Every finding on record at Baptist Nursing Home-Calhoun, Inc

Based on staff and resident interviews, record reviews and facility policy review, the facility failed to provide treatment and services to prevent pressure ulcers for one (1) of four (4) residents reviewed for pressure ulcers. Resident #1. The facility failed to provide treatment and services to prevent pressure ulcers, specifically routine skin audits and documentation. Resident #1 acquired a pressure ulcer that was not identified until it progressed to a Stage 4 requiring treatment and antibiotics. The wound was discovered by a family member and brought to the facility's attention on 8/10/2026. Based on the facility implementation of corrective actions on 08/10/2026, the SA determined this to be Past Non-Compliance (PNC) and facility was in compliance as of 08/15/2026, prior to the SA entrance on 8/17/2026. Findings Include: A review of the facility's policy, titled Skin Care: Assessment and Prevention Policy, last revision 10/2025, revealed .Policy: It is the policy of [Proper Name of Facility] to provide an interdisciplinary, standardized approach to the assessment of skin, prevention of breakdown and management of wounds.2. Skin Inspection-.The Registered Nurse (RN) Supervisor will perform weekly skin inspections according to the weekly skin assessment schedule . A record review of the facility's investigation revealed on 8/10/26 at approximately 3:00 PM, Resident #1's Resident Representative (RR) called staff to her room reporting that the resident had blood on her pants. The Nurse Manager and Wound Care Nurse (WCN) assessed Resident #1 and she was noted to have a four (4) centimeter (cm) width by 4 cm length by two (2) cm depth Stage IV pressure ulcer to her right posterior hip area with 50% (percent) eschar, 25% granulation, 25% slough, and a moderate amount of serosanguineous drainage with a foul odor. Her primary care physician was notified, and new orders were received related to wound care. New orders were received for Levaquin 500 mg (milligrams) daily for seven (7) days for infection to the wound. The facility identified that the body audit documented on 8/7/26 by Nurse Manager (NM) #1 revealed a skin audit completed on 8/7/26 with no significant findings and intact skin. The Nurse Manager responsible for completing this assessment was suspended on 8/11/26 pending termination following the completion of the investigation. Record review of the wound assessment for Resident #1, dated 8/10/26, revealed Stage IV pressure wound that was described with having eschar, exposed fat layer, granulation, moist, reddened, sloughing that was measured to be (length) 4 cm x (width) 4 cm x (depth) 2 cm, with wound bed with 50% eschar, 25% slough, 25% granulation with moderate serosanguineous drainage with foul odor. Peri wound noted to have erythema. Record review of Medication Administration Record (MAR) revealed an order for Levaquin 500 mg by mouth nightly for 7 days was started on 8/10/26. Record review of the Advanced Wound Care assessment for Resident #1, dated 8/17/26, revealed Stage IV pressure injury-necrotic tissue flap is over a portion of wound and removed with debridement. Measurements of wound 3.5 cm length by 4.6 cm width, 3.5 cm depth with yellow slough and a large amount of foul yellow drainage noted.During an interview with the Administrator on 8/17/2026 at 10:30 AM, he verified that the Root Cause Analysis (RCA) was that the Nurse Manager #1 failed to do a complete an accurate skin assessment on 8/7/26 but documented no changes in Resident #1's skin. In an interview with the Director of Nursing (DON) on 8/17/26 at 10:30 AM, she explained that the Nurse Managers were responsible for completing weekly body audits on all residents on their unit. She verified that the pressure ulcer to Resident #1's right hip should have been identified prior to it reaching a Stage 4 and requiring antibiotics. During an interview with Resident #1 on 8/17/26 at 10:45 AM, she stated that the staff only perform skin audits on her feet. She denied that they had attempted to look at any other areas of her body. She verified that she had a wound to her right hip area but was unsure how long it had been there. A telephone interview with Nurse Manager #1 on 08/17/2026 at 11:56 AM, she verified that she charted No changes on the 8/7/26 weekly body audit. She further verified that the resident was standing in the bathroom at the time of the body audit, and she could not see the right side of the resident's body, so she did not assess it. In an interview with Resident #1's RR on 8/18/26 at 10:30 AM, she shared that on 8/1/26 while picking up Resident #1's laundry she noticed blood on the resident's pants. At that time the resident told her it was from going to the bathroom and the RR was initially concerned about the resident having a urinary tract infection (UTI), but she did not. She further revealed that the following week, on 8/10/26, when she picked up Resident #1's laundry she noticed blood again on her pants as well as on her bed sheets. She called staff to the room and upon looking at her skin they found a wound on the resident's right hip that was dark in color. The facility was unsure how long the wound had been there. Record review of the face sheet revealed that the facility admitted Resident #1 on 01/26/23 with diagnosis that included Congestive Heart Failure (CHF). Record review of the Minimum Data Set Assessment (MDS) with an Assessement Reference Date (ARD) of 6/18/2026 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident #1 was cognitively intact. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 8/17/26: On 08/10/2026 at 3:05 PM, the Wound Certified Licensed Practical Nurse (WCLPN) and Registered Nurse Manager (RNM) #1 went to Resident #1 room at the request of the Resident Representative (RR). RNM #1 accessed Resident #1 skin for sources of blood found on the resident's clothing. RNM #1 discovered a Stage 4 pressure ulcer on the resident's right hip. On 08/10/2026 at 3:26 PM, RNM #1 measured the pressure ulcer to be 4-centimeter (cm) x 4 cm x 2 cm and treatment order was received from Nursing Home Medical Staff Director (NHMSD) for Xeroform dressing to be changed daily and monitored for signs and symptoms of infection. WCLPN initiated the treatment. On 08/10/2026 at 3:30 PM, WCLPN notified the Director of Nursing (DON) of the findings on Resident #1. On 08/10/2026 at 3:35 PM, WCLPN called NMMC Wound Center and Hyperbarics and scheduled an appointment for Resident #1 on 08/17/2026 at 12:45 PM and RR was made aware of the appointment.On 08/10/2026 at 3:40 PM, DON notified the NHA of the findings on Resident #1. On 08/10/2026 at 3:45 PM, DON instructed RNM #1 to perform body audits on all residents on the North Nursing Unit. On 08/10/2026 at 4:00 PM, Resident # 1's care plan was updated by Care Plan Licensed Practical Nurse (CPLPN). On 08/10/2026 at 4:30 PM, DON notified the State Agency of the incident by telephone.On 08/10/2026 at 4:35 PM, DON notified the Attorney General's Office of the incident.On 08/10/2026 at 5:00 PM, NHMSD initiated Levaquin 500 milligram (mg) by mouth daily for 7 days and the RR was notified of the new order by WCLPN. On 08/11/2026 at 6:00 AM, Staff Development Specialist (SDS) initiated staff training for Registered Nursing (RN) and Licensed Practical Nursing (LPN) staff members on timely and accurate documentation and the reinforcement of expectations for comprehensive weekly body audits, and no RN or LPN will be allowed to work until in serviced. On 08/11/2026 at 11:04 AM, DON instructed RNM #1, RNM #2, and Registered Head Nurse (RHN) to perform body audits on all residents on the North Nursing Unit. On 08/11/2026 at 2:50 PM, DON and Human Resources Representative (HRR) placed RNM #1 on an investigatory suspension. Initial process for termination started for RNM #1.On 08/11/2026 at 3:41 PM, Registered Dietitian (RD) consulted Resident #1 addressing dietary needs. Physician orders received for Vitamin C daily for 30 days and Zinc twice daily for 14 days.On 08/12/2026 at 3:30 PM, 46 body audits were completed on all residents on the North Nursing Station with no new findings. On 8/14/2026 at 1:32 PM, order was placed by WCLPN for a pressure relieving air flow mattress for Resident #1. Mattress was inflated and placed on bed. On 8/14/2026 at 3:00 PM, Ad hoc Quality Assurance (QA) meeting was held to review the deficient practice that led to the development of a pressure ulcer on Resident #1. A Root Cause Analysis (RCA) indicated the event was associated with the failure to consistently perform and document comprehensive body audits with an opportunity for improved documentation practices and staff accountability. The Skin Care Assessment and Prevention Policy and the Resident Rights Policy were reviewed and no revisions were recommended. Attendees were the NHA, NHMSD, DON, ADON, WCLPN, RNM 2, SDS, RD, HRR, Performance Improvement Coordinator LPN (PICLPN), Restorative Licensed Practical Nurse (RLPN), Infection Control Nurse Manager (ICNM), and Risk Manager (RM). On 08/14/2026 at 4:00 PM, a QA monitoring tool was created to ensure compliance and accuracy of body audits. The DON or the Assistant Director of Nursing (ADON) will conduct random body audits on two residents per hallway per week for a total of 10 residents. These audits will be compared to the previous skin audit conducted by Registered Nursing staff members. This monitor will assess compliance with skin assessment procedures through the audits for the next three months and will be reported in monthly QAPI meetings starting with the August meeting. On 08/14/2026 at 4:25 PM, DON sent an email reporting the incident to the State Agency via email.On 08/14/2026 at 4:37 PM, DON sent an email reporting the incident to the Ombudsman. Validation: The State Agency (SA) validation of the corrective actions was made on-site during the Complaint Investigation through record review and interviews on 8/17/26 through 8/19/26. The SA determined all corrective actions were completed on 8/14/2026 and the facility was in compliance on 8/15/2026 prior to the SA entrance on 8/17/26.

Based on staff interviews, record review, review of Quality Assurance and Performance Improvement (QAPI) documentation, facility investigation review, and facility policy review, the facility failed to measure the success of corrective actions and track performance to ensure improvements were sustained when the QAPI Committee failed to review monitoring required by a previous Plan of Correction involving unauthorized photographs or video recordings of residents during two (2) of four (4) quarterly QAPI meetings reviewed. The deficient practice had the potential to affect all 96 residents residing in the facility.Findings included:Record review of the facility policy, Quality Assurance and Performance Improvement (QAPI) revealed, Purpose.Feedback, Data Systems and Monitoring: [Proper Name of Facility] will put in place systems to monitor care and services, drawing data from multiple sources. Feedback systems will actively incorporate input from staff, elders, families and others who are appropriated. It will use performance indicators to monitor a wide range of care process and reviewing the findings against benchmarks and goals set by the facility. The QAPI team at [Proper Name of Facility] will decide what date to monitor routinely. A review of the facility's Plan of Correction from a previous survey finding on 7/30/25, involving unauthorized photographs/video recordings of residents, revealed the facility implemented monitoring activities to ensure corrective actions were sustained. The Plan of Correction required audits related to staff cellular telephone use, resident grievances/complaints, and abuse training. The facility's Plan of Correction specified that audit results would be reviewed through QAPI. QAPI meetings were to occur monthly for three months, every two months for six months, and quarterly thereafter.A review of the facility's QAPI documentation from August 2025 through July 2026 revealed the facility initially reviewed the required monitoring through QAPI; however, the QAPI documentation for the April 2026 and July 2026 months of the monitoring period did not contain evidence that the required audit results were reviewed by the QAPI Committee.During an interview with the Quality Improvement Nurse ([NAME]) on 8/19/26 at 10:00 AM, she verified the QAPI meeting minutes for the April 2026 and July 2026 did not document review of the audits required by the previous Plan of Correction. She further verified that the facility had no additional monitoring or auditing process in place to ensure the corrective actions related to unauthorized photographs/video recordings, and resident privacy remained effective and sustained after the monitoring process was discontinued.A review of the facility's current investigations involving Resident #3 and Resident #4 revealed the same type of deficient practice subsequently recurred when staff again used personal cellular telephones to photograph and/or video record residents. The facility's investigation determined the facility failed to protect residents' rights to privacy and confidentiality.

Based on staff and resident interviews, facility investigation review and facility policy review, the facility failed to ensure residents' rights to privacy and confidentiality were protected for two (2) of six (6) residents reviewed for Resident's Rights. Resident # 3 and Resident #4Findings included:Review of the facility's policy titled Your Rights and Protections as a Nursing Home Resident revealed, What are my rights in a nursing home? As a nursing home resident, you have certain rights and protections under Federal and state law that help ensure you get the care and services you need. You have the right. to have your personal information kept private. Be Treated with Respect: You have the right to be treated with dignity and respect.Review of the facility policy titled Wireless/Cellular Telephones: Use and Management Policy, revealed Policy: [Proper name of facility] encourages it's employees to use wireless/cellular phones in an appropriate and safe manner.Guidelines: D. Employees are not permitted to use a camera, including one built into a wireless/cellular phone to take any photograph within a facility.Review of the facility's Employees Handbook page 31 of 44 revealed: .Recording Devices and Cameras, revealed, Team members are not permitted to use cameras, camera phones, tape recorders, or other recording devices on duty or while on (name of facility) premises conducting official business unless such use has been approved by management. Accordingly, team members are prohibited from secretly recording, videotaping, or taking pictures of others. Such conduct is grounds for disciplinary action up to and including termination of employment. A review of the facility's investigation revealed that on 07/22/26, at approximately 6:30 PM, the Nursing Home Administrator was notified that Human Resources had received a complaint alleging two Certified Nursing Assistants (CNA) recorded a resident using a cellular telephone. The investigation identified that CNA #2 used CNA #1's personal cellular telephone to record Resident #4. CNA #1 reported the recording remained on her personal telephone until she returned home later that evening and deleted it. CNA #1 further reported that her boyfriend at the time may have viewed the recording before she deleted it.Further review of the facility investigation revealed CNA #2 disclosed that, within approximately the previous two months, she had also taken a photograph of Resident #3 holding a baby doll because she wanted the photograph for memories and thought it was cute.A record review of a written statement dated 07/22/26 and signed by CNA #1 revealed that she documented that Resident #4 was sitting in a recliner when CNA #2 used CNA #1's telephone camera to make the video. CNA #1 documented that the video showed Resident #4's face and that Resident #4 was talking and laughing. CNA #1 further documented that her boyfriend may have seen the video before she deleted it from her telephone.A record review of a written statement dated 07/22/26 and signed by CNA #2 revealed that she had documented that she had possessed a recording of Resident #3 kissing her baby doll.An interview with the Administrator and Director of Nursing (DON) on 08/18/26 at 1:30 PM, revealed they verified the facility's investigation determined the facility failed to protect residents' rights to privacy and confidentiality when the CNAs took photographs and video recordings of residents.Record review of the face sheet revealed that the facility admitted Resident #3 on 9/23/22 with diagnosis of Unspecified Dementia.Record Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/28/26 revealed a Brief Interview for Mental Status (BIMS) score of six (6) which indicated severely impaired cognition.Record review of the face sheet revealed that the facility admitted Resident #4 on 3/1/24 with diagnosis of chronic kidney disease. Record Review of the MDS, with an ARD of 7/27/26 revealed a BIMS score of 15 which revealed that the resident is cognitively intact.

Based on observation, resident and staff interviews, and record review, the facility failed to ensure clinical records were complete and accurately documented for two (2) of five (5) residents reviewed for clinical record accuracy. Resident #1 and Resident #2 Findings included: Record review of a statement on company letterhead, signed by the Administrator and dated 8/19/26, revealed that the facility did not have a policy regarding accurate documentation. Resident #1A record review of the facility's investigation revealed on 8/10/26 at approximately 3:00 PM Resident #1's Resident Representative (RR) called staff to her room reporting that the resident had blood on her pants. The Nurse Manager and Wound Care Nurse (WCN) assessed Resident #1 and she was noted to have a four (4)-centimeter (cm) width by 4 cm length x two (2) cm depth Stage IV pressure ulcer to her right posterior hip area with 50% (percent) eschar, 25% granulation, 25% slough, and a moderate amount of serosanguineous drainage with a foul odor. The facility identified that the body audit documented on 8/7/26 by Nurse Manager (NM) #1 was not completed in its entirety despite documentation indicating completion. The skin audit completed on 8/7/26 documented no significant findings and intact skin.In an interview with the Administrator on 08/17/2026 at 10:31 AM, he verified that the Root Cause Analysis (RCA) was that the Nurse Manager #1 failed to do a complete an accurate skin assessment on 08/07/2026 but documented no changes in Resident #1's skin. He further agreed that the documentation was not accurate.On 8/17/26 at 10:31 AM during an interview with the Director of Nursing (DON), she explained that the Nurse Managers were responsible for completing weekly body audits on all residents on their unit.In a telephone interview with Nurse Manager #1 on 08/17/2026 at 11:57 AM, she verified that she charted No changes on the 8/7/26 weekly body audit but the resident was standing in the bathroom at the time of the body audit, and she could not see the right side of the resident's body, so she did not assess it. She agreed that this documentation was not accurate as she had not assessed the resident's entire body.Record review of the face sheet revealed that the facility admitted Resident #1 on 01/26/2023 with diagnosis that included Congestive Heart Failure (CHF).Record review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 6/18/2026 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident #1 was cognitively intact.Resident #2Observation and interview of Resident #2 on 8/17/26 at 10:51 AM, revealed an intact dressing to his left wrist area dated 8/15/26. The dressing was noted to have a moderate amount of light greenish drainage outlined on the dressing. Continued observation of Resident #2 revealed a non-intact dressing on his left outer leg, also dated 8/15/26. Resident #2 shared that his dressings are supposed to be changed every day, but they did not do it yesterday because they changed nurses.Record review of the Medication Administration History dated 8/1/26 through 8/18/26, for Resident #2 revealed an order for an abrasion to left lower extremity (LLE), clean with wound cleanser, pat dry, apply Aquacel AG and cover with a dry dressing daily as well as an order for treatment to left forearm (LFA), clean weeping areas with wound cleanser, pat dry, cover with Aquacel AG, wrap with gauze daily.In a telephone interview with LPN #1, on 8/19/2026 at 9:03 AM, she verified that when signing off the medications she had given, she also signed off the treatment although she had not done it. She stated she had intended to go back and change the dressing but forgot. She agreed that treatments should not be signed off until they are completed and this constitutes inaccurate documentation.In an interview and further review of the Medication Administration History with Licensed Practical Nurse (LPN) #1 on 8/17/2026 at 10:58 AM, she verified that documentation on 8/16/26 revealed that the treatment was performed and confirmed that she had not completed the wound care. She confirmed that not performing wound care as ordered could cause a wound infection or worsening of the wound.An interview with the Director of Nursing (DON) on 8/97/26 at 9:05 AM, she verified that the documentation was not accurate and it was her expectation that the nurse would not sign off the treatment until it was performed.Record review of the face sheet revealed that the facility admitted Resident #2 on 7/28/21 with diagnosis that included Chronic Obstructive Pulmonary Disease.Record review of the MDS with an ARD of 5/28/26 revealed a BIMS score of 15, indicating that Resident #2 was cognitively intact.

Based on observations, interviews, record reviews and policy and procedure reviews, the facility did not follow established infection control procedures for the transportation, handling, and disturbing of dirty and clean linens. The facility used the public laundry and transported the dirty and clean linens in the facility van that was for resident use without cleaning the van/bus before and after each use. The facility also used public washing machines without cleaning them before and after each use and for not using hot water temperatures in accordance with infection control policies and procedures. The deficient practice had the potential to affect 93 of 93 residents living in the facility and all staff.Findings Include:The facility policy titled: Laundry Services undated, read: To assure a clean supply of linens and to protect employees who handle and process the laundry. Soiled linen should be handled as little as possible and with a minimum of agitation to prevent gross microbial contamination of the air and of persons handling the linen. All linens should be stored and transported in carts used exclusively for this purpose, or in linen carts that have been decontaminated after being used for soiled laundry. Dirty linen should be clearly separated from areas where clean linen is handled. Linens should be washed with a detergent in water hotter than 160 degrees Fahrenheit (F) for 25 minutes since this is an effective method for cleaning and for killing most vegetative bacteria.Observation and interview on 08/25/25 at 11:45 AM with the Director of Nursing (DON) confirmed that the facility laundry department had three (3) broken washing machines. DON toured the facility laundry with the State Agency (SA) and stated that they had been transporting the facility laundry to the public laundry facility in the local town. The laundry staff were placing the dirty facility linens in the facility's resident transport van/bus and taking the linens to be washed and dried and transported back to the facility in the resident transport van/bus. DON stated that there were three (3) commercial high temperature washing machines located in the facility laundry and that all three (3) were broken. The DON confirmed that the nursing home facility was located next to the community hospital and emergency room (ER) and there was only one laundry department that the hospital and the nursing home shared. The three (3) commercial washing machines were used to wash all the linens for the nursing home, the community hospital, and the ER. Therefore, since all three (3) commercial washers were broken and un-usable the laundry staff have to transport the linens for all the nursing home, the community hospital and the ER to the local public laundry facility for washing and drying. DON stated that the maintenance department had attempted to repair the washing machines, but the correct parts had not been obtained to do the repairs. Observation was made in the laundry area that there were three (3) commercial high temperature washing machines that had signs attached to all three (3) Out of Order. The DON stated that the commercial washing machines were over [AGE] years old and probably needed to be replaced. DON stated that to her knowledge the facility had been using the local public laundry facility for washing the facility's linens for approximately two (2) weeks.On 08/25/25 at 12:00 PM an interview with the Maintenance Director revealed that the facility had no way of repairing the washing machines without the proper parts and that the parts were ordered and the wrong part was sent, and they had to re-order and he had no timeframe of when the repairs would be completed. Maintenance Director confirmed that all three washing machines were broken down and unusable and stated, I don't know how it happened, probably because they are worn out. Interview on 08/25/25 at 12:40 PM with Licensed Practical Nurse (LPN) #1 confirmed that Resident #1 was on contact isolation because of Extended-spectrum Beta-Lactamase (ESBL) which required contact isolation. LPN #1 confirmed that Resident #1 had to have all linens and personal clothing placed in red bags for infectious waste and washed separately from all other residents' linens and clothing. Interview on 08/25/25 at 1:00 PM with Registered Nurse (RN) #2 revealed that Resident #3 was on contact precaution due to Carbapenem-resistant Pseudomonas aerogenesis (CRPA) of the urine. Record review of the facility roster matrix dated 08/25/2025 revealed that two (2) residents, Resident #1 and Resident #3, were documented as being placed on Transmission-Based Precautions (TBP). Interview on 08/25/25 at 1:15 PM with the Laundry Director revealed that she has been loading the linens into the facility's resident transport van/bus and transporting the dirty linens to the public laundry facility and washing them in the public washing machines and dryers and transporting them back to the facility. She sorts the laundry in the facility laundry department and places the dirty towels and bed linens inside of plastic bags and then puts them in the van and drives the dirty linen to the public laundry facility. She confirmed that she does not disinfect the van/bus and does not place any type of barrier down inside of the van/bus when transporting the dirty linens or the clean linens. Laundry Director confirmed that she does not disinfect the public washing machines prior to use and does not disinfect after use and had no way to monitor the temperature to ensure that the washer water temperature had to reach a minimum of 160-degree F in order for the detergent to break down and sanitize the linens. Laundry Director stated that the first facility commercial high temperature washing machine had been broken for approximately three (3) weeks and then approximately two (2) weeks ago the second and third facility high temperature commercial washing machines broke down, leaving them without washing machines. Laundry Director stated that all resident clothes and all red bags were washed in the facility in the small household washing machine and those were not taken to the public facility. Laundry Director stated that the small household washing machine located in the facility laundry department had no temperature gages and she had never used a thermometer to take the hot water temperature.

