Manhattan Community Care Center

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review the facility failed to provide needed care and services that would meet the resident's physical needs as evidenced by wound care not provided in one (1) of two (2) sampled residents with wounds. Resident #4. Findings include:Record review of the facility policy titled Wound Care Treatment Protocol (no review date) revealed the policy instructed staff to: Evaluate the wound daily for signs and symptoms of infection and for signs of healing. Document/Report Findings. Provide treatment as per physician's order.On 09/17/2025 at 9:22 AM, during an interview Resident #4 stated My wound care should be done every 3 days. It was done on 09/11/25 but not on 09/14/25. They just wipe it with wet gauze and cover it up. It's supposed to be irrigated with Dial soap. There's a doctor who sees wounds, but he's never looked at mine.Record review of Resident #4's electronic Treatment Administration Record (eTAR) for September 2025 revealed a physician order for treatment with a start date of 9/8/2025 Mupirocin External Ointment 2% Apply to left lateral ankle topically every day shift every (3) days for wound. Clean left lateral ankle with normal saline, pat dry, apply Mupirocin, cover with Mepilex every 3 days. The eTAR indicated wound care was provided on 09/11/2025, but not documented as provided on 09/14/2025, as evidenced by

the absence of staff initials in the designated treatment box for that date.On 09/17/2025 at 9:34, during an

interview the Director of Nursing (DON) revealed that the facility physician typically evaluates wounds, however, Resident #4 refuses the facility physician and instead is seen weekly at the Wound Clinic.On 09/17/2025 12:12 PM, in an interview Licensed Practical Nurse (LPN) #1/ Unit Manager reported that a as needed (PRN) order had been obtained for the prescribed wound care and that she administered the dressing on 09/15/2025. She added that the dressing she removed was not signed, dated, or timed, contrary to protocol.During an interview on 09/17/2025 at 3:15 PM, LPN #2/Treatment Nurse revealed that

she was unaware why the wound care was missed on 09/14/2025 and stated that she only works weekdays.During a joint interview on 09/18/2025 at 3:15 PM, the Administrator and Director of Nurses (DON) acknowledged that wound care had not been completed on 09/14/2025 and confirmed their understanding of the importance of adhering to physician orders.Record review of Resident #4's admission

Record revealed he was admitted to the facility on [DATE REDACTED] with diagnoses including Diabetes Mellitus, Non-pressure Chronic Ulcer of Unspecified Lower Limb, and Vascular Dementia. Record review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/22/2025 indicated in Section M the presence of a non-pressure ulcer. Section C indicated Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Manhattan Community Care Center

4540 Manhattan Rd Jackson, MS 39206

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Party (RP) and Primary Healthcare Provider were notified of the incident with safe wandering device bracelet orders received with bracelet applied on Resident #9 with orders for nurses to check placement and functioning every shift-9/8/25 at 3:15pm6. Head to toe body audit was conducted for Resident #9 on 9/8/25 at 3:20pm7. Temperature outside 9/8/25 at 3:00pm-clear and lower 80s8. Distance from front door 375 feet - 9/8/25On 9/08/25 nursing staff completed 100% head count of all residents not signed out on pass with all residents accounted forEmployee corrective counseling completed with former Receptionist on 9/9/25 at 8:00 am (Category 1 offence, employment terminated)100% At risk for elopement evaluations completed on all residents on 9/8/25 through 9/9/25100% in-service training started for all staff prior to working on - Elopement/Wandering, Abuse/Neglect, Behaviors, Adequate monitoring, Supervisioncompleted 9/09/25Safe wandering devices for all residents wearing them are checked every shift for placement and functioning on 9/8/25Elopement Drills were conducted on all shifts beginning on 9/8/25, 3:00 pm-11:00 pm (3-11) shift100% audit of elopement books completed on 9/8/25All doors checked for proper functioning on 9/8/25Security specialist contractor visited and checked doors for functioning on 9/9//25Quality Assurance (QA) Meeting attended by all key personnel, which included but not limited to Executive Director, Director of Nurses, Infection Preventionist and Medical Director was held 9/9/25 with root cause analysis conducted and interdisciplinary team developed strategy to prevent future elopement incidentsResident #9 to remain on 1:1 until discharge from facility; discharged [DATE REDACTED] at 1:10pmResident photos will be taken at the time of admission, regardless of elopement risk assessment results, and posted at the receptionist desk beginning 9/9/25The facility alleges all corrective actions were completed on 9/9/25 and the Immediate Jeopardy was removed on 9/10/25Monitoring included one-on-one monitoring/supervision of Resident #9 through discharge on [DATE REDACTED] and the Admissions Coordinator to monitor the communication board in the reception office to ensure the board's accuracy and currently with all new admissions' photographs posted; continued elopement assessments of all newly admitted residents at the time of admission by nursing staff; continued monitoring of positioning and functioning of safe wandering devices worn by residents at risk of elopement every shift by nursing staff; continued daily monitoring of the safe wandering system functionality by the maintenance director; review of and development of care plans for all newly admitted residents with family/resident to evaluate for history of wandering/elopement for three (3) months with monitoring results and corrective actions reviewed at QA meetings for three (3) months (first QA meeting held following incident was 9/09/25 with subsequent QA meeting held 9/18/25)On 09/18/25, SA validations were completed onsite during the complaint investigation through interviews, observations and record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on 09/10/25.

Event ID:

Facility ID:

If continuation sheet