Senatobia Healthcare & Rehab

F-F656) - Scope and Severity J. 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:

Review of the facility's policy Elopements and Wandering Residents reviewed 8/19/24 revealed, Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement .receive care

in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 9 255302 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255302 B. Wing 08/20/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Senatobia Healthcare & Rehab 402 Getwell Dr Senatobia, MS 38668

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 0656 Review of the facility's policy Comprehensive Care Plans undated, revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent Level of Harm - Immediate with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, jeopardy to resident health or nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . safety

Record review of the care plan for Resident #1, with a date initiated of 8/11/23 revealed Focus: I am an Residents Affected - Few elopement risk. Goal: I will not leave facility unattended through next review date (Target date 10/9/24). Interventions: Wander Guard to left ankle to notify staff to exit seeking. Check placement and function q shift .

During an interview on 8/19/24 at 10:05 AM, the Director of Nursing (DON) confirmed Resident #1 had been sitting unattended on the facility's front porch on 8/15/24, left the facility unsupervised and was located at the local grocery store at approximately 4:45 PM. She verified video surveillance footage indicated Resident #1 left the facility at 4:05 PM. She acknowledged a resident who is at risk for wandering/elopement should not have been left unattended and that staff should have been present with her.

During an interview on 8/19/24 at 10:15 AM, Certified Nursing Assistant (CNA) #2 stated Resident #1 wears

a Wandergaurd due to her risk of elopement. She mentioned that Resident #1 frequently sits outside on the porch unattended because she refuses to come back inside.

In an interview on 8/19/24 at 10:20 AM, Licensed Practical Nurse (LPN) #1 also confirmed that Resident #1 is at risk for elopement but often sits unattended on the facility's front porch.

An interview with the Minimum Data Set Nurse (MDS) on 8/19/24 at 12:27 PM, she verified that Resident #1's care plan was not followed when the resident was left on the front porch of the facility unsupervised and subsequently exited the premises unnoticed.

Record review of the Admission Record revealed Resident #1 was admitted to the facility on [DATE REDACTED] with diagnoses that included Cerebral Vascular Accident.

Record review of Resident #1's Quarterly Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 7/15/24 revealed a Brief Interview of Mental Status (BIMS) score of 14 , indicating that the resident is cognitively intact. Section P-Restrains and Alarms revealed An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected. This section was code that an alarm was used daily.

The facility submitted the following removal plan:

On 8/15/24 at approximately 4:15 PM, a passerby notified Certified Nursing Assistant #1 (CNA) at that she observed an individual walking up the hill that she suspected to be a resident of the center. CNA #1 immediately came into the facility and notified the receptionist. A search by staff was initiated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 9 255302 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255302 B. Wing 08/20/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Senatobia Healthcare & Rehab 402 Getwell Dr Senatobia, MS 38668

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 0656 At approximately 4:20 PM on 8/15/24, the Center's Infection Control Preventionist got in her car to go off premises to look for Resident #1. Resident #1 was observed by the Infection Control Preventionist Level of Harm - Immediate approximately a quarter mile from the facility outside a local grocery store and successfully encouraged to jeopardy to resident health or get in the car on 8/15/24 at 4:24 PM. safety

On 8/15/24 at approximately 4:25 PM, Resident #1 returned to the facility. Residents Affected - Few

On 8/15/24 at 4:40PM, the Licensed Practical Nurse completed a body audit on the resident with no injuries noted.

Beginning 8/15/24 at 4:45 PM, Resident #1 was placed on hourly staff monitoring for 24 hours.

On 8/15/24 at approximately 5:00 PM, Licensed Nurses ensured all residents were in-house via visual

observation.

On 8/15/24 at approximately 5:30 PM, education was initiated by the Director of Nursing and a Registered Nurse Supervisor on the elopement prevention policy to include the provision that any resident at risk for elopement will receive ongoing staff supervision while outside the center for all staff. No staff will be allowed to work until in serviced.

The State Survey Agency and Attorney General's office was notified on 8/15/24 at 6:10 PM and 6:20 PM respectively by the interim Director of Nursing.

On 8/16/24 at approximately 3:30 PM, Resident #1, who is alert and oriented, was provided education by the Director of Nursing to notify staff anytime she wished to go outside or leave the center.

The Director of Nursing and a Registered Nurse Supervisor completed elopement risk assessments on all residents to determine their risk of leaving the center without adequate staff supervision on 8/16/24 at 4:00 PM.

On 8/16/24 at 5:15 PM, the Quality Assurance and Performance Improvement (QAPI) Committee attended by the Director of Nursing, the Medical Director via phone, Infection Control Preventionist, and the Nursing Home Administrator updated the facility's policy on Elopement Prevention to include any resident at risk for elopement would receive ongoing staff supervision while outside the center.