Based on resident interviews, staff interviews, record reviews, observations, policy and procedure reviews, local county sheriff's report and interview, and review of the social media video, the facility failed to ensure that the rights of Resident #1 to have respect and dignity were honored when two Certified Nursing Assistants (CNAs) taunted, threatened and abused Resident #1 and posted the videos to social media. Resident #1 was one (1) of three (3) residents that were reviewed for Resident Rights. The evening of 07/22/25 two (2) facility Certified Nursing Assistants (CNA)'s posted a video to social media in which they taunted, threatened and abused Resident #1. The video was seen by the community and the family of the resident.The facility's failure to ensure the right to be treated with dignity placed Resident #1 and other residents at risk in a situation that has caused and is likely to cause serious injury, serious harm, serious impairment, or death. The SA identified Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 07/22/25. The SA notified the facility's Administrator of the IJ and SQC on 07/29/25 at 3:00 PM and provided the Administrator with the IJ templates. The facility provided an acceptable Removal Plan on 7/29/25, in which the facility alleged all corrective actions were completed to remove the IJ on 7/29/25 and the IJ removed on 7/30/25.The SA determined the IJ was removed on 7/30/25, prior to exit, and the scope and severity for CFR S483.10(a)(1) Resident Rights (F550) was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Cross Reference F600Findings Include:Review of the facility's undated policy titled Your Rights and Protections as a Nursing Home Resident read: What are my rights in a nursing home? As a nursing home resident, you have certain rights and protections under Federal and state law that help ensure you get the care and services you need. You have the right. to have your personal information kept private. Be Treated with Respect: You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose.Be Free from Abuse and Neglect: You have the right to be free from verbal, sexual, physical, and mental abuse. Record review of the facility policy titled HIPPA Sanctions Policy dated and revised 06/25 revealed, The Health Insurance Portability and Accountability Act of 1996 (HIPPA) requires that covered entities have and apply appropriate sanctions against members of their workforce who fail to comply with privacy policies and procedures of the covered entity, or the requirements of the HIPPA Security Rule. Accordingly, it is the intention of (name of facility) to ensure the confidentiality and integrity of protected health information as required by law and professional ethics.Review of the facility policy titled Photographing, Videotaping, Video imaging and/or Audiotaping Policy last revised 3/23 revealed, .Patient identifiable information is any piece of information which can potentially be used to identify, contact, or locate an individual. This includes demographic information, voice audio, facial images, or any unique characteristic of an individual. Photographic images are considered protected health information and are not limited to images of the face. Additionally, any characteristic that could uniquely identify the individual is protected health information. Purpose: To protect the patient's dignity and comply with federal and state privacy laws. Patient Authorization Required. Patient authorization is obtained prior to all photography.Review of the facility's Employees Handbook page 30 of 43 revealed: .Recording Devices and Cameras Team members are not permitted to use cameras, camera phones, tape recorders, or other recording devices on duty or while on (name of facility) premises conducting official business unless such use has been approved by management. Accordingly, team members are prohibited from secretly recording, videotaping, or taking pictures of others. Such conduct is grounds for disciplinary action up to and including termination of employment. Record review of the facility investigation and observation of the video footage revealed that on 07/23/25 at approximately 6:40 AM the facility Director of Nursing (DON) was notified by a resident of the local community that there was a video of Resident #1 posted on social media the evening of 07/22/25. The DON immediately began investigating the incident and she obtained a copy of the video which identified Resident #1 and two (2) Certified Nursing Assistants (CNA#1) and (CNA #2). The local law enforcement was notified of the incident, and they also began an investigation. The DON obtained handwritten statements from CNA #1 and CNA #2 and determined through investigation that CNA #1 and CNA #2 had posted videos of Resident #1 on social media without the permission of Resident #1 and/or her Responsible Parties (RP's). The video revealed that CNA #1 and CNA #2 were taunting, threatening and teasing Resident #1 while she was lying in bed, which lead to Resident #1 becoming agitated and upset. The video revealed that CNA #1 threatened Resident #1 with biting her and that she would be sent to Geri psych. CNA #1 was heard on the video asking Resident #1 if she had ever been bitten and if she did not behave she would bite her. The video showed that CNA #1 slapped the back of Resident #1's upper right arm and sat on Resident #1's bed on top of her lower legs. Resident #1 could be heard saying that she was hurting her legs and to get off her. During the entire video CNA #2 could be heard laughing as if she was video taping the events. It was determined through the facility investigation that the video of Resident #1 was taken in her room while she was in her bed at a time between 4:30-5:00 PM on 07/22/2025. The investigation revealed that the unauthorized video was posted to the social media platform by the two (2) facility CNA's and was later shared with other employees of the facility and then it eventually was shared with the family members of other residents in the facility, which lead to the violation of the residents' rights. In viewing the video, it was visible that Resident #1 was upset by the abuse and taunting and was heard on the video cussing the two CNAs as both were laughing at Resident #1.Record review of the facility's documentation of the incident titled: Report of Violation Under Mississippi Vulnerable Adult Act completed and signed by the facility's DON and dated 07/25/25. The report revealed: On July 23, 2025, at approximately 6:40 A.M., a video was received of (CNA #1) assigned to (Resident #1), appearing to upset her. The CNA tapped (Resident #1) on her right arm. The audio is not clear on the video, but laughing can be heard. (CNA #2) admitted during the investigation interview that she was the one that recorded the video. (CNA #2) posted the video on a private story on her (social media) page and tagged approximately six (6) people in it for viewing. (Resident #1) can be seen in the video lying in her bed in (room #). The video was screen recorded by someone and has now spread throughout the community. (Resident #1's) Resident Representative (RR#1) was notified and he voiced that him and his family had plans to come to the facility concerning the matter. (Resident #1's) family arrived at the facility on 07/23/25 at approximately 8:15 A.M. upset and showed staff members a copy of the video on their personal cell phone. The (local county Sheriff's Department) was notified and arrived at the facility to speak with the family and staff members concerning the incident. The two CNAs involved (CNA #1 and CNA#2) were arrested by (local county Sheriff's officer) on July 24, 2025, with pending charges of abuse. (Resident #1) is an [AGE] year-old female admitted to (name of facility) on April 27, 2021, per the services of (name of physician) due to dementia with behavioral disturbances. Resident #1 has a BIMS (Brief Interview of Mental Status) score of 3 indicating severe cognitive impairment. She is usually able to make her needs known and she usually understands others. She is non-ambulatory. She uses a staff propelled wheelchair for mobility. She requires two-person extensive assistance with bed mobility, personal hygiene, bathing, and dressing. She's incontinent with bowel and bladder. The report was dated 07/25/25 and signed by the DON. On 07/29/25 at 9:15 AM during an interview with the Nursing Home Administrator (NHA) he confirmed that two (2) facility CNA's (CNA #1 and CNA#2) had been terminated from the facility for the abuse of Resident #1. He stated that on 07/22/25 at or around 4:30 PM the two CNA ‘s video taped Resident #1 during delivery of care in her room and then posted the video to social media on the evening of 07/22/2025. The NHA stated that the county Sheriff arrested the two CNAs and charged them with abuse of a Vulnerable Adult. In an interview with the DON on 07/29/25 at 9:30 AM she confirmed that she obtained hand-written statements from the two (2) CNA's (CNA #1 and CNA #2) and that they had admitted to her through their statements that they did not view their interactions with Resident #1 as abuse. They stated that they were just playing with Resident #1 and that they were video taping her for her family to have memories of her. The CNAs stated that they should not have posted the video to social media but had only posted it to their private story and invited six (6) guests to view it. They had not thought that the video would be re-posted by others on various other social media platforms. The DON stated that the county Sheriff had arrested the two CNAs for abuse of a Vulnerable Adult and that they had spent the night in jail. The local news station also reported the incident as abuse of a Vulnerable Adult. The DON stated that the family came to the facility on [DATE] at approximately 8:15 AM and they were very upset that the video of Resident #1 was posted on social media the evening of 07/22/2025. The DON first learned about the video and abuse of Resident #1 at approximately 6:40 AM on 07/23/2025. On 07/29/2025 at 10:15 AM an observation and interview with Resident #1 revealed a bed bound resident lying in her bed, aroused easily when spoken to, but confused. Resident #1 was alert to self and able to answer simple questions. Resident #1 was able to tell surveyor her correct date of birth . Resident was oriented to her name but was not oriented to place and time. Resident #1 presented as having dementia. Interview on 07/29/2025 at 11:00 AM with the Quality Assurance Director (QAD) revealed that she had no knowledge of the incident with Resident #1 on 07/22/25 and it was discussed on 07/23/25 that a couple of the CNAs had video taped her during care. QAD stated that all staff are in-serviced and trained that they should never have their phones out during care and that it is a violation of the residents rights to do that and especially to post it on social media.During an interview by telephone on 07/29/2025 at 1:20 PM with Resident Representative (RR#1) revealed that he was contacted on 07/22/2025 at approximately 7:30 PM by his grandson and told that there was a video of Resident #1 posted on social media. RR#1 stated that he had no knowledge of what (proper name of social media) was or how to view it on his cell phone and his grandson sent him the video of Resident #1 being abused by two (2) CNA's. RR#1 stated that this was very upsetting to him and his family. RR#1 stated that RR#2 was most upset about the posting of the video and the abuse of Resident #1. RR#1 stated that he came to the facility on [DATE] to talk to the staff about Resident #1 and to get an explanation as to why this video was posted on social media. RR#1 stated that he received numerous phone calls from all over the community and out of state to tell him that there was a video of Resident #1 posted on social media. RR #1 stated that he felt that Resident #1 had been abused by the two (2) CNAs seen on the video. RR #1 stated that the two (2) CNAs seen on the video with Resident #1 were arrested by the county Sheriff's office for abuse of Resident #1. RR #1 stated that the posting of the video was very embarrassing to his family and to Resident #1. On 07/29/2025 at 1:55 PM an interview with RR#2 revealed that she had worked at the facility for many years and had retired from that facility. RR#2 stated that she had placed Resident #1 at the facility in 2021 because she was of the impression that she would be safe and treated well. RR#2 stated that she was very upset over the abusive way the two CNAs had treated Resident #1 on the video. RR#2 stated that she felt that if they were comfortable enough to record and post videos of abuse of Resident #1, she just wonders how long they have been doing this and to who else. RR#2 stated that on 07/23/2025 she went to her mother's room to assess her and to look at her legs and feet where the CNA #1 had sat on her. RR#2 stated that Resident #1 had a dark bruise on her right ankle. RR #2 stated that she felt that the bruise was a result of CNA #1 sitting on top of her in her bed as seen on the video. On 07/29/2025 at 2:00 PM during an interview with the County Sheriff Deputy that arrested the two (2) CNAs revealed that he arrested CNA #1 and CNA #2 for simple assault of a Vulnerable Adult. He stated that CNA #1 and CNA #2 had been placed in jail overnight and the next day they posted bail and obtained attorneys. The Deputy Sheriff provided the surveyors with a copy of the Sheriff's report dated 07/24/2025. The Deputy Sheriff confirmed that he obtained written statements from the two (2) CNAs while they were in custody, and it would be shared with the grand jury for criminal charges. The record review of the Minimum Data Set (MDS) dated [DATE] Section C-Cognitive Patterns documented that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3 which indicated that she was severely cognitively impaired. Section G-Functional Status of the MDS dated [DATE] documented that Resident #1 was a two (2) person assist for Activities of Daily Living (ADL) Assistance. The record review of the handwritten statement of CNA #1 that she gave to the facility DON revealed that CNA #1's written statement was very different from what was viewed on the video and posted on social media. CNA #1's handwritten statement that she gave to the facility's DON and was signed by CNA #1 and dated 7/23/2025 revealed: On July 22nd appr. 4:30 or no later than I took (name of Resident #1) to put her to bed. She was very combative holding on to the walls I then had to tell her it was time for her to go to bed before the other shift came. I then had to strap her on the lift, and she was refusing She punched me multiple times in doing so I was replying stop hitting me and you have to go to bed She replied with she is not going to bed. I then put her in her bed, and she was hanging on to the lift so me and (name of another staff) proceeded to remove her hands. I stated multiple times if she didn't stop she was going to hurt herself She was cussing and fighting I was trying to change her when she grabbed me by my hair. I got away from her and proceeded with the care. She then still didn't let me pull off her clothes so I then tricked her into letting me get them off when she realize I was trying to clean her she became combative again I then was changed her in a hurry and I was trying to sit her up in bed when she continued to hit me she stated Do you wanna fight I then begin to play with her and gave her a little playful tap on the shoulder after the situation was done She looked at me and said I love you sister, will you come back to sit with me I gave her a hug and told her I would see her Friday and that was the last time we talked till I picked up her supper tray and even then we were so nice to each other. Signed by CNA #1 and dated 07/23/2025 and placed in the DON's investigation. Record review of the handwritten statement given to the DON by CNA #2 and dated 7/23/2025 revealed: This is (name of CNA #2) statement. I take full responsibility for the video that's been brought to your attention. I made a huge mistake by violating HIPPA but also my resident rights. The video that was seen was a misunderstanding. As we were only playing with her I could see how it looked on the outside. This is something we're used to. When (name of Resident #1) doesn't wanna lay down she cusses, throws fits, hits everything. This was something we were used to, so we never really paid any mind. I never charted her bad behavior; I didn't see it that way because it would only be when it was time to lay down. Then she does have a touch of dementia she didn't know what she was doing, she just knew she didn't want to go to bed. But to help night shift we try to lay as many people down before they come in. Just to kind of help. In the video you do hear her cussing (CNA #1) out and hitting her, you do see (CNA #1) messing/playing with her back. This was something they often did. It was never any physical or verbal abuse. We shouldn't be playing with residents I'm aware. But it was never out of anger or anything. We just got so comfortable with her a grew a tight bond with her. She became one of our favorite residents, which I love them all and I do love my job. I made a very terrible mistake, and I truly am sorry. I am willing to prove and do anything to show whoever that this wasn't a case of abuse in any type of way. She shouldn't have been recorded I am aware and own up to my wronging. But I wouldn't allow any abuse in my presence. I didn't look at it being abuse because this something we was so use to happening. It was just a mistake and misunderstanding. Anybody in the facility could tell you we wouldn't hurt anyone and we love everyone. We did inform a nurse that was their about her hitting and cussing. I am truly sorry for what it looked like but abuse in any way wasn't the case. The date the video was taking was on July 22nd approx. after 4PM to 5ish. Handwritten statement signed by CNA #2 and dated 7/23/25 and placed in the DON's investigation. Record review of the County Sheriff's Report revealed that on 07/24/2025 CNA #1 and CNA #2 were arrested for Abuse/Neglect of A Vulnerable Adult and Exploitation of Vulnerable Adult. The narrative written on the sheriff's report read: On July 24, 2025, (name of county Sheriff's office) received a report of a (Proper name of social media) video going around that showed two health care workers assaulting an elderly female at the (name of the facility). In the video, you can see that a health care worker was in the patient's room while the other worker was videoing it. After reviewing the video, it showed that the health care worker hit the female patient. The workers were identified as (CNA #2 and CNA #1). (Name of Sheriff's Deputy interviewed both suspects. Both suspects admitted to the allegations, and both wrote out a statement. Both individuals were arrested and charged. The SA was unable to interview CNA #1 and CNA #2 because both had obtained lawyers and would not speak to us during the time the SA was investigating the abuse case.Review of the Removal Plan revealed that the facility took the following actions: The removal plan below is provided in response to the Immediate Jeopardy (IJ) received on 7/29/2025. The State Agency notified the facility administrator of the IJ on 7/29/2025. Brief Description: On July 22, 2025, at 4:30 PM, the facility failed to prevent staff from exploiting and abusing Resident #1 by allowing staff to record and share video footage on their phones of demeaning, degrading content involving the resident by staff members that were assigned to care for her in the facility. The video was posted to a social media platform where the family saw the video footage of the event. Immediate Action started on July 23, 2025, at approximately 6:40 AM: On 7/23/2025 at 6:37 AM, Director of Nursing (DON) was notified by an external source about a video of Resident #1 was posted on a social media platform. On 7/23/2025 at 6:37 AM, DON notified Nursing Home Administrator (NHA). On 7/23/2025 at 7:18 AM, Assistant Director of Nursing (ADON) received a call from NHA requesting to initiate reporting. On 7/23/2025 at 7:49 AM, ADON spoke with DON to discuss the process of reporting to State and AG. On 07/23/2025 at 8:08 AM, ADON reported the incident to MS Department of Health. On 7/23/2025 at 8:18 AM, ADON reported the incident to the Attorney General. On 7/23/2025 at 8:18 AM, ADON notified Responsible Party (RP). On 7/23/2025 at 8:30 AM, ADON and Staff Development Specialist (SDS) performed full body assessment of Resident #1. The findings were this nurse performed a full body audit that was completed per protocol. Elder's skin assessed from head to toe, including behind the ears, under the breast, axillae, abdomen, groin, back and all extremities. No bruising or lacerations noted. Elder has no wounds. Elder's skin is warm, dry and intact. Elder is alert to self only and talkative. Word salad noted. Elder tolerated assessment without distress. On 7/23/2025 at 8:45 AM, SDS continued to complete full body assessments and interviews of all residents under the care of the staff in question. No negative assessments or outcomes were found. On 7/23/2025 at 9:00 AM, Resident #1's family arrived at facility and met with ADON, Risk Manager (RM), Human Resources Manager (HRM), Licensed Social Worker (LSW), and Head Nurse (HN). On 7/23/2025 at 9:05 AM, Police Department notified. On 7/23/2025 at 9:35 AM, Chief of Police arrived at facility. On 7/23/2025 at 10:03 AM, ADON notified Ombudsmen. On 7/23/2025 at 10:49 AM, ADON notified Primary Care Provider (PCP). On 7/23/2025 at 2:30 PM, LSW discussed with Ombudsmen. On 7/23/2025 at 3:07 PM, Certified Nursing Assistant (CNA) #1 suspended and terminated on 7/23/2025. On 7/23/2025 at 3:47 PM, CNA #2 suspended and terminated on 7/23/2025. On 7/23/2025 at 4:30 PM, SDS began in-services on HIPAA, Reporting Abuse, Cell phone usage, and Vulnerable Adult Policy until 100% is completed. No staff will be allowed to work until in serviced. On 7/28/2025 at 9:30 AM, Psychiatric Mental Health Nurse Practitioner (PMHNP) evaluated Resident #1 for psychosocial harm. No issues were identified. On 7/29/2025 at 4:20 PM, an emergency QAPI meeting was held to review the immediate jeopardy related to Residents Rights and Abuse and exploitation and review policies and procedures for changes. Attendees were NHA, Nursing Home Medical Staff Director (NHMSD), DON, ADON, Quality Improvement Officer (QIO), Care Plan Nurse (CPN), SDS, HRM, and RM. Policies were reviewed and changes were made to the Quality Assurance and Performance Improvement Policy. The policy update included holding emergency meetings to discuss reportable events during the investigation time frame. The facility alleged that all corrective actions were completed on 7/29/2025, and the IJ removed as of 7/30/2025. The State Agency (SA) validation of the Removal Plan was made on 7/30/25 through interviews, observations, record reviews, and policy and procedure reviews. The SA determined all corrective actions were completed on 7/29/25 by the facility and the IJ was removed on 7/30/25.

