealed that the resident was lying on a bare mattress with no sheets or bedspread, covered only by a small velour throw, while the window in the room was open, and the outside temperature was 38 degrees. Interviews with the LPN and CNA confirmed the lack of clean linens and blankets in the building and the unnecessary opening of the window. The Administrator and the Director of Nurses acknowledged that the resident should have had proper bedding and that the window should not have been open in such cold weather. The resident involved was admitted to the facility with a medical diagnosis of Hypokalemia and had a BIMS score indicating moderate cognitive impairment. The deficiency was identified through staff interviews, record reviews, and direct observations, highlighting a failure to honor the resident's right to a dignified existence and proper care. The lack of clean linens and the open window in cold weather were significant factors contributing to the deficiency.

Penalty

Fine: $36,335

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement a comprehensive care plan for three residents requiring assistance with Activities of Daily Living (ADLs). Resident #6 was observed to be disheveled, with oily hair and unshaven facial hair, and reported not having had a shower in about two weeks. The Treatment Nurse and the Minimum Data Set (MDS) Nurse confirmed that the resident's care plan, which required extensive assistance with bathing and personal hygiene, was not being followed. The Director of Nursing (DON) also confirmed that the staff was not adhering to the care plan, resulting in the resident not receiving the necessary care. Resident #1, who requires extensive assistance with toileting due to weakness and debility, reported having to wait for a female Certified Nursing Aide (CNA) to provide care, sometimes waiting up to eight hours while wet. The resident had complained to both the head nurse and the administrator about not wanting a male CNA, but the issue persisted. The resident's care plan indicated the need for assistance with ADLs, but the facility failed to provide timely and appropriate care. Resident #3, who has an ADL self-care deficit related to chronic debilitation and weakness, reported mainly receiving bed baths and not being taken to the bathroom during the day. The resident preferred showers but could not remember the last time he had one. The DON confirmed that residents were mainly given bed baths because some aides found it easier, and acknowledged that not all nursing staff were meeting basic care expectations. The resident's care plan required extensive assistance with toileting, but the facility did not follow through with the necessary care.

Penalty

Fine: $36,335

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient staff to meet the needs of residents, resulting in inadequate assistance with bathing, grooming, and personal hygiene for three residents. Certified Nurse Aides (CNAs) reported that the night shift staffing was reduced from four to three aides per wing, making it difficult to provide timely care. One resident had to wait up to eight hours for a female CNA to provide incontinent care due to her preference for female staff, which was not accommodated promptly. Another resident had not been shaved or given a shower for about two weeks, and a third resident reported receiving mainly bed baths and not being taken to the bathroom during the day as needed. Interviews with staff confirmed the staffing issues, with one Licensed Practical Nurse (LPN) stating that the workload was overwhelming and that residents did not receive showers as they should. The Director of Nurses (DON) acknowledged that some staff were not meeting basic care expectations and that bed baths were more common due to aides finding them easier. The Workforce Manager admitted to insufficient training in scheduling, leading to low staffing levels on certain days and a lack of adjustments for call-ins or one-on-one care requirements. The Administrator was unaware of the Workforce Manager's lack of training and the resulting staffing concerns. The facility's policy on Activities of Daily Living (ADLs) was not followed, as residents did not receive care in accordance with accepted standards, their care plans, or their preferences. The deficiency was evident through observations, interviews, and record reviews, highlighting the facility's failure to provide adequate staffing and care for its residents.

Penalty

Fine: $36,335

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that call lights were functioning in all resident rooms, as evidenced by the non-functioning call lights in the rooms of two residents. An observation revealed that the call light in one resident's room was on but did not make any noise to alert staff. The resident confirmed that there were no call light cords in the room and that he had never had a bell to use. The LPN confirmed the issue and stated that a work order needed to be put in. Another observation showed that the call light cords were present but did not make any noise when activated. The LPN was unaware of the issue and stated that maintenance needed to be notified. The maintenance staff confirmed that they had not been made aware of the broken call light. Another resident confirmed that the staff responded when he called for them, but when he pressed his call light, it did not work. The treatment nurse present in the room confirmed the malfunction. The Administrator and DON confirmed that the call light would come on but not make any noise at the nurse's station, and a work order should have been submitted. The DON acknowledged that non-functioning call lights could lead to problems for residents if they are unable to call for help. Both residents involved were cognitively intact, as indicated by their BIMS scores of 13 on their respective MDS assessments.