A new Nursing Home Administrator started 8/19/24 at 8:00 AM.

A Resident Council meeting was held on 8/19/24 at 3:30 PM, by the Activities Director to provide education to residents to notify their licensed nurse and to sign out prior to leaving the center.

On 8/19/24 beginning at approximately 4:00 PM, care plans on all residents at risk for elopement were reviewed and updates initiated by the Administrator and Minimum Data set (MDS) Coordinator to ensure

they reflect individualized interventions for those residents at risk for wandering and elopement.

On 8/19/24 at 4:00 PM, the Director of Nursing initiated education on importance of accuracy of care plan interventions related to wandering/elopement prevention to Minimum Data Set Nurses (MDS), Infection Control Preventionist, Registered Nurse Supervisors, and Medical Records Coordinator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 9 255302 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255302 B. Wing 08/20/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Senatobia Healthcare & Rehab 402 Getwell Dr Senatobia, MS 38668

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 0656 On 8/19/24 beginning at approximately 4:00 PM, a 100 percent (%) Care Plan audit was conducted by the Administrator and MDS Nurses with updates for current interventions made to care plans to ensure Level of Harm - Immediate compliance for residents at risk for elopement. jeopardy to resident health or safety On 8/19/24 at approximately 4:00 PM, Resident #1's care plan was updated by the MDS Coordinator with current interventions for elopement prevention. Residents Affected - Few

An Ad Hoc Quality Assurance meeting was held on 8/19/24 at 5:45 PM, to discuss the Immediate Jeopardy Removal Plan and corrective actions, interventions, and education to ensure compliance. As part of the Ad Hoc QAPI Meeting, in-service completion for both the all-staff education on the elopement prevention policy and the importance of accurate and effective care plan interventions related to wandering/elopement prevention education for the Interdisciplinary Team (IDT) was reviewed by the Administrator and QAPI Committee Members with further instruction that no staff will be allowed to work until in serviced. It was attended by the Medical Director, Director of Nursing, Infection Control Nurse, Administrator, and RN Supervisor.

All corrective actions were completed by 8/19/24 and the facility alleges removal of the Immediate Jeopardy (IJ) 8/20/2024.

Validation:

The State Agency (SA) validation of the Removal Plan was made on-site during the Complaint Investigation (CI) MS #26203 through record review and interviews on 8/20/24. The SA determined all corrective actions were completed on 8/19/24 and the IJ was removed on 8/20/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 9 255302 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255302 B. Wing 08/20/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Senatobia Healthcare & Rehab 402 Getwell Dr Senatobia, MS 38668

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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47158 safety Based on observation, staff and resident interviews, record reviews, facility policy reviews, and the facility's Residents Affected - Few investigation, the facility failed to provide adequate supervision to prevent Resident #1, who was identified as

an elopement and wandering risk from leaving the facility unnoticed and unsupervised for one (1) of three (3) residents reviewed for wandering. Resident #1.

The facility's failure to provide supervision resulted in Resident #1 being left on the front patio, where she subsequently exited the premises unnoticed and unsupervised. The resident was later found at a grocery store approximately 0.3 miles from the facility. Video surveillance footage revealed Resident #1 left the facility at 4:05 PM and was located at the grocery store at 4:25 PM.

The facility's failure to provide supervision to a resident who was at risk for wandering and elopement placed Resident #1, and all other residents at risk for wandering and elopement, in a situation that was likely to cause serious harm, serious injury, serious impairment or death.

The State Agency (SA) identified an Immediate Jeopardy (IJ), and Substandard Quality of Care (SQC) which began on 8/15/24 when Resident #1 eloped from the facility unsupervised.

The SA notified the facility's Administrator (ADM) of the IJ and SQC on 8/19/24 at 2:00 PM, and provided IJ templates to the ADM.

The facility submitted an acceptable Removal Plan on 8/20/24, in which they alleged all corrective actions to remove the IJ were completed on 8/19/24, and the IJ removed on 8/20/24.

The SA validated the Removal Plan on 8/20/24 and determined the IJ was removed on 8/20/24, prior to exit. Therefore, the scope and severity for 42 CFR: 483.25 (d)(1)(2)- Free of Accidents Hazards/Supervision/Devices (

F-F689) - Scope and Severity J. 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:

Review of the facility's policy Elopements and Wandering Residents revealed, Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .

Record review of the Wandering Risk Scale with an effective date of 4/27/24 revealed in Section E that Resident #1 Has history of wandering.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 9 255302 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255302 B. Wing 08/20/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Senatobia Healthcare & Rehab 402 Getwell Dr Senatobia, MS 38668

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 A review of the facility's investigation into the Elopement incident revealed that on 8/15/24, Resident #1 was allowed to sit on the facility's porch. At 4:16 PM, a staff member noticed that Resident #1 was missing from Level of Harm - Immediate her wheelchair that sat on the front porch. Simultaneously, a family member reported that a resident had jeopardy to resident health or been seen walking up the hill. A Code [NAME] (elopement) was immediately announced over the intercom, safety and staff began searching for the resident. The Infection Preventionist got into her vehicle and located the resident at a local grocery store at approximately 4:24 PM, 0.3 miles from the facility. Resident #1 was Residents Affected - Few unharmed, standing upright, and cooperative when asked to get into the vehicle and return to the facility. A full assessment revealed stable vital signs and no injuries. A review of the camera footage revealed Resident #1 left the porch at 4:05 PM. Resident #1's daughter was notified of the elopement at 4:43 PM, and she stated that her mother had a history of wandering and had done so in the past and that was the reason she had placed her in a nursing home.

On 8/19/24 at 10:05 AM, during an interview, the Director of Nursing (DON) confirmed that Resident #1 had been sitting unattended on the facility's front porch on 8/15/24, left the facility unsupervised and was located at the local grocery store at approximately 4:45 PM. She verified that video surveillance footage indicated Resident #1 left the facility at 4:05 PM. She acknowledged that a resident at risk for wandering/elopement should not have been left unattended and that staff should have been present with her.

On 8/19/24 at 10:15 AM, during interview Certified Nursing Assistant (CNA) #2 stated that Resident #1 wears

a Wandergaurd due to her risk of elopement. She confirmed that Resident #1 frequently sits outside on the porch unattended because she refuses to come back inside.

On 8/19/24 at 10:20 AM, during an interview with Licensed Practical Nurse #1 (LPN) stated Resident #1 is at risk for elopement but often sits unattended on the facility porch.

During an interview on 8/19/24 at 10:35 AM, Resident #1 recounted that on the afternoon of 8/15/24, she was sitting on the porch thinking about tobacco, which prompted her to walk to the store to buy some. She stated that she walked through parking lots without going near the street. She reported no injuries and said that staff eventually picked her up and brought her back to the facility.

On 8/19/24 at 1:30 PM, in an interview with the Front Office Receptionist, the receptionist stated on 8/15/24 at approximately 3:30 PM, she turned off the door alarm to allow Resident #1 to go out and sit on the front porch. She admitted that no staff accompanied Resident #1 and that in the past, Resident #1 had been allowed to go outside without staff supervision. She also mentioned that she was not monitoring Resident #1, and no one had asked her to do so.

On 8/19/24 at 1:35 PM, during an interview with the Infection Control Preventionist (ICP) she confirmed that

she was working in the front office on 8/15/24 and was unaware that Resident #1 was still outside. She stated that no one had asked her to monitor Resident #1. At approximately 4:10 PM to 4:15 PM, a CNA informed her that Resident #1's wheelchair was on the porch, but the resident was missing. She joined other staff in searching for the resident and found Resident #1 standing near a local grocery store, talking to an acquaintance. The resident was returned to the facility at around 4:25 PM, wearing a t-shirt, black leggings, non-skid socks, and a hair bonnet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 255302 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255302 B. Wing 08/20/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Senatobia Healthcare & Rehab 402 Getwell Dr Senatobia, MS 38668

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 On 8/19/24 at 1:51 PM, during a telephone interview CNA #1 reported she went outside during her break and

a resident's family member informed her that Resident #1 was walking up the street. She notified the Front Level of Harm - Immediate Office and Nursing Supervisor. This triggered a Code [NAME] (resident elopement). By the time she reached jeopardy to resident health or the grocery store, the nurse had already arrived, and Resident #1 was in her car. safety

On 08/19/24 at 3:00 PM, during an observation of the route from the facility to the location where Resident Residents Affected - Few #1 was found, the distance was determined to be 0.3 miles from the facility, mostly flat ground.

A record review of the weather report from the website https://www.localconditions.com/weather38668 revealed that on 8/15/24 it was 95 to 97 degrees from 3:35 PM to 4:35 PM.

Record review of the Admission Record revealed Resident #1 was admitted to the facility on [DATE REDACTED] with diagnoses that included Cerebral Vascular Accident.

Record review of Resident #1's Quarterly Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 7/15/24 revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating that the resident is cognitively intact. Section P-Restrains and Alarms revealed An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected. This section was coded that an alarm was used daily.