Based on staff interviews, observations, resident interviews, record reviews, policy and procedure reviews, video review, and sheriff's arrest report review, the facility failed to protect Resident #1's right to be free from abuse when staff created a video during care of the resident, of verbal and physical abuse, of the resident and posted it to social media. Resident #1 was one (1) of three (3) residents reviewed for Abuse and Neglect. The evening of 07/22/25 two (2) facility Certified Nursing Assistants (CNA)'s posted a video to social media in which they taunted, threatened and abused Resident #1. The video was seen by the community and the family of the resident.The facility's failure to ensure the right to be free from abuse placed Resident #1 and other residents at risk for abuse and neglect in a situation that has caused and is likely to cause serious injury, serious harm, serious impairment, or death. The SA identified Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 07/22/25. The SA notified the facility's Administrator of the IJ and SQC on 07/29/25 at 3:00 PM and provided the Administrator with the IJ templates. The facility provided an acceptable Removal Plan on 7/29/25, in which the facility alleged all corrective actions were completed to remove the IJ on 7/29/25 and the IJ removed on 7/30/25.The SA determined the IJ was removed on 7/30/25, prior to exit, and the scope and severity for CFR S483.12(a)(1) Freedom from Abuse, Neglect, and ExploitationF600 was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Cross Reference F550Findings Include:Review of the facility policy titled: Abuse last review/revision 04/25, revealed, .It is the policy of (name of facility) that this facility prohibits mistreatment, neglect, or abuse of residents. The residents must not be subjected to abuse by anyone. The resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion. Major Types of Elder Abuse: Physical Abuse. Exploitation.Psychological Abuse: The infliction of mental anguish, as with insults, swearing, or threats;.Verbal Abuse refers to any oral, written, or gestured language that includes disparaging and derogatory terms to residents. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment, and deprivation. The term abuse is used in its broadest sense and refers to lack of courtesy, teasing, threatening, or overly vigorous restraint of a resident. Review of the facility policy titled Photographing, Videotaping, Video imaging and/or Audiotaping Policy last revised 3/23 revealed, .Patient identifiable information is any piece of information which can potentially be used to identify, contact, or locate an individual. This includes demographic information, voice audio, facial images, or any unique characteristic of an individual. Photographic images are considered protected health information and are not limited to images of the face. Additionally, any characteristic that could uniquely identify the individual is protected health information. Purpose: To protect the patient's dignity and comply with federal and state privacy laws. Patient Authorization Required. Patient authorization is obtained prior to all photography.Review of the facility's Employees Handbook page 30 of 43 revealed: .Recording Devices and Cameras Team members are not permitted to use cameras, camera phones, tape recorders, or other recording devices on duty or while on (name of facility) premises conducting official business unless such use has been approved by management. Accordingly, team members are prohibited from secretly recording, videotaping, or taking pictures of others. Such conduct is grounds for disciplinary action up to and including termination of employment. Record review of the facility investigation and observation of the video footage revealed that on 07/23/25 at approximately 6:40 AM the facility Director of Nursing (DON) was notified by a resident of the local community that there was a video of Resident #1 posted on social media the evening of 07/22/25. The DON immediately began investigating the incident and she obtained a copy of the video which identified Resident #1 and two (2) Certified Nursing Assistants (CNA#1) and (CNA #2). The local law enforcement was notified of the incident, and they also began an investigation. The DON obtained handwritten statements from CNA #1 and CNA #2 and determined through investigation that CNA #1 and CNA #2 had posted videos of Resident #1 on social media without the permission of Resident #1 and/or her Responsible Parties (RP's). The video revealed that CNA #1 and CNA #2 were taunting, threatening and teasing Resident #1 while she was lying in bed, which lead to Resident #1 becoming agitated and upset. The video revealed that CNA #1 threatened Resident #1 with biting her and that she would be sent to Geri psych. CNA #1 was heard on the video asking Resident #1 if she had ever been bitten and if she did not behave she would bite her. The video showed that CNA #1 slapped the back of Resident #1's upper right arm and sat on Resident #1's bed on top of her lower legs. Resident #1 could be heard saying that she was hurting her legs and to get off her. During the entire video CNA #2 could be heard laughing. It was determined through the facility investigation that the video of Resident #1 was taken in her room while she was in her bed at a time between 4:30-5:00 PM on 07/22/2025. The investigation revealed that the unauthorized video was posted to the social media platform by the two (2) facility CNA's and was later shared with other employees of the facility and then it eventually was shared with the family members of other residents in the facility. In viewing the video, it was visible that Resident #1 was upset by the abuse and taunting and was heard on the video cussing thetwo CNAs as both were laughing at Resident #1.Record review of the facility's documentation of the incident titled: Report of Violation Under Mississippi Vulnerable Adult Act completed and signed by the facility's DON and dated 07/25/25. The report revealed: On July 23, 2025, at approximately 6:40 A.M., a video was received of (CNA #1) assigned to (Resident #1), appearing to upset her. The CNA tapped (Resident #1) on her right arm. The audio is not clear on the video, but laughing can be heard. (CNA #2) admitted during the investigation interview that she was the one that recorded the video. (CNA #2) posted the video on a private story on her (social media) page and tagged approximately six (6) people in it for viewing. (Resident #1) can be seen in the video lying in her bed in (room #). The video was screen recorded by someone and has now spread throughout the community. (Resident #1's) Resident Representative (RR#1) was notified and he voiced that he and his family had plans to come to the facility concerning the matter. (Resident #1's) family arrived at the facility on 07/23/25 at approximately 8:15 A.M. upset and showed staff members a copy of the video on their personal cell phone. The (local county Sheriff's Department) was notified and arrived at the facility to speak with the family and staff members concerning the incident. The two CNAs involved (CNA #1 and CNA#2) were arrested by (local county Sheriff's officer) on July 24, 2025, with pending charges of abuse. (Resident #1) is an [AGE] year-old female admitted to (name of facility) on April 27, 2021, per the services of (name of physician) due to dementia with behavioral disturbances. Resident #1 has a BIMS (Brief Interview for Mental Status) score of 3 indicating severe cognitive impairment. She is usually able to make her needs known and she usually understands others. She is non-ambulatory. She uses a staff propelled wheelchair for mobility. She requires two-person extensive assistance with bed mobility, personal hygiene, bathing, and dressing. She's incontinent with bowel and bladder. The report was dated 07/25/25 and signed by the DON. In an interview with the Nursing Home Administrator (NHA) on 07/29/25 at 9:15 AM he confirmed that two (2) facility CNA's (CNA #1 and CNA#2) had been terminated from the facility on 7/23/25 for the abuse of Resident #1. He stated that on 07/22/25 at or around 4:30 PM the two CNA ‘s video taped Resident #1 during delivery of care in her room and then posted the video to social media on the evening of 07/22/2025. The NHA stated that the county Sheriff arrested the two CNAs and charged them with abuse of a Vulnerable Adult. On 07/29/25 at 9:30 AM in an interview with the DON she confirmed that she obtained hand-written statements from the two (2) CNA's (CNA #1 and CNA #2) and that they had admitted to her through their statements that they did not view their interactions with Resident #1 as abuse. They stated that they were just playing with Resident #1 and that they were video taping her for her family to have memories of her. The CNAs stated that they should not have posted the video to social media but had only posted it to their private story and invited six (6) guests to view it. They had not thought that the video would be re-posted by others on various other social media platforms. The DON stated that the county Sheriff had arrested the two CNAs for abuse of a Vulnerable Adult and that they had spent the night in jail. The local news station also reported the incident as abuse of a Vulnerable Adult. The DON stated that the family came to the facility on [DATE] at approximately 8:15 AM and they were very upset that the video of Resident #1 was posted on social media the evening of 07/22/2025. The DON first learned about the video and abuse of Resident #1 at approximately 6:40 AM on 07/23/2025. In an interview on 07/29/25 at 10:00 AM with the Assistant Director of Nursing (ADON) it was revealed that she was working on 07/22/2025 and had gone into Resident #1's room around 4:30 PM to talk to CNA #1 about a full-time position at the facility. ADON stated that she did not see any abuse occurring at that time and had no knowledge of the incident until she was told about it on the next day 07/23/2025. ADON stated that CNA #1 and CNA #2 both had been working at the facility for close to a year and she stated that she hated to think about what occurred to the resident just moments after she left the room from talking to CNA #1 regarding swapping from part time to full time.Observation and interview on 07/29/2025 at 10:15 AM with Resident #1 revealed a bed bound resident lying in her bed, aroused easily when spoken to, but confused. Resident #1 was alert to self and able to answer simple questions. Resident #1 was able to tell surveyor her correct date of birth . Resident was oriented to her name but was not oriented to place and time. Resident #1 presented as having dementia. Interview by telephone on 07/29/2025 at 1:20 PM with Resident Representative (RR#1) revealed that he was contacted on 07/22/2025 at approximately 7:30 PM by his grandson and told that there was a video of Resident #1 posted on social media. RR#1 stated that he had no knowledge of what (proper name of social media) was or how to view it on his cell phone and his grandson sent him the video of Resident #1 being abused by two (2) CNA's. RR#1 stated that this was very upsetting to him and his family. RR#1 stated that RR#2 was most upset about the posting of the video and the abuse of Resident #1. RR#1 stated that he came to the facility on [DATE] to talk to the staff about Resident #1 and to get an explanation as to why this video was posted on social media. RR#1 stated that he received numerous phone calls from all over the community and out of state to tell him that there was a video of Resident #1 posted on social media. RR #1 stated that he felt that Resident #1 had been abused by the two (2) CNAs seen on the video. RR #1 stated that the two (2) CNAs seen on the video with Resident #1 were arrested by the county Sheriff's office for abuse of Resident #1. RR #1 stated that the posting of the video was very embarrassing to his family and to Resident #1. Interview on 07/29/2025 at 1:55 PM with RR#2 revealed that she had worked at the facility for many years and had retired from that facility. RR#2 stated that she had placed Resident #1 at the facility in 2021 because she was of the impression that she would be safe and treated well. RR#2 stated that she was very upset over the abusive way the two CNAs had treated Resident #1 on the video. RR#2 stated that she felt that if they were comfortable enough to record and post videos of abuse of Resident #1, she just wonders how long they have been doing this and to who else. RR#2 stated that on 07/23/2025 she went to her mother's room to assess her and to look at her legs and feet where the CNA #1 had sat on her. RR#2 stated that Resident #1 had a dark bruise on her right ankle. RR #2 stated that she felt that the bruise was a result of CNA #1 sitting on top of her in her bed as seen on the video. Interview on 07/29/2025 at 2:00 PM with the County Sheriff Deputy that arrested the two (2) CNAs revealed that he arrested CNA #1 and CNA #2 for simple assault of a Vulnerable Adult. He stated that CNA #1 and CNA #2 had been placed in jail overnight and the next day they posted bail and obtained attorneys. The Deputy Sheriff provided the surveyors with a copy of the Sheriff's report dated 07/24/2025. The Deputy Sheriff confirmed that he obtained written statements from the two (2) CNAs while they were in custody, and it would be shared with the grand jury for criminal charges. The record review of the Minimum Data Set (MDS) dated [DATE] Section C-Cognitive Patterns documented that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3 which indicated that she was severely cognitively impaired. Section G-Functional Status of the MDS dated [DATE] documented that Resident #1 was a two (2) person assist for Activities of Daily Living (ADL) Assistance. The record review of the handwritten statement of CNA #1 that she gave to the facility DON revealed that CNA #1's written statement was very different from what was viewed on the video and posted on social media. CNA #1's handwritten statement that she gave to the facility's DON and was signed by CNA #1 and dated 7/23/2025 revealed: On July 22nd appr. 4:30 or no later than I took (name of Resident #1) to put her to bed. She was very combative holding on to the walls I then had to tell her it was time for her to go to bed before the other shift came. I then had to strap her on the lift, and she was refusing She punched me multiple times in doing so I was replying stop hitting me and you have to go to bed She replied with she is not going to bed. I then got her in her bed, and she was hanging on to the lift so me and (name of another staff) proceeded to remove her hands. I stated multiple times if she didn't stop she was going to hurt herself She was cussing and fighting I was trying to change her when she grabbed me by my hair. I got away from her and proceeded with the care. She then still didn't let me pull off her clothes so I then tricked her into letting me get them off when she realize I was trying to clean her she became combative again I then was changed her in a hurry and I was trying to sit her up in bed when she continued to hit me she stated Do you wanna fight I then begin to play with her and gave her a little playful tap on the shoulder after the situation was done She looked at me and said I love you sister, will you come back to sit with me I gave her a hug and told her I would see her Friday and that was the last time we talked till I picked up her supper tray and even then we were so nice to each other. Signed by CNA #1 and dated 07/23/2025 and placed in the DON's investigation. Record review of the handwritten statement given to the DON by CNA #2 and dated 7/23/2025 revealed: This is I (name of CNA #2) statement. I take full responsibility for the video that's been brought to your attention. I made a huge mistake by violating HIPPA but also my resident rights. The video that was seen was a misunderstanding. As we were only playing with her I could see how it looked on the outside. This is something we're used to. When (name of Resident #1) doesn't wanna lay down she cusses, throws fits, hits everything. This was something we were used to, so we never really paid any mind. I never charted her bad behavior; I didn't see it that way because it would only be when it was time to lay down. Then she does have a touch of dementia she didn't know what she was doing, she just knew she didn't want to go to bed. But to help night shift we try to lay as many people down before they come in. Just to kind of help. In the video you do hear her cussing (CNA #1) out and hitting her, you do see (CNA #1) messing/playing with her back. This was something they often did. It was never any physical or verbal abuse. We shouldn't be playing with residents I'm aware. But it was never out of anger or anything. We just got so comfortable with her a grew a tight bond with her. She became one of our favorite residents, which I love them all and I do love my job. I made a very terrible mistake, and I truly am sorry. I am willing to prove and do anything to show whoever that this wasn't a case of abuse in any type of way. She shouldn't have been recorded I am aware and own up to my wrongings. But I wouldn't allow any abuse in my presence. I didn't look at it being abuse because this something we was so use to happening. It was just a mistake and misunderstanding. Anybody in the facility could tell you we wouldn't hurt anyone and we love everyone. We did inform a nurse that was their about her hitting and cussing. I am truly sorry for what it looked like but abuse in any way wasn't the case. The date the video was taking was on July 22nd approx. after 4PM to 5ish. Handwritten statement signed by CNA #2 and dated 7/23/25 and placed in the DON's investigation. Record review of the County Sheriff's Report revealed that on 07/24/2025 CNA #1 and CNA #2 were arrested for Abuse/Neglect of A Vulnerable Adult and Exploitation of Vulnerable Adult. The narrative written on the sheriff's report read: On July 24, 2025, (name of county Sheriff's office) received a report of a Snapchat video (social media) going around that showed two health care workers assaulting an elderly female at the (name of the facility). In the video, you can see that a health care worker was in the patient's room while the other worker was videoing it. After reviewing the video, it showed that the health care worker hit the female patient. The workers were identified as (CNA #2 and CNA #1). Sheriff's Deputy's interviewed both suspects. Both suspects admitted to the allegations, and both wrote out a statement. Both individuals were arrested and charged. The SA was unable to interview CNA #1 and CNA #2 because both had obtained lawyers and would not speak to us during the time the SA was investigating the abuse case.Review of the Removal Plan revealed that the facility took the following actions: The removal plan below is provided in response to the Immediate Jeopardy (IJ) received on 7/29/2025. The State Agency notified the facility administrator of the IJ on 7/29/2025. Brief Description: On July 22, 2025, at 4:30 PM, the facility failed to prevent staff from exploiting and abusing Resident #1 by allowing staff to record and share video footage on their phones of demeaning, degrading content involving the resident by staff members that were assigned to care for her in the facility. The video was posted to a social media platform where the family saw the video footage of the event. Immediate Action started on July 23, 2025, at approximately 6:40 AM: On 7/23/2025 at 6:37 AM, Director of Nursing (DON) was notified by an external source about a video of Resident #1 was posted on a social media platform. On 7/23/2025 at 6:37 AM, DON notified Nursing Home Administrator (NHA). On 7/23/2025 at 7:18 AM, Assistant Director of Nursing (ADON) received a call from NHA requesting to initiate reporting. On 7/23/2025 at 7:49 AM, ADON spoke with DON to discuss the process of reporting to State and Attorney General (AG). On 07/23/2025 at 8:08 AM, ADON reported the incident to MS Department of Health. On 7/23/2025 at 8:18 AM, ADON reported the incident to the Attorney General. On 7/23/2025 at 8:18 AM, ADON notified Responsible Party (RP). On 7/23/2025 at 8:30 AM, ADON and Staff Development Specialist (SDS) performed full body assessment of Resident #1. The findings were this nurse performed a full body audit that was completed per protocol. Elder's skin assessed from head to toe, including behind the ears, under the breast, axillae, abdomen, groin, back and all extremities. No bruising or lacerations noted. Elder has no wounds. Elder's skin is warm, dry and intact. Elder is alert to self only and talkative. Word salad noted. Elder tolerated assessment without distress. On 7/23/2025 at 8:45 AM, SDS continued to complete full body assessments and interviews of all residents under the care of the staff in question. No negative assessments or outcomes were found. On 7/23/2025 at 9:00 AM, Resident #1's family arrived at facility and met with ADON, Risk Manager (RM), Human Resources Manager (HRM), Licensed Social Worker (LSW), and Head Nurse (HN). On 7/23/2025 at 9:05 AM, Police Department notified. On 7/23/2025 at 9:35 AM, Chief of Police arrived at facility. On 7/23/2025 at 10:03 AM, ADON notified Ombudsmen. On 7/23/2025 at 10:49 AM, ADON notified Primary Care Provider (PCP). On 7/23/2025 at 2:30 PM, LSW discussed with Ombudsmen. On 7/23/2025 at 3:07 PM, Certified Nursing Assistant (CNA) #1 suspended and terminated on 7/23/2025. On 7/23/2025 at 3:47 PM, CNA #2 suspended and terminated on 7/23/2025. On 7/23/2025 at 4:30 PM, SDS began in-services on HIPAA, Reporting Abuse, Cell phone usage, and Vulnerable Adult Policy until 100% is completed. No staff will be allowed to work until in serviced. On 7/28/2025 at 9:30 AM, Psychiatric Mental Health Nurse Practitioner (PMHNP) evaluated Resident #1 for psychosocial harm. No issues were identified. On 7/29/2025 at 4:20 PM, an emergency QAPI meeting was held to review the immediate jeopardy related to Residents Rights and Abuse and exploitation and review policies and procedures for changes. Attendees were NHA, Nursing Home Medical Staff Director (NHMSD), DON, ADON, Quality Improvement Officer (QIO), Care Plan Nurse (CPN), SDS, HRM, and RM. Policies were reviewed and changes were made to the Quality Assurance and Performance Improvement Policy. The policy update included holding emergency meetings to discuss reportable events during the investigation time frame. The facility alleged that all corrective actions were completed on 7/29/2025, and the IJ removed as of 7/30/2025. The State Agency (SA) validation of the Removal Plan was made on 7/30/25 through interviews, observations, record reviews, and policy and procedure reviews. The SA determined all corrective actions were completed on 7/29/25 by the facility and the IJ was removed on 7/30/25.

Based on staff interviews, record review and facility policy review, the facility failed to protect the resident's right to be free from sexual abuse for one (1) of 20 residents on the Special Care Unit. Resident #56. Resident #56 was found on 4/24/25 at approximately 3:00 PM, by a Certified Nursing Assistant (CNA) with Resident #16 in the bed and on top of her, with his hand inside her incontinence brief, performing jabbing motions. Resident #16 became violent with the staff when they tried to remove him from Resident #16's room where he hit a staff member with his fist. The facility's failure to prevent the sexual abuse of Resident #56 placed Resident #56 and other residents at risk for sexual assault, in a situation that caused and was likely to cause serious injury, serious harm, serious impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 11/05/24 when Resident #16 began to exhibit sexual behaviors towards staff and the facility did not implement interventions to prevent further sexual behaviors. The SA notified the facility's Administrator of the IJ and SQC on 4/30/25 at 1:20 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on 5/02/25, in which they alleged all corrective actions to remove the IJ and SQC were completed on 5/1/25, and the IJ removed on 5/2/25. The SA validated the Removal Plan on 5/05/25 and determined the IJ and SQC was removed on 5/2/25, prior to exit. Therefore, the scope and severity for 42 CFR: 483.12 (a)(1)- Free from Abuse, Neglect and Exploitation (F600), was lowered from a scope and severity of 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. Cross Reference F609, F656 Findings Include: Record review of the facility policy Abuse and or Suspected Crimes Reporting Under the Elder Justice Act, last reviewed 3/24 revealed, .Sexual abuse includes .sexual assault . It is the policy of [Proper Name of Facility] that all residents will be free from physical, mental, and/or verbal abuse . Record review of the facility investigation revealed that on 4/24/25 at approximately 3:00 PM, a Certified Nursing Assistant (CNA) was walking down the hall and saw Resident #16 on top of Resident #56 in an inappropriate manner. Both residents were clothed. The CNA called for assistance from other staff to remove Resident #16 from Resident #56's bed. Upon assessment by the Registered Nurse (RN), Resident #56 was noted to have scratches on her upper legs and scratches and bruising on her labia. The CNA reported that Resident #16's hand was down inside Resident #56's diaper, and he was making a jabbing motion with his hand. Record review of the Default Flowsheet Data for Resident #56, under Genitourinary on 4/24/25 at 4:13 PM, documented scratches, skin discoloration, and slight edema noted to the labia; maroon/purple and pale overall paleness; maroon/purple bruising noted to the left thigh; maroon/purple bruising with yellow outer edges noted to the left lateral eyebrow; and scratches noted to the left thigh and bilateral outer labia with bruising and redness to both areas. Record review of the Nursing Note for Resident #56, dated 4/29/25, written by Licensed Practical Nurse (LPN) #2 revealed a late entry for 4/24/25 that stated, This nurse alerted by CNA to come to elder's room. When this nurse entered room, observed a male elder on top of this female elder, both were fully clothed, male elder refuses to get off of female elder and required 2 (two) more CNA to assist, male elder becomes violent and punches one of the CNAs in the nose, male elder removed from this elder's room and taken back to his room with supervision. [Proper Name of Administrator] aware . Social Worker (SW) aware and she talked to family, and [Proper Name of Physicians] aware per this nurse . Record review of the Nursing Note for Resident #16, dated 4/24/25, documented that a CNA doing a visual check observed the elder in a female elder's room on top of her. The clothes were intact. When attempts were made to remove this elder, he became violent and punched a CNA in the nose. He was returned to his room, and supervision was provided at his doorway to maintain the female resident's safety. In an interview with CNA #3 on 4/29/25 at 10:45 AM, she stated that on the afternoon of 4/24/25, she came out of another resident's room and heard a commotion. She saw staff going into Resident #56's room, so she followed and saw Resident #16 lying on top of Resident #56. Both residents were fully dressed, and Resident #16 had his hand up Resident #56's pants leg. She said staff were attempting to remove him and he became agitated, hitting a CNA in the face. She stated it took about four staff members to remove him. CNA #3 further stated that Resident #16 frequently makes inappropriate statements about wanting sex and has grabbed CNAs between their legs, but she had never seen him attempt to touch another resident in this way. She said CNAs usually take two people when giving him care and try to discourage his behavior, but that he still grabs staff between their legs. After the incident, he was taken to his room, and the CNAs on duty conducted visual checks, but he was not on 1:1 supervision. At some point, he came out of his room and was in the dining area making sexual statements in front of other residents, so they returned him to his room. In an interview with the Administrator on 4/29/25 at 12:50 PM, he stated that on 4/24/25 at approximately 3:20 PM, he was notified by LPN #2 that Resident #16 was found on top of Resident #56, and he called for a Registered Nurse (RN) to assess her. He stated that at that time he was not informed that Resident #16 had his hands in Resident #56's brief. He stated that the resident's responsible party was notified by the Social Worker, and the physician was also notified. He verified that he reported the incident online to the Attorney General's Office. The Administrator stated that staff working the unit were instructed to supervise Resident #16 until he was transferred to the geriatric hospital on the afternoon of 4/25/25. He verified that no other residents were assessed for signs of abuse at that time and no other body audits were performed. The Administrator confirmed that this is a memory care unit that both Resident #56 and Resident #16 reside on. In an interview with RN #3 on 4/30/25 at 9:15 AM, she stated that on 4/24/25 around 4:00 PM, she was called to assess Resident #56 after Resident #16 was found on top of her. Resident #56 was noted to have irregularly shaped scratches and bruising on her left thigh, approximately the size of a quarter, bruising to her left eye, and scratches and bruising on both sides of her labia. She stated she notified the Administrator and Social Worker of her finding in the body audit. In an interview with CNA #6, #7, and #8 on 4/30/25 at 10:00 AM, they all stated that Resident #16 has a history of touching and grabbing staff's private parts and making comments like give me that p**** in front of other residents. They stated they had never seen him attempt to touch other residents, but he does touch staff and that he makes inappropriate sexual comments to other residents. They said that after the incident on 04/24/25, while Resident #16 was in the dining area on 4/25/25, he was fondling himself, making sexual gestures at female residents, and making inappropriate sexual statements, after which he was returned to his room. In an interview with LPN #3 on 4/30/25 at 10:15 AM she stated that Resident #16 has always exhibited aggressive verbal sexual behaviors. He makes sexual gestures toward anyone who walks by and says things like I want your p****. She stated he grabs CNAs during Activity of Daily Living (ADL) care and masturbates in common areas. She said that on the morning of 4/25/25, she was instructed to keep him under supervision in the dining room, but he continued to display inappropriate sexual behaviors. Although he was returned to his room, he is ambulatory and would come right back out. She added that he wanders and walks around the unit and, if his roommate is in the bathroom, he will go into other resident's room to use the restroom. In a telephone interview with CNA #2 on 4/30/25 at 2:00 PM, she confirmed that on the afternoon of 4/24/25, she was returning from filling the ice cart and saw Resident #16 on top of Resident #56 with his hand under her pants, fondling her forcefully. She stated that she witnessed Resident #56 lying on her back with her hands shaking and held over her head and face, while Resident #16 held her down forcefully with his left arm. CNA #2 yelled for help, and three other CNAs came. They physically removed Resident #16, who was aggressive, agitated, and combative, hitting and kicking at staff. She stated he hit her, CNA #3, in the face with his fist. After much effort, the staff removed him from Resident #56's bed and returned him to his room for supervision. She described him as violent and said he has always made sexual statements and grabbed staff. In a telephone interview with LPN #2 on 4/30/25 around 2:30 PM, she stated she was called to Resident #56's room on the afternoon of 4/24/25 and witnessed Resident #16 on top of Resident #56. Both were clothed, and she did not see his hand in her brief. She confirmed Resident #16 had a history of inappropriate sexual verbalizations, but she had not seen him touch other residents. She verified she notified the Administrator. In a telephone interview with the Psychiatric Nurse Practitioner (NP) on 5/1/25 at 10:15 AM, she stated that the staff keep her updated on Resident #16's behaviors and notify her if he has any increases. She verified that Resident #16 had inappropriate sexual behaviors and had an increase of these behaviors in November of last year and at that time his Depakote was increased on 11/4/25. During a further record review of the medical record for Resident#16 the notes below were revealed: Record review of Nursing Note for Resident #16 dated 11/5/24 revealed elder has inappropriate behaviors of groping at staff .sexually inappropriate behaviors, regularly touch his genitalia in public . Record review of Psychiatric Progress Note and Case Conceptualization note for Resident #16 dated 11/7/24 completed by Nurse Practitioner, revealed a diagnosis of Dementia. Review of the Case Conceptualization note revealed His Depakote was recently increased due to increase in inappropriate behaviors Record review of Psychiatric Progress Noted for Resident #16 dated 1/9/25 completed by Nurse Practitioner, revealed Staff reports that patient continues to exhibit inappropriate sexual behaviors . Record review of Social Work note, for Resident #16 dated 2/3/25 revealed Elder made eye contact with the Social Worker and made sexual statements during the interview .According to staff, the resident makes inappropriate sexual comments to staff routinely . Record review of Progress Notes, for Resident #16 dated 2/12/25, and signed by the PTA revealed Pt (patient) stated, 'I'll go for a walk with you if you give me some sugar' Then patient attempted to use his foot to inappropriately touch Licensed Physical Therapy Assistant (LPTA) where he stated give me some p**** . Record review of Progress Notes, for Resident #16 dated 2/17/25, and signed by the Physical Therapy Assistant (PTA) revealed Attempted Physical Therapy Treatment where patient was very inappropriate where he kept attempting to inappropriately touch Licensed Physical Therapy Assistant (LPTA) .patient kept attempting to inappropriately touch LPTA while saying very inappropriate stuff. LPTA discontinued treatment. Nursing staff notified. Record review of Nurses Notes, for Resident #16 dated 2/20/25 revealed .elder stuck his foot between CNA's legs in a sexual manner . Record review of the Nursing Note for Resident #16, dated 4/25/25, revealed that the elder ambulated off the unit with staff times two for transfer to [Proper Name of Facility]. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/3/25 for Resident #16 revealed a Brief Interview for Mental Status Score (BIMS) score of 3 indicating severe cognitive impairment. Record review of Psychiatric Progress Note for Resident #16 revealed a diagnosis of Dementia and he was admitted to the facility on [DATE]. Record review of the MDS with an ARD of 2/13/25 for Resident #56 revealed a BIMS score of 7 indicating severe cognitive impairment. Record review of the demographic page for Resident #56 revealed that the facility admitted her on 4/15/21 with diagnosis to include Alzheimer's Disease. Review of the removal plan revealed that the facility took the following actions: Immediate Action started on 4/24/2025 at approximately 2:53 PM: 1. On 04/24/2025 at 2:53 PM, Certified Nursing Assistant (CNA) 1 saw Resident #16 on top of Resident #56. CNA 1 yelled for help. Licensed Practical Nurse (LPN) 1 and CNA 1, CNA 2, and CNA 3 entered the room and removed Resident #16 and took him back to his room where supervision was provided by CNA 2. 2. On 04/24/2025 at 3:05 PM, Licensed Master Social Worker (LMSW) and Nursing Home Administrator (NHA) notified by LPN of the incident. 3. On 4/24/2025 at 3:06 PM, a CNA was stationed outside the door of Resident #16 until transportation arrived to take him to an inpatient geropsychiatric unit. 4. On 4/24/2025 at 3:50 PM, LMSW went to evaluate Resident #16 for mood or behavior changes, and none were noted. 5. On 04/24/2025 at 4:13 PM, Staff Development Specialist (SDS) performed a full body audit on Resident # 56. The findings included red purple bruising with yellow edges noted to left outer eyebrow, scratches, skin discoloration and slight edema noted to exterior labia overall paleness maroon/purple bruising noted to left thigh approximate size of a quarter scratches noted to left thigh and bilateral outer labia with bruising and redness noted to both areas. 6. On 04/24/2025 at 4:21 PM, Nursing Home Medical Staff Director (NHMSD) notified by phone by RN 1 of findings from body audit. No orders received. 7. On 04/24/2025 at 4:28 PM, NHA notified the Ombudsman of the incident. 8. On 04/24/2025 at 5:49 PM, the LMSW notified Resident #56's Responsible Party (RP) of the incident. 9. On 04/24/2025 at 5:54 PM, NHA and Risk Manager (RM) notified the Director of Risk Management (DRM) of the event. to discuss the event and necessary actions steps needed to be implemented immediately to prevent any further harm. The recommended actions included continuing to seek inpatient geropsychiatric unit placement for Resident # 16 and continuing supervision. 10. On 04/24/2025 at 6:00 PM, RP of Resident # 16 was notified by LMSW regarding the incident and an order for inpatient geriatric psych placement. 11. On 04/24/2025 at 7:00 PM, LMSW verified that a CNA was placed outside Resident #16's room. 12. On 4/25/2025 at 11:23 AM, NHA notified the Mississippi State Department of Health (MSDH) of the incident by telephone. 13. On 04/25/2025 at 12:19 PM a follow-up weekly body audit completed on Resident # 56. No additional injuries identified. 14. On 04/25/2025 at 1:32 PM, Primary physician notified of Resident # 16 acceptance at behavioral health facility. 15. On 04/25/2025 at 3:46 PM, NHA notified the Attorney General's Office of the incident. 16. On 04/25/2025 at 3:53 PM, NHA sent an email reporting the incident to the MSDH via email to facilityreportedincidents@msdh.ms.gov. 17. On 04/25/2025 at 4:16 PM, Resident # 16 was transferred to a behavioral health facility. 18. On 04/30/2025 at 8:30 AM, NHA notified local law enforcement of the incident. 19. On 04/30/2025 at 3:30 PM, local law enforcement on-site. 20. On 04/30/2025 at 4:48 PM, Incident report received from local law enforcement. 21. On 4/30/2025 at 5:00 PM, the Director of Risk Management in-serviced the NHA and the Interim Director of Nursing (IDON) on timely reporting of suspected abuse. 22. On 4/30/2025 at 6:00 PM, the Interim Director of Nursing and SDS initiated Abuse training to include types of abuse, prevention and employee responsibilities for reporting suspected abuse for all 129 employees. No staff will be allowed to work until in serviced. 23. On 4/30/2025 at 6:00 PM, the IDON and SDS initiated an in-service for all Nursing Staff on implementing and developing Comprehensive Care Plans to include interventions that address inappropriate sexual behaviors. No staff will be allowed to work until in serviced. 24. No staff, including the Director of Nursing, will be allowed to work until in serviced. 25. On 4/30/2025 at 7:30 PM, an Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, interim-Director of Nursing (DON), Infection Control Nurse Manager (ICNM), and RM. 26. On 5/1/2025 at 3:29 PM, a Follow-up Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, DON, ICNM, RM, Human Resources Manager (HRM), and RN 1. 27. On 5/1/2025 at 5:30 PM, the Minimum Data Set Nurse (MDSN) completed a 100% care plan audit for behaviors for all 95 residents to include residents at risk for sexual behaviors. Findings of the audit revealed that no other residents had inappropriate sexual behaviors. Facility alleged Immediate Jeopardy was removed as of 5/2/25. Validation: The State Agency (SA) validation of the Removal Plan was made during an on-site survey through record review and interviews on 5/5/25. The SA determined all corrective actions were completed on 5/1/25 by the facility and the IJ was removed on 5/2/25.