The facility implemented the following removal plan:

On 8/15/24 at approximately 4:15 PM, a passerby notified Certified Nursing Assistant #1 (CNA) at that she observed an individual walking up the hill that she suspected to be a resident of the center. CNA #1 immediately came into the facility and notified the receptionist. A search by staff was initiated.

At approximately 4:20 PM on 8/15/24, the Center's Infection Control Preventionist got in her car to go off premises to look for Resident #1. Resident #1 was observed by the Infection Control Preventionist approximately a quarter mile from the facility outside a local grocery store and successfully encouraged to get in the car on 8/15/24 at 4:24 PM.

On 8/15/24 at approximately 4:25 PM, Resident #1 returned to the facility.

On 8/15/24 at 4:40 PM, the Licensed Practical Nurse completed a body audit on the resident with no injuries noted.

Beginning 8/15/24 at 4:45 PM, Resident #1 was placed on hourly staff monitoring for 24 hours.

On 8/15/24 at approximately 5:00 PM, Licensed Nurses ensured all residents were in-house via visual

observation.

On 8/15/24 at approximately 5:30 PM, education was initiated by the Director of Nursing and a Registered Nurse Supervisor on the elopement prevention policy to include the provision that any resident at risk for elopement will receive ongoing staff supervision while outside the center for all staff. No staff will be allowed to work until in serviced.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 255302 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255302 B. Wing 08/20/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Senatobia Healthcare & Rehab 402 Getwell Dr Senatobia, MS 38668

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 The State Survey Agency and Attorney General's office was notified on 8/15/24 at 6:10 PM and 6:20 PM respectively by the interim Director of Nursing. Level of Harm - Immediate jeopardy to resident health or On 8/16/24 at approximately 3:30 PM, Resident #1, who is alert and oriented, was provided education by the safety Director of Nursing to notify staff anytime she wished to go outside or leave the center.

Residents Affected - Few The Director of Nursing and a Registered Nurse Supervisor completed elopement risk assessments on all residents to determine their risk of leaving the center without adequate staff supervision on 8/16/24 at 4:00 PM.

On 8/16/24 at 5:15 PM, the Quality Assurance and Performance Improvement (QAPI) Committee attended by the Director of Nursing, the Medical Director via phone, Infection Control Preventionist, and the Nursing Home Administrator updated the facility's policy on Elopement Prevention to include any resident at risk for elopement would receive ongoing staff supervision while outside the center.

A new Nursing Home Administrator started 8/19/24 at 8:00 AM.

A Resident Council meeting was held on 8/19/24 at 3:30 PM, by the Activities Director to provide education to residents to notify their licensed nurse and to sign out prior to leaving the center.

On 8/19/24 beginning at approximately 4:00 PM, care plans on all residents at risk for elopement were reviewed and updates initiated by the Administrator and Minimum Data set (MDS) Coordinator to ensure

they reflect individualized interventions for those residents at risk for wandering and elopement.

On 8/19/24 at 4:00 PM, the Director of Nursing initiated education on importance of accuracy of care plan interventions related to wandering/elopement prevention to Minimum Data Set Nurses (MDS), Infection Control Preventionist, Registered Nurse Supervisors, and Medical Records Coordinator.

On 8/19/24 beginning at approximately 4:00 PM, a 100 percent (%) Care Plan audit was conducted by the Administrator and MDS Nurses with updates for current interventions made to care plans to ensure compliance for residents at risk for elopement.

On 8/19/24 at approximately 4:00 PM, Resident #1's care plan was updated by the MDS Coordinator with current interventions for elopement prevention.

An Ad Hoc Quality Assurance meeting was held on 8/19/24 at 5:45 PM, to discuss the Immediate Jeopardy Removal Plan and corrective actions, interventions, and education to ensure compliance. As part of the Ad Hoc QAPI Meeting, in-service completion for both the all-staff education on the elopement prevention policy and the importance of accurate and effective care plan interventions related to wandering/elopement prevention education for the Interdisciplinary Team (IDT) was reviewed by the Administrator and QAPI Committee Members with further instruction that no staff will be allowed to work until in serviced. It was attended by the Medical Director, Director of Nursing, Infection Control Nurse, Administrator, and RN Supervisor.

All corrective actions were completed by 8/19/24 and the facility alleges removal of the Immediate Jeopardy (IJ) 8/20/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 255302 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255302 B. Wing 08/20/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Senatobia Healthcare & Rehab 402 Getwell Dr Senatobia, MS 38668

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 Validation:

Level of Harm - Immediate The State Agency (SA) validation of the Removal Plan was made on-site during the Complaint Investigation jeopardy to resident health or (CI) MS #26203 through record review and interviews on 8/20/24. The SA determined all corrective actions safety were completed on 8/19/24 and the IJ was removed on 8/20/24.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 255302