Based on record review, staff interviews, and facility policy review, the facility failed to report alleged violations of sexual abuse that occurred within the two (2) hour timeframe to the proper authorities for one (1) of one (1) allegations of sexual abuse. Resident # 56 On 4/24/25 at approximately 3:00 PM, Resident #56 was found by a Certified Nursing Assistant (CNA) with Resident #16 in the bed and on top of her, with his hand inside her incontinence brief, performing jabbing motions. Resident #16 became violent with the staff when they tried to remove him from Resident #16's room where he hit a staff member with his fist. The facility's failure to report sexual abuse of Resident #56 to the proper authorities within prescribed timeframes placed Resident #56 and other residents at risk for sexual assault, in a situation that caused and was likely to cause serious injury, serious harm, serious impairment, or death. The SA identified Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 4/24/25 when Resident #16 was found in the bed and on top of Resident #56, with his hand inside her incontinence brief, performing jabbing motions. The SA notified the facility's Administrator of the IJ and SQC on 4/30/25 at 1:20 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on 5/02/25, in which they alleged all corrective actions to remove the IJ and SQC were completed on 5/1/25, and the IJ removed on 5/2/25. The SA validated the Removal Plan on 5/5/25 and determined the IJ and SQC was removed on 5/2/25, prior to exit. Therefore, the scope and severity for 42 CFR: 483.12 (c)(1)-Reporting of alleged violations (F609)-Scope and Severity J, was lowered from a scope and severity of 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. Cross Reference F600, F656 Findings Include: Record review of the facility policy Abuse and or Suspected Crimes Reporting Under the Elder Justice Act, last reviewed 3/24 revealed Elder Justice Act-refers to Section 1150B of the Social Security Act, as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010. Section 1150B of the Act requires certain individuals in a federally funded long-term care facility to timely report any reasonable suspicion of a crime committed against a resident of that facility. Those reports must be submitted to at least one law enforcement agency of jurisdiction and the State Survey Agency . Procedure: 1. If the reportable event involves serious bodily injury to a resident receiving care in this facility, the staff member shall report the suspicion immediately, but not later than two (2) hours after forming the suspicion . Record review of the facility investigation revealed that on 4/24/25 at approximately 3:00 PM, a Certified Nursing Assistant (CNA) was walking down the hall and saw Resident #16 on top of Resident #56 in an inappropriate manner. Both residents were clothed. The CNA called for assistance from other staff to remove Resident #16 from Resident #56's bed. Upon assessment by the Registered Nurse (RN), Resident #56 was noted to have scratches on her upper legs and scratches and bruising on her labia. The CNA reported that Resident #16's hand was down inside Resident #56's diaper, and he was making a jabbing motion with his hand. Record review of the Default Flowsheet Data for Resident #56 under Genitourinary on 4/24/25 at 4:13 PM documented scratches, skin discoloration, and slight edema noted to the labia; maroon/purple and pale overall paleness; maroon/purple bruising noted to the left thigh; maroon/purple bruising with yellow outer edges noted to the left lateral eyebrow; and scratches noted to the left thigh and bilateral outer labia with bruising and redness to both areas. Record review of the Nursing Note for Resident #56, dated 4/29/25, written by Licensed Practical Nurse (LPN) #2 revealed a late entry for 4/24/25 that stated, This nurse alerted by CNA to come to elder's room. When this nurse entered room, observed a male elder on top of this female elder, both were fully clothed, male elder refuses to get off of female elder and required 2 (two) more CNA to assist, male elder becomes violent and punches one of the CNAs in the nose, male elder removed from this elder's room and taken back to his room with supervision. [Proper Name of Administrator] aware . Social Worker (SW) aware and she talked to family, and [Proper Name of Physicians] aware per this nurse . Record review of the Nursing Note for Resident #16, dated 4/24/25, documented that a CNA doing a visual check observed the elder in a female elder's room on top of her. The clothes were intact. When attempts were made to remove this elder, he became violent and punched a CNA in the nose. He was returned to his room, and supervision was provided at his doorway to maintain the female resident's safety. In an interview with the Administrator on 5/2/25 at 12:50 PM he confirmed that he did not identify this as sexual abuse at first and therefore did not report the incident to the State Department within two (2) hours. He revealed that he thought he had 24 hours to report it, so he called the report in the next day on 4/25/25. He further stated that he did not report the incident to the local police department because he did not see it as a crime. Review of the removal plan revealed that the facility took the following actions: Immediate Action started on 4/24/2025 at approximately 2:53 PM: 1. On 04/24/2025 at 2:53 PM, Certified Nursing Assistant (CNA) 1 saw Resident #16 on top of Resident #56. CNA 1 yelled for help. Licensed Practical Nurse (LPN) 1 and CNA 1, CNA 2, and CNA 3 entered the room and removed Resident #16 and took him back to his room where supervision was provided by CNA 2. 2. On 04/24/2025 at 3:05 PM, Licensed Master Social Worker (LMSW) and Nursing Home Administrator (NHA) notified by LPN of the incident. 3. On 4/24/2025 at 3:06 PM, a CNA was stationed outside the door of Resident #16 until transportation arrived to take him to an inpatient geropsychiatric unit. 4. On 4/24/2025 at 3:50 PM, LMSW went to evaluate Resident #16 for mood or behavior changes, and none were noted. 5. On 04/24/2025 at 4:13 PM, Staff Development Specialist (SDS) performed a full body audit on Resident # 56. The findings were red purple bruising with yellow edges noted to left outer eyebrow, scratches, skin discoloration and slight edema noted to exterior labia overall paleness maroon/purple bruising noted to left thigh approximate size of quarter scratches noted to left thigh and bilateral outer labia with bruising and redness noted to both areas. 6. On 04/24/2025 at 4:21 PM, Nursing Home Medical Staff Director (NHMSD) notified by phone by RN 1 of findings from body audit. No orders received. 7. On 04/24/2025 at 4:28 PM, NHA notified the Ombudsman of the incident. 8. On 04/24/2025 at 5:49 PM, the LMSW notified the Responsible Party (RP) of the incident. 9. On 04/24/2025 at 5:54 PM, NHA and Risk Manager (RM) notified the Director of Risk Management (DRM) of the event. to discuss the event and necessary actions steps needed to be implemented immediately to prevent any further harm. The recommended actions included continuing to seek inpatient geropsychiatric unit placement for Resident # 16 and continuing supervision. 10. On 04/24/2025 at 6:00 PM, RP of Resident # 16 was notified by LMSW regarding the incident and an order for inpatient geriatric psych placement. 11. On 04/24/2025 at 7:00 PM, LMSW verified that a CNA was placed outside Resident #16 ' s room. 12. On 4/25/2025 at 11:23 AM, NHA notified the Mississippi State Department of Health (MSDH) of the incident by telephone. 13. On 04/25/2025 at 12:19 PM a follow-up weekly body audit completed on Resident # 56. No additional injuries identified. 14. On 04/25/2025 at 1:32 PM, Primary physician notified of Resident # 16 acceptance at behavioral health facility. 15. On 04/25/2025 at 3:46 PM, NHA notified the Attorney General's Office of the incident. 16. On 04/25/2025 at 3:53 PM, NHA sent an email reporting the incident to the MSDH via email to facilityreportedincidents@msdh.ms.gov. 17. On 04/25/2025 at 4:16 PM, Resident # 16 was transferred to a behavioral health facility. 18. On 04/30/2025 at 8:30 AM, NHA notified local law enforcement of the incident. 19. On 04/30/2025 at 3:30 PM, local law enforcement on-site. 20. On 04/30/2025 at 4:48 PM, Incident report received from local law enforcement. 21. On 4/30/2025 at 5:00 PM, the Director of Risk Management in-serviced the NHA and the Interim Director of Nursing (IDON) on timely reporting of suspected abuse. 22. On 4/30/2025 at 6:00 PM, the Interim Director of Nursing and SDS initiated Abuse training to include types of abuse, prevention and employee responsibilities for reporting suspected abuse for all 129 employees. No staff will be allowed to work until in serviced. 23. On 4/30/2025 at 6:00 PM, the IDON and SDS initiated an in-service for all Nursing Staff on implementing and developing Comprehensive Care Plans to include interventions that address inappropriate sexual behaviors. No staff will be allowed to work until in serviced. 24. No staff, including the Director of Nursing, will be allowed to work until they are in-serviced. 25. On 4/30/2025 at 7:30 PM, an Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, interim-Director of Nursing (DON), Infection Control Nurse Manager (ICNM), and RM. 26. On 5/1/2025 at 3:29 PM, a Follow-up Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, DON, ICNM, RM, Human Resources Manager (HRM), and RN 1. 27. On 5/1/2025 at 5:30 PM, the Minimum Data Set Nurse (MDSN) completed a 100% care plan audit for behaviors for all 95 residents to include residents at risk for sexual behaviors. Findings of the audit revealed that no other residents had inappropriate sexual behaviors. Facility alleged Immediate Jeopardy was removed as of 5/2/25. Validation: The State Agency (SA) validation of the Removal Plan was made during an on-site review through record review and interviews on 5/5/25. The SA determined all corrective actions were completed on 5/1/25 and the IJ was removed on 5/2/25.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement a comprehensive care plan for 1) for Resident #16 who was a known risk for sexual behaviors towards others, to prevent the resident from entering Resident #56's room and sexually assaulting her while she lay in her bed, 2) transfer assistance for a dependent resident (Resident #5), and 3) assistance with Activities of Daily Living (ADL) (Resident #40, #90, and #92) for five (5) of 22 resident care plans reviewed. Resident's # 5, #16, #40, #90 and #92. This facility failed to implement the sexual behavior care plan for Resident #16 which led to Resident #56 being sexually assaulted in her room on 4/24/25 at approximately 3:00 PM, when a Certified Nursing Assistant (CNA) observed Resident #16 in the bed on top of Resident #56, with his hand inside her incontinence brief, performing jabbing motions. The facility's failure to prevent the sexual abuse of Resident #56 placed Resident #56 and other residents at risk for sexual assault, in a situation that caused and was likely to cause serious injury, serious harm, serious impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) which began on 11/05/24 when Resident #16 began to exhibit sexual behaviors towards staff and the facility did not implement interventions to prevent further sexual behaviors. The SA notified the facility's Administrator of the IJ on 4/30/25 at 1:20 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on 5/02/25, in which they alleged all corrective actions to remove the IJ were completed on 5/01/25, and the IJ removed on 5/02/25. The SA validated the Removal Plan on 05/05/25 and determined the IJ was removed on 5/02/25, prior to exit. Therefore, the scope and severity for 42 CFR: 483.21(b) Comprehensive Care Plans - (F656) - Scope and Severity J was lowered from a scope and severity of 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 facility policy titled, Care Plans with a revision date of 11/07/2023, revealed, An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Record review of facility policy titled, Purposes of a Nursing Care Plan dated, 03/14/2024, revealed, Following the resident's current individualized care plan is crucial and a legal duty as a clinical care team member. Following the resident's current care plan ensures we as a team are providing the best care for each resident. Resident # 16 Cross Reference F600 Record review of the Encounter Problems (Active) for Resident #16 revealed Problem: Mood/Behaviors, with a start date of 11/4/24, Description: I exhibit sexually inappropriate behaviors . Review of intervention description revealed .Protect the rights and safety of others .Elder and others will not experience harm from agitated behaviors . Record review of the facility investigation revealed that on 4/24/25 at approximately 3:00 PM, a Certified Nursing Assistant (CNA) was walking down the hall and saw Resident #16 on top of Resident #56 in an inappropriate manner. Both residents were clothed. The CNA called for assistance from other staff to remove Resident #16 from Resident #56's bed. Upon assessment by the Registered Nurse (RN), Resident #56 was noted to have scratches on her upper legs and scratches and bruising on her labia. The CNA reported that Resident #16's hand was down inside Resident #56's diaper, and he was making a jabbing motion with his hand. During an interview with the Care Plan Nurse on 5/01/25 at 8:55 AM she confirmed that staff did not follow the care plan related to Resident #16's sexual behaviors and therefore did not protect the safety of others. She revealed the purpose of the comprehensive care plan is to identify any specific resident needs and direct staff of resident specific care needed. Review of the removal plan revealed that the facility took the following actions: Immediate Action started on 4/24/2025 at approximately 2:53 PM: 1. On 04/24/2025 at 2:53 PM, Certified Nursing Assistant (CNA) 1 saw Resident #16 on top of Resident #56. CNA 1 yelled for help. Licensed Practical Nurse (LPN) 1 and CNA 1, CNA 2, and CNA 3 entered the room and removed Resident #16 and took him back to his room where supervision was provided by CNA 2. 2. On 04/24/2025 at 3:05 PM, Licensed Master Social Worker (LMSW) and Nursing Home Administrator (NHA) notified by LPN of the incident. 3. On 4/24/2025 at 3:06 PM, a CNA was stationed outside the door of Resident #16 until transportation arrived to take him to an inpatient geropsychiatric unit. 4. On 4/24/2025 at 3:50 PM, LMSW went to evaluate Resident #16 for mood or behavior changes, and none were noted. 5. On 04/24/2025 at 4:13 PM, Staff Development Specialist (SDS) performed a full body audit on Resident # 56. The findings were red purple bruising with yellow edges noted to left outer eyebrow, scratches, skin discoloration and slight edema noted to exterior labia overall paleness maroon/purple bruising noted to left thigh approximate size of a quarter scratches noted to left thigh and bilateral outer labia with bruising and redness noted to both areas. 6. On 04/24/2024 at 4:21 PM, Nursing Home Medical Staff Director (NHMSD) notified by phone by RN 1 of findings from body audit. No orders received. 7. On 04/24/2025 at 4:28 PM, NHA notified the Ombudsman of the incident. 8. On 04/24/2025 at 5:49 PM, the LMSW notified Resident #56's Responsible Party (RP) of the incident. 9. On 04/24/2025 at 5:54 PM, NHA and Risk Manager (RM) notified the Director of Risk Management (DRM) of the event. to discuss the event and necessary actions steps needed to be implemented immediately to prevent any further harm. The recommended actions included continuing to seek inpatient geropsychiatric unit placement for Resident # 16 and continuing supervision. 10. On 04/24/2025 at 6:00 PM, RP of Resident # 16 was notified by LMSW regarding the incident and an order for inpatient geriatric psych placement. 11. On 04/24/2025 at 7:00 PM, LMSW verified that a CNA was placed outside Resident #16's room. 12. On 4/25/2025 at 11:23 AM, NHA notified the Mississippi State Department of Health (MSDH) of the incident by telephone. 13. On 04/25/2025 at 12:19 PM a follow-up weekly body audit completed on Resident # 56. No additional injuries identified. 14. On 04/25/2025 at 1:32 PM, Primary physician notified of Resident # 16 acceptance at behavioral health facility. 15. On 04/25/2025 at 3:46 PM, NHA notified the Attorney General's Office of the incident. 16. On 04/25/2025 at 3:53 PM, NHA sent an email reporting the incident to the MSDH via email to facilityreportedincidents@msdh.ms.gov. 17. On 04/25/2025 at 4:16 PM, Resident # 16 was transferred to a behavioral health facility. 18. On 04/30/2025 at 8:30 AM, NHA notified local law enforcement of the incident. 19. On 04/30/2025 at 3:30 PM, local law enforcement on-site. 20. On 04/30/2025 at 4:48 PM, Incident report received from local law enforcement. 21. On 4/30/2025 at 5:00 PM, the Director of Risk Management in-serviced the NHA and the Interim Director of Nursing (IDON) on timely reporting of suspected abuse. 22. On 4/30/2025 at 6:00 PM, the Interim Director of Nursing and SDS initiated Abuse training to include types of abuse, prevention and employee responsibilities for reporting suspected abuse for all 129 employees. No staff will be allowed to work until in serviced. 23. On 4/30/2025 at 6:00 PM, the IDON and SDS initiated an in-service for all Nursing Staff on implementing and developing Comprehensive Care Plans to include interventions that address inappropriate sexual behaviors. No staff will be allowed to work until in serviced. 24. No staff, including the Director of Nursing, will be allowed to work until they are in-serviced. 25. On 4/30/2025 at 7:30 PM, an Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, interim-Director of Nursing (DON), Infection Control Nurse Manager (ICNM), and RM. 26. On 5/1/2025 at 3:29 PM, a Follow-up Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, DON, ICNM, RM, Human Resources Manager (HRM), and RN 1. 27. On 5/1/2025 at 5:30 PM, the Minimum Data Set Nurse (MDSN) completed a 100% care plan audit for behaviors for all 95 residents to include residents at risk for sexual behaviors. Findings of the audit revealed that no other residents had inappropriate sexual behaviors. Facility alleges Immediate Jeopardy was removed as of 5/2/25. Validation: The State Agency (SA) validation of the Removal Plan was made on-site during the survey through record review and interviews on 5/5/25. The SA determined all corrective actions were completed on 5/2/25 and the IJ was removed on 5/2/24. Resident #5 Record review of facility investigation revealed that on 1/27/25 at approximately 1:35 PM Resident #5 was being assisted from her bed to the wheelchair by two (2) Certified Nursing Assistants (CNA), her legs got weak, and the CNAs assisted her to the floor. She was assisted from the floor without difficulty and the Registered Nurse (RN) assessment revealed no injuries. On 1/28/25 at approximately 4:00 PM, Resident #5 complained of pain to her right leg, the physician was notified, and orders were obtained for a radiographic study. The resident was noted to have bruising and edema to her right leg. Her Responsible Party was notified of the findings, and the resident was transferred to the hospital. Evaluation at the hospital revealed that she had a right tibial plateau fracture. Record review of the Encounter Problems (Active) for Resident #5 revealed Problem: Activities of Daily Living (ADLs) (Certified Nursing Assistant Care Plan) revealed I need assistance with my ADLs because of impaired vision, frequent bladder and bowel incontinence, generalized weakness, falls with right hip fracture . Under intervention description Transfers: Extensive assistance two (2) care partners (using rolling walker). On 4/30/25 at 9:00 AM, in an interview with CNA #5 she stated that she and CNA #4 were assigned to take care of Resident #5 on 1/27/25. She stated that CNA #4 instructed her that they were going to transfer Resident #5 to the wheelchair because she was supposed to transfer to another room. She stated that she had never transferred Resident #5 before, and CNA #4 instructed her to get beside the resident and stand her up by placing her arm under the resident's arm and lifting. She stated that she questioned CNA#4 on the technique because she had never transferred a resident in this way and did not think it was correct, but that CNA #4 instructed her that that was the way to transfer this resident. She stated they stood the resident, but she was not able to bear weight and CNA #4 told her to lower the resident to the floor. She stated as they were lowering the resident her right leg went up underneath her. She stated that she does not recall exactly how the resident was positioned or if the resident complained because she left the room when the resident was put back in the chair because she was upset that the resident had to be lowered to the ground, because she did not feel she had a good hold on the resident during the transfer due to her position beside the resident. She verified that they did not use a rolling walker. She stated that she had not checked the care plan to determine how the resident transferred because CNA #4 had transferred her before. On 5/2/25 at 12:00 PM, during a telephone interview with CNA #4, she stated that on 1/27/25 she and CNA #5 went in to assist Resident #5 to the wheelchair to transport her to another room. She stated that she told CNA #5 to get on one side, and she would get on the other and assist the resident to the wheelchair. She stated during the transfer Resident #5 was unable to bear weight on her legs and they had to lower her to the floor. She stated that she did not notice Resident #5's leg going under her while they were lowering her to the floor. She stated that she called the nurse who came in to check the resident. CNA #4 stated that she always transferred Resident #5 this way and had no problems. She stated she felt like CNA #5 did not have a good hold on the resident during the transfer. CNA #4 admitted that she did not use a walker when transferring the resident, stating that she had never used a walker when transferring the resident. CNA #4 further stated that she did not check the residents care plan to see how she was supposed to transfer but agreed that had she used the walker it is likely that the resident could have used it to help bear weight and would not have had to be lowered to the ground. During an interview with the Care Plan Nurse on 5/01/25 at 8:53 AM, she revealed the purpose of the comprehensive care plan is to identify any specific resident needs and direct staff of resident specific care needed. She also verified that the CNAs are to check the resident ADL Care plans weekly & sign that they have checked them. She revealed after reviewing the ADL care plan for Resident #5 staff did not follow the care plan related to transfers if staff did not use a walker as specified during the resident's transfer. Record review of the demographic page for Resident # 5 revealed the facility admitted her on 6/14/24. 46013 Resident #40 Record review of Resident #40's Care Plan revealed that she had Diabetes Mellitus, and the description of care to be received with a start date of 11/25/24 revealed, Diabetic nail care weekly per 7/3 RN. On 4/29/25 at 11:13 AM an observation and interview Resident #40 revealed she liked her fingernails short. She stated she could not remember the last time they were trimmed. This observation confirmed that Resident #40's fingernails long past the tips of her fingers and jagged. On 4/30/25 at 2:22 PM, during an observation and interview Registered Nurse (RN) #1 confirmed that Resident #40's nails looked like it had been a while since they were tended to. She confirmed they were long and jogged, and that the residents plan of care had not been followed. She further stated that the RN's were supposed to do nail care with their weekly body audits. In an interview on 4/30/25 at 3:17 PM, Minimum Data Set (MDS) Nurse #1 confirmed that if Resident #40's nail care was not being done as it was supposed to have been, then it is safe to say that her care plan was not being followed. She revealed she is responsible for developing the residents' care plans and they are developed to identify and address each resident's needs so the staff will know how to care for each resident. Review of the Resident #40's demographic page revealed the resident was admitted to the facility on [DATE] with medical diagnoses of Type 2 Diabetes Mellitus with Diabetic Nephropathy. Record review of Resident #40's Section C of the Annual MDS dated [DATE] revealed the BIMS score was 12, indicating the resident has moderate cognitive impairment. Resident #92 Record review of Resident #92's CNA Care Plan with a start date of 11/25/24 revealed, .nail care weekly . Record review of Resident #92's Skin Care Plan with a start date of 11/25/24 revealed, Finger and toenail care with trimming weekly as needed per RN Supervisor. On 4/29/25 at 11:31 AM an observation and interview revealed Resident #92's fingernails were long and dirty. The resident's nails appeared to be approximately 1/2 (one-half) inch long and had a brown substance under the nail beds. Resident #92 stated that he had asked them to cut and clean, and they always say they will get back to me. On 4/30/25 at 11:15 AM, during an observation CNA #1 confirmed that Resident #92's fingernails were long and dirty. She confirmed that the CNA's are responsible for cleaning the residents' nails. An observation and interview on 4/30/25 at 11:35 AM, LPN#1 confirmed that Resident #92's nail care, which is in his care plan, was not being followed, and it should have been. She confirmed that the resident's nails needed trimming and cleaning. In an interview on 4/30/25 at 3:05 PM, MDS Nurse #1 revealed that Resident #92's care plan was not followed if his fingernails were long and unkempt. Record review of the Resident #92's demographics revealed the resident was admitted to the facility on [DATE] with medical diagnoses including Metabolic Encephalopathy. Record review of Resident #92's Section C of the Annual MDS dated [DATE] revealed the BIMS score was 11, indicating the resident has a moderate cognitive impairment. 48845 Resident #90 Record review of CNA Care Plan with start date 11/6/24 revealed, .nail care weekly . An observation on 4/29/25 at 11:08 AM revealed Resident #90's fingernails were long and jagged with a brown substance under the nail beds. On 4/30/25 at 11:41 AM during an observation and interview with Licensed Practical Nurse (LPN) #3, she confirmed that Resident #90's fingernails were long with a brown substance underneath and needed cleaning and clipping. During an interview on 5/5/25 at 10:00 AM with the Care Plan Nurse, she confirmed Resident #90's care plan was not followed. She revealed that failure to follow the care plan could result in the residents' nails remaining unclean. Record review of Demographics revealed the facility admitted Resident #90 on 2/15/24 with primary diagnosis of Alzheimer's Dementia. Record review of Resident #90's MDS with an ARD of 2/5/25 revealed a BIMS score of 7, which indicated the resident had moderate cognitive impairment.

Based on staff interview, record review, and facility policy review the facility failed to ensure a resident was free from accident hazards when the facility failed to ensure staff transferred the resident with the proper assistive devices for one (1) of three (3) residents reviewed for accidents. Resident #5. Findings Include: Record review of the facility policy Falls Management revealed It is the goal of [Proper Name of Facility] to assure that our residents remain free of accident hazards as possible and that each resident receives adequate supervision and assistive devices as needed to prevent accidents. Record review of the facility investigation revealed that on 1/27/25 at approximately 1:35 PM Resident #5 was being assisted from her bed to the wheelchair by two (2) Certified Nursing Assistants (CNA), her legs got weak, and the CNAs assisted her to the floor. She was assisted from the floor without difficulty and the Registered Nurse (RN) assessment revealed no injuries. On 1/28/25 at approximately 4:00 PM, Resident #5 complained of pain to her right leg, the physician was notified, and orders were obtained for a radiographic study. The resident was noted to have bruising and edema to her right leg. Her Responsible Party was notified of the findings, and the resident was transferred to the hospital. Evaluation at the hospital revealed that she had a right tibial plateau fracture. Record review of the Resident #5's History and Physical, dated 1/28/25 for Resident #5 revealed the patient arrived to the hospital after a fall at her nursing home a couple of days ago. She states that she twisted he right knee under her when she fell and had pain. It has continued to swell and have ecchymosis. She finally presented for evaluation today and was found to have a right tibial plateau fracture. She is being admitted for orthopedic evaluation and surgical consideration . Record review of a Nursing Note dated 1/29/25 10:01 AM revealed a late entry for 1/27/25 at 1:35 PM indicating that Resident was lowered to the floor during a transfer when her knees became weak. No injuries were noted, and the resident had no complaints. There was no indication that the Residents responsible party was notified of the incident. Record review of the Encounter Problems (Active) for Resident #5 revealed Problem: Activities of Daily Living (ADLs) (Certified Nursing Assistant Care Plan) revealed I need assistance with my ADLs because of impaired vision, frequent bladder and bowel incontinence, generalized weakness, falls with right hip fracture . Under intervention description Transfers: Extensive assistance two (2) care partners (using rolling walker). In an interview with CNA #5 on 4/30/25 at 9:00 AM, she stated that she and CNA #4 were assigned to take care of Resident #5 on 1/27/25. She stated that CNA #4 instructed her that they were going to transfer Resident #5 to the wheelchair because she was supposed to transfer to another room. She stated that she had never transferred Resident #5 before, and CNA #4 instructed her to get beside the resident and stand her up by placing her arm under the resident's arm and lifting. She stated that she questioned CNA#4 on the technique because she had never transferred a resident in this way and did not think it was correct, but that CNA #4 instructed her that that was the way to transfer this resident. She stated they stood the resident, but she was not able to bear weight and CNA #4 told her to lower the resident to the floor. She stated as they were lowering the resident her right leg went up underneath her. She stated that she does not recall exactly how the resident was positioned or if the resident complained because she left the room when the resident was put back in the chair because she was upset that the resident had to be lowered to the ground, because she did not feel she had a good hold on the resident during the transfer due to her position beside the resident. She verified that they did not use a rolling walker. She stated that she had not checked the care plan to determine how the resident transferred because CNA #4 had transferred her before. Telephone interview with CNA #4 on 5/2/25 at 12:00 PM, she stated that on 1/27/25 she and CNA #5 went in to assist Resident #5 to the wheelchair to transport her to another room. She stated that she told CNA #5 to get on one side, and she would get on the other and assist the resident to the wheelchair. She stated during the transfer Resident #5 was unable to bear weight on her legs and they had to lower her to the floor. She stated that she did not notice Resident #5's leg going under her while they were lowering her to the floor. She stated that she called the nurse who came in to check the resident. CNA #4 stated that she always transferred Resident #5 this way and had no problems. She stated she felt like CNA #5 did not have a good hold on the resident during the transfer. CNA #4 admitted that she did not use a walker when transferring the resident, stating that she had never used a walker when transferring the resident. CNA #4 further stated that she did not check the residents care plan to see how she was supposed to transfer but agreed that had she used the walker it is likely that the resident could have used it to help bear weight and would not have had to be lowered to the ground. Interview with the Administrator (ADM) on 5/1/25 at 8:15 AM, he stated that he was not the ADM when the incident occurred with Resident #5, but that he had since spoken to the resident's Resident Representative (RR). He further stated that he explained to the RR that the cause of the fracture was not due to the RN not notifying him, but that it was caused by the CNAs not transferring the resident correctly. Record review of Resident #5's Demographic Page revealed the facility admitted the resident on 6/14/24.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings were held at least quarterly with the mandatory staff present for two (2) of the most recent four (4) quarters. November 2024 and February 2025 Findings include: Record review of facility policy titled Quality Assurance and Performance Improvement, with revision date of October 2024, revealed, All QAPI (Quality Assurance and Performance Improvement) activities will be unified across all areas of care and services at our facility. There will be a representative of each area of service on the QAA Committee. Each area will be discussed regardless of whether the representative is present or not. All areas will work together to combine care and services across our continuum of care to better meet the needs of the elders living in our facility. Record review of Monthly Quality Assurance/Improvement Meeting sign-in sheets revealed the facility had not had a Quality Assurance meeting since 08/2024. During an interview on 5/2/25 at 11:21 AM, the Interim Director of Nursing (DON) confirmed that the facility failed to hold quarterly QAPI meetings with the mandatory staff members present and admitted that she could not find evidence of a meeting since 08/2024. She stated that the hospital and the facility had a combined monthly QAPI meeting but admitted that the required staff were not present. During an interview on 5/2/25 at 12:00 PM, the Administrator confirmed the facility failed to hold a quarterly QAPI meeting with the required staff members present. He stated he took over the position of Administrator on 2/25/25, admitted that he had not held a facility QAPI meeting since he started. During a phone interview on 5/2/25 at 12:05 PM, the Medical Director confirmed there was a scheduled QAPI meeting on 4/16/25, which was canceled, and this meeting was not rescheduled

Based on resident and staff interview, record reviews, and facility policy review, the facility failed to promptly resolve grievances regarding cold food for four (4) of six (6) residents present in Resident Council. (Resident #34, # 37, #47, and #84) Findings Include: Review of facility policy titled, Patient Complaint and Grievance Policy effective date 3/18, last review date 1/22, revealed, Policy: Providing quality services is the primary objective .Feedback and comments received by patients or their representatives provide the organization with opportunities for improvement and enhancements of services. Patients and/or their representatives have the right to voice concerns verbally or in writing when their expectations are not met . During the Resident Council meeting held on 4/30/25 at 2:00 PM, Residents #34, #37, #47, and #84 expressed ongoing concerns regarding cold food, specifically highlighting that eggs served at breakfast were consistently cold. Resident #34 mentioned that she was often the last to receive her food tray and recalled that previously a brick was placed under the plate to keep it warm, but this practice has ceased. All residents agreed that they raised these food concerns in multiple Resident Council meetings over the past months, but no improvements have been made. Record review of the Resident Council Minutes dated 11/27/24, 2/28/25, and 3/26/25 revealed repeated documentation of complaints regarding cold food yet there was no evidence to track what the facility did to resolve the complaints. An interview with the Activities Director (AD) #1 on 4/30/25 at 2:44 PM, she acknowledged that residents had previously communicated their dissatisfaction with cold food during Resident Council meetings. She revealed that after a Resident Council meeting, if a resident made a complaint, she made a copy of the minutes and gave it to the department to handle. She revealed that she never got anything back from the departments to know if the issues were resolved or ongoing. She confirmed the cold food complaints were not written up as a grievance and verbalized the issue was ongoing. The AD#1 admitted she was unaware of any specific actions taken by the dietary department in response to the food complaints. An interview with the Licensed Master Social Worker (LMSW) #1 on 4/30/25 at 2:55 PM, revealed that she was not aware of the food concerns and could only address issues if it was brought to her attention. An interview with the Dietary Manager (DM) on 5/01/25 at 10:40 AM revealed she was aware of the residents' complaints regarding cold food and had received copies of the meeting minutes. Furthermore, she revealed the facility had discussed the concerns during the morning stand up meeting. She explained that the kitchen monitored the temperatures on all the foods prior to starting the tray line and had not noticed any concerns with the temperatures. She revealed they used a heated plate to ensure the food stayed warm. The DM explained that she had noticed a delay in the staff getting the trays passed and had reported her concerns to the administrative staff. She revealed they (the kitchen) announced when the trays were ready, and it was up to the staff to distribute them timely. An interview with the Administrator on 5/1/25 at 3:00 PM revealed he was aware of the complaints regarding cold food made during Resident Council meetings. He confirmed these complaints should have been written up as a grievance and they (the staff) should have a tracking process of documentation to ensure the grievances were resolved in a timely manner. Record review of the Admission Record revealed the facility admitted Resident #34 on 8/17/22. Record review of Resident #34's Minimum Data Set (MDS) with an Assessment Reference Date (ARD)of 4/7/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #37 on 6/8/17. Record review of the Resident #37's MDS with an ARD of 3/12/25 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #47 on 8/5/21. Record review of Resident #47's MDS with an ARD of 3/12/25 revealed a BIMS score of 15 which indicated the resident was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #84 on 2/12/25. Record review of Resident #84's MDS with an ARD of 2/19/25 revealed a BIMS score of 15 which indicated the resident was cognitively intact.

Based on staff interview, record review and facility policy review, the facility failed to notify a Resident Representative (RR) following an accident for one (1) of three (3) residents reviewed for notifications of change. Resident #5. Cross Reference F689, F656 Findings Included: Record review of the facility policy titled Notification of Changes revealed, Policy: i. To immediately notify the resident, consult with the resident's physician, and if known, notify the resident's legal representative or interested family member when: a. An accident involving the resident which results in injury or has the potential for requiring physician intervention . Record review of the facility investigation revealed that on 1/27/25 at approximately 1:35 PM Resident #5 was being assisted from her bed to the wheelchair by two Certified Nursing Assistants (CNA), her legs got weak, and the CNAs assisted her to the floor. She was assisted from the floor without difficulty and the Registered Nurse (RN) assessment revealed no injuries. On 1/28/25 at approximately 4:00 PM, Resident #5 complained of pain to her right leg, the physician was notified, and orders were obtained for a radiographic study. The resident was noted to have bruising and edema to her right leg. Her RR was notified of the findings, and the resident was transferred to the hospital. Evaluation at the hospital revealed that she had a right tibial plateau fracture. Record review of the X-ray of the right tibia fibula dated 1/28/25 revealed Mildly displaced transverse fracture through the proximal tibial metadiaphysis and a minimally displaced fracture of the fibula head. Record review of a Nursing Note dated 1/29/25 10:01 AM revealed a late entry for 1/27/25 at 1:35 PM indicating that Resident #5 was lowered to the floor during a transfer when her knees became weak, no injuries were noted, and the resident had no complaints. This review revealed no indication that the RR was notified of the incident. An interview with the Administrator (ADM) on 5/1/25 at 8:15 AM revealed that he was not the ADM when the incident occurred with Resident #5 on 1/27/25. He admitted that he had since spoken to the RR regarding the fact that the RN did not notify them of the residents' fall. He confirmed that the RN did not notify the RR following the residents fall, but she should have. Record review of the Resident #5's demographic page revealed the facility admitted the resident on 6/14/24.

Based on staff interview, record review, and facility policy review, the facility failed to carry out a physician ordered gradual dose reduction (GDR) for one (1) of five (5) residents reviewed for medication. Resident #64 Findings Include: Review of the facility policy titled Resident's Rights and Privileges with no revision date revealed, 21. Freedom from Chemical and Physical Restraints: Residents in the proper name of the facility shall enjoy freedom from chemical or physical restraints . Record review of the Consultant Pharmacist Recommendation dated September 3, 2024, revealed the physician ordered a decrease in Resident #64's Effexor (antidepressant) from 75 milligrams daily to 37.5 milligrams daily. Additionally, review of the Consultant Pharmacist Recommendation dated 3/21/25 revealed the physician ordered a decrease in Zyprexa (antipsychotic) 5 milligram to 2.5 milligrams at bedtime. Record review of the 4/2025 Medication Administration Record for Resident #64 revealed the residents continued to receive Olanzapine (Zyprexa) 5 milligrams nightly and Venlafaxine (Effexor-XR) 75 milligrams daily with breakfast. During an interview with the Interim Director of Nursing (DON) on 5/01/25 at 2:45 PM confirmed the physician ordered dose reductions for Resident #64 had never been implemented and further explained that this would have been the DON's responsibility. Additionally, she revealed the lack of not implementing these dose reductions caused Resident #64 to take more medication than was ordered to treat his depression. This could have resulted in mood changes and weight loss due to him sleeping more than usual. During an interview with the Administrator on 5/01/25 at 2:52 PM, he stated that his expectations were for the physician ordered dose reductions to be implemented by the next day. Record review of the demographics record revealed the facility admitted Resident #64 on 3/01/23 with medical diagnoses that included Unspecified Dementia and Major Depressive Disorder, recurrent, with Psychotic Symptoms. Record review of Resident #64's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/24/25 revealed under Section C 1000 revealed the resident was moderately cognitively impaired.

Based on observation, staff interview, and record review, the facility failed to accurately complete section P of the Minimum Data Set (MDS) for one (1) of 22 sampled residents. Resident #19 Findings Include: The facility provided a statement on letterhead that revealed, MDS (Minimum Data Set) at proper name of the facility follows the RAI (Resident Assessment Instrument) Guidelines. Record review of the MDS with an Assessment Reference Date (ARD) of 4/03/25 revealed under section P, a bed rail was coded as a physical restraint that was used daily. An observation on 4/29/25 at 11:27 AM revealed Resident #19 with no type of restraint in use. Record review of Resident #19's Restraint Usage Evaluation dated 4/03/25 revealed under, Has any type of restraint been used in the past 7 days? No was indicated. During an interview on 4/30/25 at 1:51 PM with the MDS Nurse #2, she revealed that the facility did not have any physical restraints in the building. She confirmed the bed rails were coded as a restraint for Resident #19 and indicated this was an error. She verbalized that she reviewed the assessments before submission, but she did not always review every section. Record review of the demographic record revealed the facility admitted Resident #19 on 9/11/20 with a medical diagnosis that included Vascular Dementia. Record review of the MDS with an ARD of 4/03/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 4, which indicated Resident #19 was severely cognitively impaired.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide care to maintain personal hygiene for three (3) of 95 residents in the facility. Resident #40, #90, and #92. Findings include: Review of facility policy titled, Activities of Daily Living (ADL'S) last review date 4/3/18, revealed, Policy .to assist residents in achieving maximum function with Activities of Daily Living .will provide assistance to residents as necessary . Resident #40 An observation and interview on 4/29/25 at 11:13 AM revealed Resident #40's fingernails to be approximately 3/4th (three-fourth) inch long and jagged past the tips of the fingers. Resident #40 stated she would like them to be shorter, and she wasn't sure the last time that her fingernails were trimmed. An interview and observation on 4/30/25 at 11:25 AM, Certified Nurse Aide (CNA) #1 confirmed the resident's fingernails were long and revealed that the nurses are responsible for cutting the resident's fingernails. During an interview and observation on 4/30/25 at 12:05 PM, Licensed Practical Nurse (LPN) #1 revealed the Registered Nurses (RN) are supposed to do the weekly fingernail care for each resident. She confirmed the resident's fingernails were long and jagged, and she wasn't sure when the last time they were cut. During an interview on 4/30/25 at 2:22 PM, Registered Nurse (RN) #1 revealed nail care is supposed to be done by an RN weekly when they do the body audit. She confirmed the resident's nails were long and jagged and revealed it looked like it had been quite some time since her fingernails were tended to. A record review of Resident #40's Orders revealed, Nail Care Routine, Weekly. Record review of the resident demographics revealed Resident #40 was admitted to the facility on [DATE] with a medical diagnoses that included Type 2 Diabetes Mellitus with Diabetic Nephropathy. Record review of Resident #40's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/25/2025 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident has moderate cognitive impairment. Resident #92 An observation and interview on 4/29/25 at 11:31 AM revealed Resident #92's fingernails to be approximately 1/2 (one-half) inch long past the tips of his fingers, dirty in appearance, with a brown substance under the nail beds. Resident #92 stated, I've told them I need them cut, and they say I'll get back to you. He stated These fingernails are just too long. If I could get a hold of my son, I would have him bring me in some fingernail clippers, and I'll do it myself. An observation on 4/30/25 at 8:40 AM revealed Resident #92's fingernails remain unchanged from the previous day. An observation on 4/30/25 at 11:15 AM, CNA #1 revealed that she was assigned to Resident #92 and confirmed that his fingernails were long and dirty with a brown substance underneath. She revealed that we can clean underneath the resident's fingernails, but the CNAs cannot cut them. She stated, I think he will get his bed bath today, and we will clean his fingernails. An observation and interview on 4/30/25 at 11:35 AM, LPN#1 confirmed that CNAs are responsible for cleaning the fingernails each time the resident gets bathed. She confirmed that Resident #92's fingernails were long, jagged, and dirty. She stated, Wow, these need to be cut. She confirmed it looked like it had been a while since his fingernails were cut and cleaned, revealing that he could scratch himself and cause a skin tear or infection with his nails being that long and jagged. A record review of Resident #92's Orders revealed, Nail Procedure Routine, Weekly, Finger and toenail care weekly as needed per RN Supervisor. Record review of the resident demographics revealed Resident #92 was admitted to the facility on [DATE] with a medical diagnosis of Metabolic encephalopathy. Record review of Resident #92's MDS with an ARD of 2/20/2025 revealed a BIMS score of 11, indicating the resident has a moderate cognitive impairment. 48845 Resident #90 During an observation on 4/29/25 at 11:08 AM, Resident #90 was found lying in bed with eyes closed. Notably, his fingernails were approximately 3/4 inch long, appeared dirty, and had jagged edges with a brown substance underneath. During an observation and interview on 4/30/25 at 11:41 AM with LPN #3, she confirmed that Resident #90's fingernails were approximately 3/4 inch long with a brown substance underneath, jagged edges and needed cleaning and clipping. The LPN stated that CNAs are responsible for cleaning underneath the fingernails but cannot cut them per facility policy. She noted that the CNAs should have performed this cleaning during the residents' bath. The LPN emphasized that nurses are required to trim nails. She further mentioned that Resident #90 tends to dig, which makes it important for his nails to be kept clean and trimmed, as unkempt nails could lead to infection. During an interview on 5/5/25 at 10:24 AM with the Interim Director of Nursing (DON), she confirmed that nail care should be performed during showers and as needed. Record review of Demographics revealed the facility admitted Resident #90 on 2/15/24 with primary diagnosis of Alzheimer's Dementia. Record review of Resident #90's MDS with an ARD of 2/5/25 revealed in Section C a BIMS score of 7, which indicated the resident had moderate cognitive impairment.

Based on observation, staff interview, and facility policy review, the facility failed to ensure medications were stored appropriately for one (1) of 95 residents residing in the facility. Resident # 32 Findings Include: Review of the facility policy titled Administration for Oral Medications unrevised, revealed under, Policy: It is the policy of proper name of the facility that all services provided or arranged by the facility must meet professional standards of quality. Record review of the Nursing Department QA (Quality Assurance) for Med Pass revised 2/15/12 revealed, Ensure that resident has taken and swallowed medication. An observation of Resident #32 on 4/29/25 at 11:40 AM revealed she was lying on her left side in bed with her eyes closed. A clear medication cup was observed sitting on the bedside table with seven (7) pills inside. An observation and interview with Licensed Practical Nurse (LPN) #2 on 4/29/25 at 11:50 AM confirmed that Resident #32's medications were left at the bedside. She revealed that the medication was the resident's morning medication and explained that she had entered the resident's room earlier in the morning to administer them, but the resident was asleep. She revealed she should have taken the medications back with her to secure them, in order to prevent another resident from accessing them. An interview with the Interim Director of Nursing (DON) on 4/29/25 at 12:16 PM confirmed that the nurse should have taken the Resident #32's medication with her when she left the room to ensure that no one else accessed it. She agreed that many things could happen when medications are left at a resident's bedside such as, another resident could take them, or a family member could come in and take them home. Record review of Resident #32's Demographic Record revealed the facility admitted the resident on 2/10/17 with medical diagnoses that included Acute on Chronic Heart Failure. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/29/25 revealed under section C, a Brief interview for Mental Status (BIMS) summary score of 13, which indicated Resident #32 was cognitively intact.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure food was stored and served under sanitary conditions, when staff failed to remove perishable food items, including milk, from the resident's room in a timely manner. This resulted in the potential for foodborne illness due to prolonged exposure of food to room temperature for one (1) of five (5) days of survey. (Resident #90) Findings include: Review of the facility policy titled, Dietary Services undated, revealed under, Purpose: To prevent contamination of food products and therefore prevent foodborne illness. Additionally revealed under, . VI. Proper Food Handling . P. Foods that have stood for several hours at room temperature cannot be considered safe and free from contamination . An observation on 4/29/25 at 11:08 AM revealed Resident #90's breakfast tray was still in the room located on the bedside table. The tray contained leftover contents of breakfast including half a carton of milk. An interview on 4/30/25 at 11:42 AM with Licensed Practical Nurse (LPN) #3 revealed that the breakfast trays were delivered around 6:30 AM. She explained that Resident #90 usually did not eat his breakfast at that time but ate it later, so they left it for him. She confirmed that leaving the breakfast tray until lunchtime could cause the milk to spoil and could cause Resident #90 to have gastrointestinal upset and illness. Record review of Resident #90's Demographics Record revealed the facility admitted Resident #90 on 2/15/24 with a primary diagnosis of Alzheimer's Dementia. Record review of Resident #90's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/05/25 revealed under section C, a BIMS summary score of 7, which indicated the resident was moderately cognitively impaired.

Based on observation, staff interview, and facility policy review the facility failed to put infection control measures in place to prevent the possible spread of infections for one (1) of 95 residents residing in the facility. Resident #81 Findings include: Record review of facility policy titled, Contact Precautions dated 2018, revealed, It is the intent of this facility to use contact precautions for residents known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Contact Precautions shall be used in addition to Standard Precautions for residents with infections that can be easily transmitted by direct and indirect contact. Resident #81 An observation on 4/29/25 at 12:55 PM revealed an isolation cart outside of Resident #81's room. There was no signage to indicate the type of isolation or precautions to be used. During an interview on 4/30/25 at 8:45 AM, Registered Nurse #1 revealed that Resident #81 was in contact isolation for a wound infection with MRSA (Methicillin-resistant Staphylococcus aureus). She confirmed there was no contact isolation signage for this resident to inform staff or visitors of what precautions were required for this specific isolation. During an interview on 4/30/25 at 8:50 AM, the Interim Director of Nursing (DON) confirmed that signage was necessary to indicate what type of isolation and what precautions were required to decrease the spread of infection. She admitted that the facility failed to provide signage to inform staff and visitors of the precautions that were needed. She stated that isolation signage was required for residents in isolation so that visitors and staff were informed of what type of precautions needed to be used. Record review of Resident #81's Physician's Orders revealed an order for contact isolation status . starting on Monday 2/24/25 . Organism : MRSA (Methicillin-resistant Staphylococcus aureus); Source: Wound. Record review of Resident #81's Demographic Sheet revealed the facility admitted the resident on 1/4/24. Record review of Resident #81's Problem List revealed the resident had a diagnosis of Alzheimer's Disease, Vascular Dementia, and Pressure Injury of Buttock. Record review of Resident #81's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/27/25 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 5 which indicated the resident had severe cognitive impairment. 48845

Based on observation, record review, interview and policy review, the facility failed to anticipate pain prior to wound care for a non verbal resident identified with a Stage III Pressure Ulcer. The licensed staff further failed to stop wound care and provide pain medication after the resident exhibited signs of discomfort. This affected Resident #9, one (1) of nine (9) residents observed for pain assessments during provision of care. Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set), with an Assessment Reference Date of 02/21/13, identified Resident #9 with severely impaired cognitive skills for daily decision making. The resident has no speech and rarely/never understands and is rarely/never understood. Resident #9 is totally dependent on staff for all Activities of Daily Living (ADLs), incontinence of bowel, has an indwelling catheter and receives nutrition by a feeding tube. The MDS identified that Resident #9 has a Stage III Pressure Ulcer. A review of the "Care Plan," with a problem onset date of 2/21/2013, documented as follows: "Pain Management: Potential for pain/discomfort related to: multiple physical dxs (diagnoses) ...Goal and Target Date: Will maintain adequate level of comfort as evidenced by no s/sx (signs/symptoms) of unrelieved pain or distress..." Approaches included "Administer prescribed medications for pain per MD (Medical Doctor) orders ...Consider premedicating for pain as needed to optimize resident's participating in ADLS ..." A review of the "physician's orders [REDACTED]. "...Tylenol 325 mg (milligram) tab (tablet) 1 (one) per [DEVICE] (gastrostomy) every four (4) hours prn (as needed) pain ...Clean ulcer right buttock with wound cleanser, pat dry, pack lightly with [MEDICATION NAME] packing strips apply (brand) ointment around site, apply skin prep to periwound, cover with a bordered gauze daily & (and) PRN." An observation of wound care for Resident #9 was conducted on 03/20/13 at 9:30 a.m. with Licensed Practical Nurse (LPN) #2 and Registered Nurse (RN) #3 present. The licensed staff informed the resident of the treatment but did not ask the resident about pain. The resident was positioned on the left side and LPN #2 began wound care without verbally assessing the resident for pain. During the observation, RN #3 measured the area on the right buttock and described the area as a Stage III pressure ulcer, measuring 3 cm (centimeters by 2 cm with a depth of 1.6 cm). The LPN cleansed the area on the right buttock with wound cleanser and began to pack the area with [MEDICATION NAME] Gauze strips. The resident began to grimace, jerking lower extremities and shaking both arms. The LPN said "I'm sorry, I'm almost done." The LPN did not stop the treatment or ask the resident about pain. Resident #9 made a grunting noise and continued to shake both arms. RN #3 placed her hand on the resident's leg and told the resident that the LPN was almost through with the treatment, without asking the resident about the pain. LPN #2 did not stop the wound care, continued to finish packing the wound and completed the wound care without assessing the resident for pain. An interview was conducted with LPN #2 on 03/20/13 at 3:20 p.m. During the interview the LPN was asked about Resident #9's wound treatment and she said that the resident had a Stage III wound on the right buttock. The LPN acknowledged that the resident did not receive any pain medication prior to the wound care and that Resident #9 was a nonverbal resident. LPN #2 said that a pain assessment in a nonverbal resident was made by observing for facial expressions, grunting or moving. The LPN was asked about her observations of Resident #9 during wound care. The LPN said she couldn't see the resident's face but felt her movements were pulling away and felt the resident tensing up when she started packing the wound. The LPN acknowledged that she should have given the resident something for pain prior to treatment or stopped the care, given something for pain and finished the care later. An interview was conducted with RN #3 on 03/20/13 at 3:45 p.m. During the interview, the RN acknowledged that no pain medication was administered to Resident #9 prior to wound treatment on 03/20/13. The RN acknowledged that Resident #9 was non verbal and pain assessments were done by observing for facial grimacing and guarding in non-verbal residents. The RN was asked about her observations of Resident #9 during the wound treatment when LPN #2 started packing the wound. The RN said she noticed the resident was pulling up her leg and she could see the tension in the resident's body. The RN said she laid her hand on the resident's leg to comfort the resident. RN #3 was asked what nurses could do for a resident with a Stage III wound. The RN said to anticipate pain or stop the treatment, give something for pain and go back to do the treatment later. The RN said the resident could have been given something for pain prior to the treatment. An interview was conducted with RN #4, responsible for staff education, on 03/20/13 at 4:10 p.m. During the interview the RN was asked how nurses should assess residents for pain. The RN said that non verbal residents are assessed by the "faces scale" and look for grimacing or grunting. The RN said if the resident exhibits pain the nurse should stop the treatment, give pain meds and go back to do the treatment. The RN also said "Ideally give the pain med before the treatment." A review of the facility's policy "PRESSURE ULCER, CARE AND PREVENTION OF," (not dated) documented as follows: "...c. Stage III. A full thickness of skin is lost, exposing the subcutaneous tissues -presents as a deep crater with or without undermining adjacent tissue ..." A review of the facility's policy "Pain Management," (not dated) documented as follows: "Purpose: The purpose of pain management is to prevent pain or decrease the severity of pain by providing appropriate nursing skills and interventions. It is the responsibility of the licensed nurse to assess the resident for signs/symptoms of pain." A review of the facility's policy "Pain Management," revised 03/2013, documented as follows: "Rationale: To provide guidelines for providing proper pain management services. Policy: It is the policy of (name of facility) for residents to receive proper pain management of services. Procedure: When providing pain management services, the guidelines below should be followed: 1. Residents should be evaluated for presence of pain through a pain evaluation that is consistent with treatment and the resident's condition. 2. Evaluation of pain should be consistent using the appropriate scale. The patient's self report should be the primary indicator of pain. Accepted scales are verbal (0-10 rating), for non-verbal adult residents, use a communication board or the adult faces scale ...Guidelines ...7. A proactive approach should be utilized re: anticipated pain producing events, e.g. (for example) exercise, wound care, diagnostic/therapeutic procedures ...Faces Pain Scale ...Pain Intensity Non-Verbal Pain Scale: 1. Relaxed, 2. Guarding, 3. Grimacing, 4. Moans, 5. Altered vs (vital signs)."

Based on observation, record review and staff interviews, the facility failed to ensure preventative measures were in place, and modified timely to prevent the development of or worsening of pressure ulcers for Resident # ' s 7 and 13. This affected two (2) of nine (9) residents identified with pressure ulcers. Findings Include: Resident # 7 Resident # 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. . Review of the physician's orders [REDACTED]." The most recent Minimum Data Set ((MDS) dated [DATE] identified Resident # 7 as having "Pressure Ulcer Risk Score of 9, indicating resident is considered "High Risk" for development of pressure ulcers. Body audit on 12/08/12 indicated two (2) Stage I pressure ulcers were being treated to her right and left toes...She is encouraged to elevate her feet/legs by sitting in her recliner during the day. A pressure reducing mattress is used on her bed..." According to the MDS, Resident # 7 had no arterial or vascular wounds during this assessment period. On 03/19/13 at 4:00 p.m., the treatment/wound nurse identified Resident # 7 as being diabetic and she had a problem with her shoes. She revealed after Resident # 7 developed areas to her toes that no other preventative measures were attempted due to the resident ' s refusal to change to diabetic shoes. She revealed Resident #7 still had a wound that was being treated to her toe. On 03/21/13 at 5:10 p.m., the treatment/wound nurse identified the wounds as pressure ulcers. When asked what interventions were changed to promote healing and prevent further pressure to the toes she revealed she was unsure. Resident # 13 Resident # 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), dated [DATE], identified Resident # 13 as having wounds and requiring extensive assistance of one with all activities of daily living except eating. On 02/20/13, Resident # 13 was identified as having wounds on the Right (R) ankle, Left (L) inner buttock and L ankle. On 03/21/13 at 10:15 a.m., the treatment nurse revealed the residents wounds occurred due to ill fitting shoes. On 03/21/13 at 11:42 a.m., the MDS Nursewas asked what interventions were added to the care plan prior to the development of the pressure ulcers and if resident did not keep pillows in place what other interventions were attempted. She revealed no other interventions were added to the care plan. On 03/21/13 at 5:10 p.m., the registered nurse who performed the treatments identified in-house pressure ulcers that developed on 2/20/13 on the bilateral heels and the coccyx stated, " They developed as the result of the resident sleeping in her recliner. " She revealed they had tried to put pillows underneath her legs but that the resident would not always keep the pillows underneath. She was asked what other interventions/approaches were tried. She did not reveal any other methods tried to prevent pressure to the heels. The care plan for "Pressure Ulcers" dated 02/26/13, identified measure to prevent pressure while in the bed (only used a turning schedule), but did not address approaches on how to prevent pressure to the heels while Resident # 13 was in her recliner and/or wheelchair.

CI MS # Based on record review, staff interview and policy/procedure review, the facility failed to ensure that one (1) of four (4) resident's reviewed (Resident #1) was free of neglect and failed to provide the services necessary to avoid physical harm as evidenced by: Resident #1 was transferred by the use of a sit to stand hoyer lift instead of the 2 person manual transfer that was on the Activities of Daily Living (ADL) Care Plan. As a result of the incorrect transfer, Resident #1 suffered a dislocated left shoulder. Findings include: Cross Refer to F-323 for the facility ' s failure to ensure that Residents #1 was free from an avoidable injury. The facility failed to prevent an accident involving Resident #1 when she was transferred.

CI MS # Based on record review, staff interview and policy/procedure review, the facility failed to ensure that one (1) of four (4) residents reviewed (Resident #1) received adequate supervision and assistance to prevent accidents as evidenced by: Resident #1 was transferred by use of a sit to stand hoyer lift instead of the two (2) person manual transfer that was on the Activities of Daily Living (ADL) Care Plan. As a result of the improper transfer, Resident #1 suffered a dislocated left shoulder. Findings include: Record review of Resident #1 revealed an admission date of [DATE] with the following Diagnosis: [REDACTED]. Record review of the most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/25/12, revealed a cognitive level of 2 meaning: the resident is moderately impaired; decision making is poor; and the resident requires cues/supervision regarding decision making. Resident #1 takes the following medications: [REDACTED]. Record review of Resident #1's "Resident evaluation for lift and/or transfer assistance" assessment, dated 9/25/12, revealed Resident #1 was assessed to require 2 persons to transfer her to and from bed, bed to chair, chair to toilet and chair to chair. "N/A" is in the space where type of lift to be used should be. Record review of Resident #1's Certified Nursing Assistant (CNA) Care Plan, dated 9/26/12, revealed "TRANSFERS: Extensive Assist 2 CNAs" Record review of 11/7/12, written at 1:05 p.m., nurse's note written by RN #2, revealed "in dining room at this time, Resident (Rt) could only (c/o) lower (L) arm/shoulder pain with movement. Shoulder/arm assess, Left shoulder joint asymmetrical and pronounced. Rt guarding Left shoulder/arm, unable to move arm/shoulder without pain. Incontinent care provided per CNAs with stand-up lift after lunch today." Record review of Resident #1's x-ray of the left Humerus Final report dated 11/7/12 at 2:02 p.m., stated "Reason for Exam: TRAUMA", "HISTORY: Pain after trauma", "Findings/impression: Two views left humerus presented for interpretation. There is anterior/inferior dislocation of the left humeral head from the glenohumeral joint. Scapula intact. Humerus intact. No fracture is identified. Visualized ribs intact. Elbow joint intact." Interview with RN #1 on 12/10/12 at 3:12 p.m. revealed "The CNAs used a stand up lift to perform incontinent care on Resident #1. She was a 2 person extensive assist. Sometimes the girls used the hoyer lift on her. It wouldn't hurt her to use the full body lift. I witnessed the CNAs do that one time and told the CNAs to use the full body lift if they felt like they needed to that day. I have told CNAs in the past that if they needed more help with her they could the full body lift, not the sit to stand lift. I didn't think it would hurt her to use the full body lift. It would provide more assistance if it was needed for that resident but I didn't change the Care Plan. When she got hurt, I reviewed the Care Plan again and it still had 2 person manual. So, yes ma'am, I knew the Care Plan said 2 persons assist. It was possible to use the 2 person manual, she could pivot. I never saw them use a sit to stand lift; I saw them use the full body sling lift. It didn't trigger in my mind to change the Care Plan. The CNAs were CNA #1 and CNA #2. They do have their Care Plan that shows them what type of lift to use on the patient. CNA #2 asked me if they could use a lift. I told them it was ok to use the full body lift. I don't know why they used the sit to stand lift. I wasn't even on the floor when this happened. Another nurse came and got me. I went to see Resident #1. I looked at it and her left shoulder looked dislocated. She was complaining of pain. She was saying, "Oh my arm's killing me, my arm's killing me, it hurts." I went and called her doctor and sent her to the emergency room . Another nurse told me the CNAs had used the stand up lift. That's how I found out what lift was used. The CNAs admitted they used the sit to stand lift." Interview with CNA #1 on 12/10/12 at 4:31 p.m., revealed "I was (as needed) PRN and went to help Resident #1's regular CNA, CNA #2. I was helping her that day because she didn't have a partner. We were going to change Resident #1. CNA #2 said CNA #3 told her that we could get her up with a stand up lift. I didn't think nothing of it; I didn't know Resident #1. I used to be full time so I know that she'll holler out when care is done. CNA #2 brought the stand up lift in the room. CNA #2 got behind Resident #1 hooking her up to the lift. I pushed the button to make the lift move. She didn't go up 1-2 inches and started hollering. I stopped. Resident #1 had her hands on the lift. It's a bar that the resident's hold. It's a U shaped bar. The bars are what pull the residents up out of their chair. We immediately put her back down. We unhooked her. She was still hollering. RN #2 came over to try and calm her down. RN #2 touched her arm, her left arm, she hollered out so RN #2 took her back down to her room. When we got her out of bed that morning we used a full body lift. After she got hurt, a nurse brought the Care Plan book to us. I had never seen a book until then. When we partner up, we split patients, we go into rooms together. We have to trust that the assigned CNA knows what to do for any particular resident. On my patients I would read on the computer screen how to care for each one. So I thought CNA #2 knew what to do with her patients. You always follow what's on the Care Plan. CNA #2 was her assigned CNA. As soon as we went to chart in the book, we looked at Resident #1's. It said a 2 person lift. No mechanical lift was mentioned. I showed that to her and said you should have looked at it before using a mechanical lift on her. I've never had a nurse tell me to do anything different than what is on the Care Plan." Interview on 12/11/12 at 1:25 p.m., with CNA #5 revealed, "I have used a stand up lift with Resident #1. I told CNA #2 that we have used the stand up lift on Resident #1 before. I was trying to help her out because they were new on the hall. I've never seen a mechanical lift on her Care Plan. Nobody ever told me I could use a mechanical lift on her. I used the sit to stand lift as a short cut for incontinence care. I didn't tell CNA #2 to use it, only that we had used it before." Interview on 12/11/12 at 1:50 p.m., with RN #2 revealed, "I was not aware of a lift being used on residents that shouldn't have lifts, not until Resident #1's incident. We were in the dining room when Resident #1 hollered out, I went over and touched her left hand and she hollered out again. I assessed her with the other nurses. I noticed that her left arm was dislocated. I went and asked CNA #1 and CNA #2 how they got her up. They said we did it with the stand up lift. I went and got the ADL book and showed them she was a 2 person manual lift. They said someone told them to use that lift on her. CNA #2 came to me later that day and told me it was CNA #3 that told her to use the sit to stand lift." Interview on 12/11/12 at 2:05 p.m., with RN #4 revealed, "I didn't know when the incident happened. They used that stand up lift on Resident #1. Resident #1 was hollering, so I went to her room and she was complaining of pain in her left arm. I went to CNA #1 and CNA #2 and asked what happened to Resident #1. CNA #2 said she didn't do anything to her. They had just done incontinence care and somehow it (during the conversation) came out they used the stand up lift to get her out of her wheelchair. I asked them who told them to use the stand up lift. They said another CNA told them." Review of the facility's policy/procedure's revealed an undated policy/procedure for "DAILY RESIDENT CARE PLAN". The policy/procedure revealed "A daily plan of care is developed for each resident admitted to this institution. Included in the Care Plan were the following: Diet and meal service; Diet therapy when prescribed; Medications and treatments as prescribed; Bathing and grooming schedules including preventive skin care; Safety measures as indicated and restraining measures as ordered; and Planned rest, exercise, and activity periods." Review of the facility's policy/procedure's revealed an "Abuse" policy revised on 10/26/2005. The policy/procedure stated "Neglect: This includes intentional or unintended failure to fulfill a caretaking obligation, for example: the withholding of food, medication, denial of health related services, or any other services required to maintain the health and well being of the elder".

CI MS #9586 Based on observation, record review, staff interview and policy review, the facility failed to ensure that one (1) of four (4) residents reviewed (Resident #1) was free from neglect. Resident #1 sustained a fall from her bed while being provided incontinent care on 7/18/11. Resident #1 received a 10.2 cm (centimeter) x 9.0 cm hematoma to the right forehead. Findings Include: Cross Refer to F-323 for the facility's failure to ensure that Resident #1 received adequate assistance to prevent neglect with injury.

CI MS # 9586 Based on observation, record review, staff interview and policy review, the facility failed to ensure that one (1) of four (4) residents reviewed, Resident #1 received adequate staff assistance to prevent neglect and injury. Resident #1 sustained a fall from her bed while being provided incontinent care on 7/18/11. Resident #1 received a 10.2 cm (centimeter) x 9.0 cm hematoma to the right forehead. Findings Include: On 7/20/11 the State Agency (SA) received a facility self reported incident of neglect. Review of the facility submitted documentation revealed that on 7/18/11 Certified Nursing Assistants (CNA) #1 and CNA #2 failed to provide care together to the same resident at the same time. CNA #1 was providing care to Resident #1 while CNA #2 was providing care to Resident #1's roommate. On 7/18/11 at 12:25 a.m., Resident #1 fell out of the bed while receiving incontinent care. Resident #1 sustained a 2 cm (centimeter) hematoma to the right forehead at the time of the fall. CNA #1 and CNA #2 had picked Resident #1 up out of the floor and put her back in the bed prior to notifying the nurse. On 7/18/11 at 9:20 a.m., the hematoma measured 10.2 cm x 9.0 cm, pinkish red and abraised with 20% reddish, 30% purplish and 50% light blue. The outer edges were slightly raised and uneven. Facility investigation revealed through admission of CNA #1 and CNA #2 that they entered the room and provided care to each resident alone. CNA #1 and CNA #2 were terminated for violating protocol which caused injury to Resident #1. Resident #1 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #1 on 9/19/11 at 11:35 a.m. revealed that she was sitting in a reclined geri chair and offers no verbal response when addressed. Review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/8/11 revealed that Resident #1's Brief Interview for Mental Status (BIMS) score was 00. This score on a scale of 0-7 represents a severe cognitive impairment for daily decision-making skills. Resident #1 is coded as total dependence of two (2) + (plus) persons for transfers and extensive assist of two (2) + persons for bed mobility. Review of Resident #1's "Fall Risk Evaluation" dated for 6/8/11 revealed that Resident #1 had a score of 22. A resident who scores a 10 or higher is at risk for falls. Review of Resident #1's "Resident Assessment for Lift/Transfer Assistance" dated for 6/8/11 revealed that Resident #1 was assessed for a two (2) person total (mechanical) lift transfer. Review of previous assessments revealed that Resident #1 had required two (2) people to reposition her in bed and two (2) people to lift/transfer her since her 10/10 assessment. Review of a "MDS Progress Note" dated 6/8/11 revealed that Resident #1 seldom speaks, is non-ambulatory using the geri chair propelled by staff and requires extensive assist of two (2) + persons to total dependence of two (2) persons for transfers and bed mobility. Review of Resident #1's "Care Plan ADL Book" dated 6/8/11 revealed "CNA Care Plan Resident requires assistance with Activities of Daily Living (ADL's) d/t (due to) dementia and requires assist for appropriate decisions, dependent for mobility, limitations in ROM (range of motion), hx (history) of ORIF (open reduction/internal fixation) left hip fx (fracture). Approaches: *Mechanical lift of all transfers *Review current care plan *Turn with drawsheet every 2 (two) hours *Incontinent care to be provided every 2 hours *Bed mobility and repositioning: Total assist 2 (two) CNA's *Transfers: Total dependence 2 (two) CNA's use mechanical lift for all transfers *Dressing: 2 (two) CNA's *Level of assist for toileting: Total 2 CNA's." Interview with the Director of Nursing (DON) on 9/19/11 at 12:05 p.m. and 9/20/11 at 11:20 a.m., revealed that since approximately 2005 it has been the facility's policy of practice to use the "buddy system", although not written in policy. The DON stated that the buddy system is two (2) staff working together to provide hands on care to the residents, for resident and staff safety. The DON stated that on 7/18/11 she questioned CNA #1 and CNA #2 about the fall with Resident #1 at 12:25 a.m. on 7/18/11 and both of their stories were the same. The DON stated that the facility has video surveillance in the halls, nurse's stations and the exit doors. The DON stated that she had viewed the camera surveillance and had questions about the amount of time they spent in Resident #1's room. The DON stated that she had both CNA #1 and CNA #2 to write a statement of the incident. The DON stated that she brought CNA #1 and CNA #2 back in together for questioning a second time. The DON stated that after several questions CNA #2 confessed that they did not follow protocol for providing resident care. CNA #2 stated to the DON that she was providing care to Resident #1's roommate while CNA #1 provided care to Resident #1. The DON stated that both CNA #1 and CNA #2 admitted that they did not follow protocol and that Resident #1 fell off the bed during care and they both lifted Resident #1 off the floor to the bed and then notified the nurse. Random interviews with other staff (CNA's and Nurse's) on 9/19/11 revealed that using the buddy system has been protocol for as long as they could remember. Interview with CNA #1 on 9/19/11 at 1:30 p.m. revealed that she and CNA #2 were assigned partners on the night of 7/18/11. CNA #1 stated that on 12:00 a.m. rounds CNA #2 was providing care to Resident #1's roommate while she provided care to Resident #1. CNA #1 stated that as she was turning Resident #1 toward her to fasten the brief the bed started to roll away from her and Resident #1 fell off the bed face down onto the floor. CNA #1 stated that she yelled to CNA #2 for help, who was at the roommates bed. CNA #1 stated that they picked Resident #1 up from the floor and place her back into the bed, then went and reported the fall to the nurse. CNA #1 stated that she had been trained on the buddy system and knew that she should not have provided care to Resident #1 by herself. CNA #1 stated that she though she could provide incontinent care for Resident #1 by herself. Interview with CNA #2 on 9/19/11 at 2:35 p.m. revealed that she and CNA #1 were assigned partners on the night of 7/18/11. CNA #2 stated that she was providing care to Resident #1's roommate while CNA #1 provided care to Resident #1. CNA #2 stated that CNA #1 yelled to her for help and when she turned around she saw Resident #1 laying face down on the floor. CNA #2 stated that she and CNA #1 panicked and lifted Resident #1 from the floor back to the bed and then reported the fall to the nurse. CNA #2 stated that she had been trained on the buddy system but that she did not know Resident #1 was a two (2) person assist. CNA #2 stated that she did not review Resident #1's care plan before entering the room. Interview with the Education Coordinator (Registered Nurse) RN #3 on 9/20/11 at 9:05 a.m. revealed that during orientation of a new employee she covers what the buddy system means, although she does not have this written anywhere. RN #3 stated that during orientation she instructs new staff that they are not to provide any hands on care for a resident unless they have a partner present. RN #3 stated that she has not provided any in-service recently related to falls, the buddy system, moving residents after a fall or reviewing the Activity of Daily Living (ADL) care plan. RN #3 stated that these were scheduled upcoming topics for annual in-service. Review of a hand written statement by CNA #1 dated 7/18/11 at 11:43 a.m. revealed "As CNA #1 and CNA #2 made 12 o'clock rounds. CNA #2 done (name) Resident #1's roommate I provided care to (name) Resident #1. She was turned toward the window. As I pulled her underwear and put another one on. I pulled her toward the door to grab the other part of the diaper so I can fasten it. I pulled her arm and leg toward and then placed one hand on her back and the other on her arm. Her bed started to roll toward the window and that's when (name) Resident #1 started to fall toward the floor. I tried pulling her shirt so I can get her back in bed but the shirt was to lose. That's when we got her back in bed as quickly as possible." Review of a hand written statement by CNA #2 dated 7/18/11 at 11:43 a.m. revealed "When going into (name) Resident #1's room and (name) roommates room I began to give care to (name) roommate changing and dressing her. (Name) CNA #1 began to change and dress (name) Resident #1. (Name) CNA #1 called out for me to help her. I turned and (name) Resident #1 was on the floor. I went to her and (name) Resident #1 was laying face down on the floor. Her arm was under her. I told (name) CNA #1 to pick her up. We put her back on the bed." Review of a facility policy "Falls Management" updated 12/19/08 revealed "It is the goal of Calhoun Health Services to assure that our resident's environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistive devices as needed to prevent accidents. The purpose is to inscribe quality assurance efforts to decrease the incidence of geriatric falls at Calhoun Health Services. To prevent resident falls and to enable staff to recognize those residents who are at an increased risk for falls." Review of a facility policy "Safety (General Guidelines for Resident Safety)", not dated revealed "Purpose 1. To create a safe environment of the resident 2. To communicate concerns about resident safety issues. General Instructions 5. Before performing any procedure, check the resident's identity, the prescriber's order and the resident's care plan." Review of the facility's policy "Abuse" with a revised date of 12/08 revealed "It is the policy of Calhoun Health Services that this facility prohibits mistreatment, neglect, or abuse of residents. Neglect:This includes the intentional or unintended failure to fulfill a caretaker obligation."

CI MS #9338 Based on observation, record review, staff interview and policy review, the facility failed to ensure that measures were put into place to prevent one (1) of six (6) residents reviewed, Resident #1, from exiting the facility without the knowledge of staff. This was evidenced by Resident #1 exiting the facility on 05/08/11. Resident #1 was ambulating unsupervised away from the facility on Burke CC Road, using a walker, approximately 75 yards away (1/2 {one half} way between the hospital and nursing home). The temperature was approximately 82 degrees Fahrenheit (F) on 05/08/11. Resident #1 did not have on a bracelet, which had been previously ordered and applied to her leg to alert staff of the resident being near an exit door. Resident #1 went out a door that has a key pad code for exit and which has an alarm to notify staff that a resident with a security alert bracelet was near the door. That door would have locked down, if the bracelet had been on the resident leg as ordered. There was a risk of harm while Resident #1, diagnosed with [REDACTED]. The facility's failure to ensure that Resident #1 received adequate supervision, and to ensure a security alarm was applied to her leg was deemed as Substandard Quality of Care (SQC) and an Immediate Jeopardy (IJ) on 05/25/11 at 12:00 p.m. The Director of Nursing was notified at that time. The DON notified the Administrator as he was not at the facility. The IJ was identified to begin on 05/08/11 through 05/26/11. The facility provided an acceptable credible Allegation of Compliance (AoC) on 05/26/11 at 5:30 p.m. Based on the facility's implementation of corrective actions the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 05/27/11 to a "D" level which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions. Findings Include: Review of a report received by the State Licensing Agency on 05/09/11 that revealed: "On May 8, 2011 at approximately 5:30 p.m., (name of Resident #1), followed visitors out of the front door and walked to the edge of driveway and then continued on Burke CC Road toward the hospital. Another resident who went outside to smoke observed the resident walking and tapped on the door to get the attention of a Certified Nursing Assistant (CNA) who was working near by. The CNA called down the hall to the LPN and DON that the resident was outside the facility. By the time I stepped outside and observed the resident, she had ambulated approximately 85 yards. (Please note, staff indicates that is was approximately 75 yards vs. 85 yards.) The LPN and I both ran to the resident who stated, "I am going home to Derma to tend to the Children. "The resident was then led back into the facility without further incident." This document was signed by the Director of Nursing (DON). A "Statement of Investigation" written and signed by the DON revealed: "On May 8, 2010 (2011), at approximately 5:00 p.m., I made an unannounced visit to the nursing home. I went to the New Side nurses station of the facility and was speaking to (Name of Licensed Practical Nurse {LPN} #1), one of the LPN's that was making med (medication) pass. She was telling me about a sick resident. During the conversation, a CNA that was making rounds down the hall (name of CNA #12) hollered up the hall that a resident was outside the facility. (LPN #1) and I went immediately to the hall door and upon my first observation the resident, (Resident #1), was propelling her walker down the street toward the hospital. She was approximately 75 yards away from the nursing home parking lot. (LPN #1) and I both ran down the street and escorted the resident back to the facility without further incident. During the walk back, LPN (#9) arrived and also walked with us. He checked for the resident's Secure Care Monitor Ankle Bracelet but it was not present. When asked, the resident responded, "I am going home to Derma, the children are waiting for me." "When I returned to the facility, I questioned staff about the missing ankle bracelet. I did not have my work keys so I telephoned LPN (#32) as to the location of a new bracelet. (LPN #32) arrived and a new bracelet was placed on the resident." "At 6:00 p.m. I spoke with CNA (#10) and asked about the placement of the ankle bracelet. (CNA #10) stated the ankle bracelet was there that morning after breakfast when the resident toileted." "At 6:30 p.m., when CNA (#78) arrived, I questioned her about the ankle bracelet. She stated that during her morning care, she did not physically touch the bracelet as the resident had her socks on but she believed it to be in place because of the way the sock bulged out." "When maintenance arrived, they measured the distance of the elopement and changed the security code. Social Services wrote and mailed letters to family members encouraging them to use the front door and to ask for assistance when leaving the facility." "The education coordinator was notified and instructed to prepare an in-service about the Secure Care System and Security Code." The Letter mailed to family members revealed: "May 9, 2011 Dear Family Members: We would like to ask for all family members and visitors to enter and exit through the main entrance door. We are not allowed to give the code to visitors, please do not ask an employee for the access code. Please ask an employee for assistance with the code and he/she will be more than happy to let you out of the building. The lock-coded entrance door is designed for the resident's safety. Please be aware that some of our nursing home resident wandering the facility and attempt to get out of facility through the front entrance and other exiting doors. Using the lock-coded door and allowing only staff access to the secure code helps eliminate the chance of resident elopement. Please be sure to close the door securely when you enter and exit the facility." That letter was signed by the facility Licensed Social Worker, Social Services Director. Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Annual Assessment Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/11 revealed that Resident #1 had a score of six (6) on the Brief Interview for Mental Status (BIMS), which was defined as severely impaired. Cognitive Patterns (Section C) revealed that Resident #1 had the behaviors of inattention and disorganized thinking. Behavior (Section E) revealed wandering behaviors had occurred one (1) to three (3) days prior to the assessment. Functional Status (Section G) revealed that the resident was Independent in ambulation. Review of the original handwritten order revealed: "06/18/08 11:30 am Security Transmitter to Right ankle due to high risk for elopement. Check position of Security Transmitter on ankle q (every) shift. Test secure transmitter by assisting resident through Secure Care System q Sunday". Review of the computer generated Physician order [REDACTED]. Review of a document provided to the State Licensing Agency dated 05/19/11 which was signed by LPN #32 revealed: "We had no Elopement/Wandering Assessment form prior to (Resident #1) elopement from the facility. We have since then made an Elopement/Wandering Assessment form (completed today, 05/19/11) and are in the process of doing one on each resident in the facility. This form will be completed with each new admission, quarterly assessment and status change." Review of that Elopement/Wandering Assessment, dated 05/19/11, for Resident #1 confirmed the risk of elopement. Evaluation factors were: ambulates independently, resident has wandered. Resident is cognitively impaired with poor decision making skills, resident has visual communication deficits, wandering places them at a significant risk of danger for elopement outside the facility, desire to go home, medications that increase restlessness or agitation. "Based on the above evaluation, the resident IS considered a wander/elopement risk." Review of the Social Services Progress Note dated 04/15/11 revealed: "Wandering. Exhibited 4 of 7 days." Review of the Care Plan for Resident #1 with the problem onset date of 04/15/11 revealed approaches for: Security Transmitter, check resident where-abouts every 30 minutes for elopement potential; Security Transmitter is intact and on ankle each shift; and, Security Transmitter function tested by assisting resident through Secure Care System weekly." Interview with the DON on 05/24/11 at 09:40 a.m. revealed that the security bracelet that was missing from Resident #1 on 05/08/11 was not found in the facility and it was undetermined how the bracelet was removed from the resident. Observation of Resident #1 on 05/24/11 at 10:00 a.m. revealed the resident to be in the bed and she stated her name. A security alarm bracelet was observed on the left ankle, instead of the right ankle as the order was written. Interview with the DON on 05/24/11 at 01:44 p.m. confirmed that the facility had not conducted any elopement drills. Interview with the Education Nurse on 05/24/11 at 03:15 p.m. stated that no elopement drills had been performed but would begin and be performed quarterly. Interview with LPN #1 on 05/24/11 at 03:05 p.m. revealed that she was not the nurse providing care for Resident #1 on 05/08/11 when she eloped from the facility. She stated that most days the resident tries to go home and wants to find someone going in the direction of her home. She stated that the DON had come to visiting the facility and a CNA came out of a room and another resident got her attention and she started screaming that Resident #1 was outside. The DON and LPN #1 ran to the door and could see her going down the street with her walker. She was tired. "Said she was glad I caught her. I started back with her and (Name of DON) met us-she did not need a chair-she walked back with us fine. Had to stop to rest. (Name of LPN #9) was working that day; he helped us get her back. Sat her in the lobby by the air conditioning and got her a drink. She wanted to go lay down." Interview with LPN #9 on 05/24/11 at 03:40 p.m. revealed that Resident #1 "has bad Alzheimer's and is always wanting to go home. I was doing med pass and a CNA said she (Resident # 1) was out. I looked out the door and she was outside. (LPN # 1) and (DON) had gotten to her. Took her to her room. I know she wears one (Security Bracelet) and I often see it but did not see it that day. She will come and ask me what time I get off. Never seen her go to door but she likes to sit in lobby with her friend. Ambulates with a rolling walker." Interview with CNA #10 on 05/24/11 at 04:15 p.m. revealed that she worked the day Resident #1 eloped from the building. She stated she had seen the bracelet on the resident. She stated that the staff looked for the missing bracelet and could not find it. Observation of Resident #1 was made on 05/24/11 at 04:30 p.m. She was in the lobby area continually stated she needed to get out and go to Derma before dark. She needs to get home-needs to get out of here. She got up off of chair, ambulated to door with walker and tried to open the door, which did not open. She then headed in another direction. On 05/24/11 at 12:30 p.m. Resident #1 was observed ambulating near the nurse's desk stating "I want to go home". Review of a facility policy "Elopement or Missing Person Plan", which had no date of implementation, revealed: "Purpose: It is the policy of this facility to develop an elopement or missing resident plan to enable us to find the missing resident as quickly as possible for the resident's safety, dignity, and privacy. A situation in which a resident is attempting to leave the premises who is not visualized within seventy (70) feet of any exit is considered elopements. IF a resident is visualized within this distance and the employee joins him or her outside and walks with him or her for greater than seventy (70) feet, this is not an elopement due to the staff member accompanying him or her." "Procedures: *1. A current list of dementia residents who wander or are a wandering or elopement risk will be kept in a binder at the nursing station. These residents who are at risk will be identified by medical and nursing personnel and will wear a monitoring device, such as a security transmitter, ordered by the physicians, which will cause the door to automatically lock and alarm if the resident tries to exit outside the facility. *2. A picture of these dementia residents who are "exit seekers" will be kept in the binder and should be current. The list and picture of resident will be kept updated by the Social Service Department." "E6. If this resident had a monitoring system attached when he/she eloped, investigate and examine the circumstances which allowed the resident to elope before being stopped; such as a member of the facility staff disarming the alarm without retrieving and redirecting the resident. His may happen if the resident is not seen immediately by the staff member, or they think after they disarm it, someone else will retrieve the resident, etc. Appropriate preventive measures should be taken after the through (thorough) investigation to assure that history does not repeat itself. This may mean reprimanding personnel of endangerment of resident safety." "DOCUMENTATION AND TESTING OF SECURE CARE SYSTEM TRANSMITTER WEEKLY Each day, the nurse responsible for the care of the resident utilizing the Secure Care System, must ensure that the ankle transmitter is in place. This must be done during each shift. The CNA's will be responsible for checking that the ankle transmitter is intact and on the ankle each shift and will document in the E-Care Guide. This will be recorded on each resident with a Secure Care System Transmitter. A documented test of each ankle transmitter at the facility must be made each week on Sunday during the 7-3 shift. The procedure involves assisting the resident through the Secure Care System. Documentation is recorded is (in) E-Care Guide for each particular resident." Interview with CNA #15 on 05/24/11 at 11:10 a.m. revealed that the alarms are tested every week but the testing had not been done as "we supposed to been doing". Interview with LPN #1 on 05/24/11 at 03:05 p.m. revealed that the CNAs check the security bracelets "as far as what we (nurses) chart and check on, we don't". Interview with the DON on 05/25/11 at 10:00 a.m. confirmed that the CNA's are the staff who do the alarm checks and it had been changed to Monday. Interview with Registered Nurse (RN) #10 on 05/25/11 at 02:45 p.m. revealed that she knew about the bracelets on residents and that there was a list of residents at risk for wandering but she had never seen a book that contained that information. Interview with LPN #4 on 05/25/11 at 12:15 p.m. revealed that the security bracelets are to be checked on Sundays by the CNA's by taking the resident to the door. Immediate Jeopardy was identified on 05/25/11 at 12:00 p.m. and the Director of Nursing was notified. The DON notified the Administrator as he was not at the facility. The facility provided a credible Allegation of Compliance (AoC) on 05/26/11 at 05:30 p.m.. The AoC is as follows: "Allegation of Compliance On May 8, 2011, at approximately 5:05 p.m., it was noted that Resident #1 was ambulating alone away from the facility on Burke CC Road using a walker and was approximately 75 yards away (1/2 {one half} way between the hospital and nursing home). LPN #1 and the DON ran down the hill and Resident #1 was escorted back inside the facility without any resistance or injury. LPN #9 came to assist returning Resident #1 up the hill and reached down and noted that the ankle bracelet was missing. Resident #1 was returned to the facility and given something to drink and sat in the cool area to rest for a few minutes. Resident #1 was then escorted to her room between 5:30 p.m. and 5:45 p.m. but the missing bracelet was not found and a new Secure Care Ankle Bracelet was placed on the left ankle. On May 9, 2011, at the direction of the DON, Social Services Director (Social Service #1) typed and mailed letters to family members of residents asking them to enter and exit the facility through the main entrance and not to ask staff for the access code for the doors. On May 9, 2011, the front (interior lobby) door access code was changed by maintenance personnel #3. Upon entering the facility, the sign to Visitors reads: "Visitors, The front door code has changed and will continue to change monthly for the safety of our residents. Please ask a staff member to assist you with the code when you are ready to leave the facility. Staff members are not permitted to give the codes to our family members, resident or visitors. Thank you for your cooperation." When exiting the facility, the poster reads, "ASK FOR ASSISTANCE TO EXIT". On May 10, 2011, at approximately 10:00 am, the DON and Maintenance Director toured the facility and checked all seven (7) exit doors which included three (3) doors with Secure Care System. All seven (7) doors functioned properly. On May 11, 2011, the DON printed the Physician order [REDACTED]. Seventeen (17) of one hundred eight (108) residents had a physician order [REDACTED].#32 and DON. On May 18, 2011, the DON showed the Education/ Safety Officer (Registered Nurse #12) how the Secure Care System worked and RN #12 then began in-servicing about "Preventing Elopement" and "Code Secure 12 (Missing Patients Search)". This in-service included instruction for announcing "Code Secure 12" and the location to alert personnel to search floors and parking areas, knowing residents who are elopement risk, knowing that the wandering book at the nurse station has information on residents who may be at risk of elopement, making sure those at risk have secure transmitters anklets on, knowing Replacement Bracelets are located in the narcotic box of each medication care (cart), testing the working condition of anklets by escorting resident through the alarm system each week on Monday, when door alarms sound that the doors need to be checked by going to the door to verify who went out or came in, to be aware of wandering residents sanding near or at exit doors and re-direct them away from the door, when exiting the building to be sure no residents follow you out, make sure doors are secure and that no employee shall give the code to visitors. No employees will be permitted to continue employment without receiving the in-service/re-education. On May 18, 2011, LPN #32 conducted a Quality Assurance check and physically checked each resident that had a physician order [REDACTED].#4. Resident #'s 3, 8 and 15 did not have bracelets on and were replaced by RN #4 and RN #5. It was not determined why Resident #'s 3, 8, and 15 Secure Care Ankle Bracelets were missing. On May 19, 2011 an "Elopement Potential Evaluation" was developed and implemented. This evaluation tool helps to identify residents who are at risk of elopement. The Elopement Potential Evaluation was completed on all residents who had a physician order [REDACTED].#11. On May 20, 2011, sixteen cameras were installed by maintenance personnel #1, #2 and #3 in different areas of the nursing home. The cameras monitor all corridors and exit doors and have recording capabilities. On May 24, 2011, the Director of Nursing personally checked all Secure Care Ankle Bracelets for placement with all bracelets noted to be in place. On May 25, 2011, the responsibility of checking Secure Care Ankle Bracelets and function test was reassigned from Certified Nursing Assistants and given to the floor nurses. As of May 26, 2011, it will be the responsibility of the medication nurse to: *1. Test security transmitter function by assisting resident through secure care system weekly on Monday. The nurse will document on the " Security Transmitter " documented located with the Medication Administration Record (MAR). *2. Check that transmitter is intact and on ankle each shift. The nurse will document on the "Security Transmitter" document located with the Medication Administration Record (MAR) each shift that the transmitter was intact and on the ankle. The Certified Nursing Assistants will continue to check each shift and document on the Activity of Daily Living (ADL) each shift that the ankle transmitter was intact and present on ankle. *3. The medication Nurse will direct CNA's each shift to check resident's where-abouts every 30 minutes for elopement potential. The nurse will document on the "Security Transmitter" document located with the Medication Administration Record (MAR) each shift. The Certified Nursing Assistants will continue to chart on the Activity of Daily Living (ADL) that residents where-abouts where (were) checked every hour. *4. The expiration date was checked by the Quality Assurance (QA) Nurse on 5-25-11 and will be checked each month and documented on the Security Transmitter QA Form. *5. If a resident exhibits increased elopement risk behaviors, interventions will be reassessed and care plan updated and additional interventions will be added as needed." Random observations, interviews, and review of in-service records were conducted. It was verified that letters to family members of residents were mailed. It was verified that the front door access code was changed. It was verified that all seven (7) exit doors with Secure Care System functioned properly. All 17 residents with a physician's orders [REDACTED]. It was verified that the facility staff were inserviced, monitoring Secure Care Ankle Bracelets, function testing as assigned, and documenting appropriately. It was verified that Security Transmitters were checked for expiration dates. It was verified that Elopement Potential Evaluations were completed on residents; and, cameras were noted in all corridors and exit doors. Based on verification of the facility's corrective actions and an acceptable credible Allegation of Compliance (AoC) the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 5/27/11 to a "D" level which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions.

CI MS #9338 Based on observation, record review, staff interview and policy review, the facility failed to ensure that facility was administered in a manner to ensure measures were put into place to prevent one (1) of six (6) residents reviewed, Resident #1, from exiting the facility without the knowledge of staff. This was evidenced by Resident #1 exiting the facility on 05/08/11. Resident #1 was ambulating unsupervised away from the facility on Burke CC Road, using a walker, approximately 75 yards away (1/2 {one half} way between the hospital and nursing home). The temperature was approximately 82 degrees Fahrenheit (F) on 05/08/11. Resident #1 did not have on a bracelet, which had been previously ordered and applied to her leg to alert staff of the resident being near an exit door. Resident #1 went out a door that has a key pad code for exit and which has an alarm to notify staff that a resident with a security alert bracelet was near the door. That door would have locked down, if the bracelet had been on the resident leg as ordered. There was a risk of harm while Resident #1, diagnosed with [REDACTED]. The facility's failure to ensure measure were in place to ensure Resident #1 received adequate supervision, and to ensure a security alarm was applied to her leg was deemed as Substandard Quality of Care (SQC) and an Immediate Jeopardy (IJ) on 05/25/11 at 12:00 p.m. The Director of Nursing was notified at that time. The DON notified the Administrator as he was not at the facility. The IJ was identified to begin on 05/08/11 through 05/26/11. The facility provided an acceptable credible Allegation of Compliance (AoC) on 05/26/11 at 5:30 p.m. Based on the facility's implementation of corrective actions the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 05/27/11 to a "D" level which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions. Findings Include: Cross refer findings to F-323 for the facility's failure to ensure that Resident #1 received adequate supervision to leave the facility without staff knowledge and supervision; and, to ensure a security alarm was applied to her leg. The facility provided a credible Allegation of Compliance (AoC) on 05/26/11 at 05:30 p.m.. The AoC is as follows: "Allegation of Compliance On May 8, 2011, at approximately 5:05 p.m., it was noted that Resident #1 was ambulating alone away from the facility on Burke CC Road using a walker and was approximately 75 yards away (1/2 {one half} way between the hospital and nursing home). LPN #1 and the DON ran down the hill and Resident #1 was escorted back inside the facility without any resistance or injury. LPN #9 came to assist returning Resident #1 up the hill and reached down and noted that the ankle bracelet was missing. Resident #1 was returned to the facility and given something to drink and sat in the cool area to rest for a few minutes. Resident #1 was then escorted to her room between 5:30 p.m. and 5:45 p.m. but the missing bracelet was not found and a new Secure Care Ankle Bracelet was placed on the left ankle. On May 9, 2011, at the direction of the DON, Social Services Director (Social Service #1) typed and mailed letters to family members of residents asking them to enter and exit the facility through the main entrance and not to ask staff for the access code for the doors. On May 9, 2011, the front (interior lobby) door access code was changed by maintenance personnel #3. Upon entering the facility, the sign to Visitors reads: "Visitors, The front door code has changed and will continue to change monthly for the safety of our residents. Please ask a staff member to assist you with the code when you are ready to leave the facility. Staff members are not permitted to give the codes to our family members, resident or visitors. Thank you for your cooperation." When exiting the facility, the poster reads, "ASK FOR ASSISTANCE TO EXIT". On May 10, 2011, at approximately 10:00 am, the DON and Maintenance Director toured the facility and checked all seven (7) exit doors which included three (3) doors with Secure Care System. All seven (7) doors functioned properly. On May 11, 2011, the DON printed the Physician order [REDACTED]. Seventeen (17) of one hundred eight (108) residents had a physician order [REDACTED]. On May 18, 2011, the DON showed the Education/ Safety Officer (Registered Nurse #12) how the Secure Care System worked and RN #12 then began in-servicing about "Preventing Elopement" and "Code Secure 12 (Missing Patients Search)". This in-service included instruction for announcing "Code Secure 12" and the location to alert personnel to search floors and parking areas, knowing residents who are elopement risk, knowing that the wandering book at the nurse station has information on residents who may be at risk of elopement, making sure those at risk have secure transmitters anklets on, knowing Replacement Bracelets are located in the narcotic box of each medication care (cart), testing the working condition of anklets by escorting resident through the alarm system each week on Monday, when door alarms sound that the doors need to be checked by going to the door to verify who went out or came in, to be aware of wandering residents sanding near or at exit doors and re-direct them away from the door, when exiting the building to be sure no residents follow you out, make sure doors are secure and that no employee shall give the code to visitors. No employees will be permitted to continue employment without receiving the in-service/re-education. On May 18, 2011, LPN #32 conducted a Quality Assurance check and physically checked each resident that had a physician order [REDACTED].#4 and RN #5. It was not determined why Resident #'s 3, 8, and 15 Secure Care Ankle Bracelets were missing. On May 19, 2011 an "Elopement Potential Evaluation" was developed and implemented. This evaluation tool helps to identify residents who are at risk of elopement. The Elopement Potential Evaluation was completed on all residents who had a physician order [REDACTED].#11. On May 20, 2011, sixteen cameras were installed by maintenance personnel #1, #2 and #3 in different areas of the nursing home. The cameras monitor all corridors and exit doors and have recording capabilities. On May 24, 2011, the Director of Nursing personally checked all Secure Care Ankle Bracelets for placement with all bracelets noted to be in place. On May 25, 2011, the responsibility of checking Secure Care Ankle Bracelets and function test was reassigned from Certified Nursing Assistants and given to the floor nurses. As of May 26, 2011, it will be the responsibility of the medication nurse to: *1. Test security transmitter function by assisting resident through secure care system weekly on Monday. The nurse will document on the " Security Transmitter " documented located with the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] *2. Check that transmitter is intact and on ankle each shift. The nurse will document on the "Security Transmitter" document located with the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Certified Nursing Assistants will continue to check each shift and document on the Activity of Daily Living (ADL) each shift that the ankle transmitter was intact and present on ankle. *3. The medication Nurse will direct CNA's each shift to check resident's where-abouts every 30 minutes for elopement potential. The nurse will document on the "Security Transmitter" document located with the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. *4. The expiration date was checked by the Quality Assurance (QA) Nurse on 5-25-11 and will be checked each month and documented on the Security Transmitter QA Form. *5. If a resident exhibits increased elopement risk behaviors, interventions will be reassessed and care plan updated and additional interventions will be added as needed." Random observations, interviews, and review of in-service records were conducted. It was verified that letters to family members of residents were mailed. It was verified that the front door access code was changed. It was verified that all seven (7) exit doors with Secure Care System functioned properly. All 17 residents with a physician's orders [REDACTED]. It was verified that the facility staff were inserviced, monitoring Secure Care Ankle Bracelets, function testing as assigned, and documenting appropriately. It was verified that Security Transmitters were checked for expiration dates. It was verified that Elopement Potential Evaluations were completed on residents; and, cameras were noted in all corridors and exit doors. Based on verification of the facility's corrective actions and an acceptable credible Allegation of Compliance (AoC) the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 5/27/11 to a "D" level which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions.