Every finding on record at Bedford Care Center of Picayune

Based on staff interview, record review, and facility policy review, the facility failed to ensure resident medications were protected from misappropriation for one (1) of four (4) medication carts. Findings include:A review of the facility's policy Abuse, Neglect and Exploitation, Revised 2/3/26 revealed, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions.Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful.use of a resident's belongings or money without the resident's consent. A record review of the facility's investigation Alleged Medication Diversion, dated 3/13/26, revealed that on 3/12/26 during the 7:00 PM shift change narcotic count the following medications were missing from the narcotic box on one medication cart: Resident #1, four (4) Percocet 5-325 mg (milligrams); Resident #2, one (1) Percocet 10-325 mg; Resident #3, two (2) Norco 5-325 mg; and Resident #4, one (1) Norco 7.5-325 mg, all oral medications. Further investigation revealed Licensed Practical Nurse (LPN) #1 reported on 3/12/26 during the day shift she provided her medication cart narcotic keys to Registered Nurse (RN) #1 while she was performing a urine specimen collection. LPN #1 confirmed the narcotic count was correct earlier on 3/12/26; however, upon returning, she observed the medication cart in the nurses' station and unlocked. RN #1 later confirmed she did not administer any medications, despite having moved the medication cart into the nurses' station. Discrepancies were identified during the shift change narcotic count on 3/12/26 at 7:00 PM. RN #1 admitted to not administering any medications to residents during the period she had possession of LPN #1's medication cart keys. The facility placed both RN #1 and LPN #1 on suspension pending the investigation. An in-house drug screen performed on both nurses revealed LPN #1 tested negative for all 10 panels, and RN #1 tested positive for oxycodone. RN #1 reported she had taken an oxycodone tablet on March 10 or 11, 2026, for dental pain and provided an outdated prescription dated August 2025. The facility's corrective actions included staff education regarding key control, medication security, and proper reporting procedures. The facility performed in-services with all nursing staff covering controlled substance accountability, cart and key security, chain of custody protocols, and immediate reporting requirements. The facility notified the pharmacy of the missing narcotics and paid for the replacement of all missing controlled substances. On 3/13/26, the facility reported the incident to the Board of Nursing, Board of Pharmacy, Office of Inspector General, and State Agency (SA). The conclusion of the facility investigation revealed there were missing controlled medications, unauthorized handling of a medication cart, and a positive drug screen for RN #1. All required corrective actions, notifications, and staff education were completed prior to the SA entering the facility on 3/30/26.Resident #1A record review of the admission Record, revealed the facility admitted Resident #1 on 12/6/24 with diagnoses including Dementia.A record review of the Order Audit Report, revealed Resident #1 had a physician's order, dated 0/10/25 for Oxycodone-Acetaminophen Tablet 5-325 mg to be given 1 (one) tablet by mouth every 12 hours as needed for pain.A record review of the facility's Individual Patient Narcotic-Controlled Drug log revealed on 2/27/25 at 1:11 AM, Oxycod (Oxycodone)- APAP (Acetaminophen) Tablet 5-325 mg, one (1) tablet was documented as administered to Resident #1 with a remaining balance of 20 tablets. On 3/12/26, the log had an entry to correct the count to 16 tablets to indicate there were four (4) missing tablets.Resident #2A record review of the admission Record revealed the facility admitted Resident #2 on 3/9/26 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). A record review of the Order Audit Report, revealed Resident #2 had a physician's order, dated 3/9/26 for Oxycodone-Acetaminophen Oral Tablet 10-325 MG to be given one (1) tablet by mouth every eight (8) hours as needed for pain. A record review of the facility's Individual Patient Narcotic-Controlled Drug log revealed on 3/12/26 at 7:01 PM, Oxycod (Oxycodone)-APAP (Acetaminophen) Tablet10-325 mg, one (1) tablet was documented as administered to Resident #2 with a remaining balance of five (5) tablets. On 3/12/26, the log had an entry to correct the count to four (4) tablets to indicate there was one (1) missing tablet. Resident #3A record review of the admission Record revealed the facility initially admitted Resident #3 on 3/15/23 with diagnoses including Dysphasia.A record review of the Order Audit Report, revealed Resident #3 had a physician's order, dated 7/23/25 for Hydrocodone-Acetaminophen Tablet 5-325 mg, to be given one (1) tablet by mouth every 24 hours as needed for pain.A record review of the facility's Individual Patient Narcotic-Controlled Drug log revealed on 7/29/25 at 5:00 PM, Resident #3 had two (2) tablets of Hydrocodone/APAP 5-325 mg tablets when he returned from being out on pass. There was no medication administrations documented. On 3/12/26, the log had an entry to correct the count to zero (0) tablets to indicate there were two (2) missing tablets. Resident #4A record review of the admission Record revealed the facility admitted Resident #4 on 1/25/24 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy.A record review of the Order Audit Report revealed Resident #4 had a physician's order, dated 1/14/26 for Hydrocodone-Acetaminophen Tablet 7.5-325 mg, to be given one (1) tablet every six (6) as needed for pain.A record review of the facility's Individual Patient Narcotic-Controlled Drug log revealed on 3/12/26 at 2:05 PM, Hyrocodone-APAP Tablet 7.5-325, one (1) tablet was documented as administered to Resident #4 with a remaining balance of eight (8) tablets. On 3/12/26, the log had an entry to correct the count to seven (7) tablets to indicate there was one (1) missing tablet. On 3/31/26 at 10:50 AM, during an interview with LPN #1, she confirmed that on 3/12/26, following the 7:00 AM narcotic count, all controlled substance counts were correct when she received the medication cart keys. She revealed that during the 7:15 PM narcotic count, discrepancies were identified involving four (4) residents, with medications missing from the medication packs for four (4) residents. She confirmed that she and the relieving nurse conducted a thorough search of the medication cart and nurses' station to determine if the medications were misplaced; however, the medications were not located, and she notified the Director of Nursing (DON) immediately. She revealed that earlier in the shift she provided the medication cart keys to RN #1, without completing a narcotic count before or after transferring the keys, which was not in accordance with facility policy. She said she was suspended while the facility completed an investigation. She confirmed a drug screen was completed and returned negative, and she received additional education on narcotic/medication key control, medication security, and reporting procedures.On 3/31/26 at 10:55 AM, during an interview with RN #1, she confirmed she was present in the facility and had received the medication cart keys from another nurse to monitor the cart; however, she denied taking any narcotics. She reported that, since she was new, she moved the medication cart into the nurses' station so she could observe it. RN #1 further reported she would never take a resident's narcotics.On 3/31/26 at 11:10 AM, during a phone interview with the Director of Pharmacy, she confirmed the facility notified the pharmacy on 3/12/26 regarding missing controlled substances involving four (4) residents. She revealed a reconciliation was conducted comparing dispensing records, delivery logs, and expected on-hand quantities, which confirmed discrepancies consistent with missing controlled substances for the identified residents. She confirmed the medications had been dispensed appropriately to the facility and the discrepancy did not originate from the pharmacy. She revealed the incident met criteria for misappropriation of resident property and required reporting to applicable regulatory agencies. She further confirmed the pharmacy collaborated with the facility to replace the missing medications, provided guidance on controlled substance accountability, and recommended ongoing audits and strict adherence to chain of custody and key control procedures to prevent recurrence.On 3/31/26 at 1:50 PM, during an interview with the Director of Nursing (DON), she confirmed the facility identified a narcotic discrepancy on 3/12/26 during the evening count involving multiple residents. She revealed the facility's expectation is that medication cart keys remain secured with the assigned nurse at all times and that a narcotic count is completed whenever keys are transferred. She said that this process was not followed when the LPN #1 provided the keys to RN #1 without completing a count. The DON revealed the facility immediately initiated an investigation whenever the narcotic count indicated missing medications and LPN #1 and RN #1 were suspended during the investigation. She also confirmed the facility completed drug testing on the two (2) nurses, notified appropriate agencies, and implemented corrective actions including staff re-education, audits, and Quality Assurance Performance Improvement (QAPI) review to prevent recurrence. The DON confirmed that RN #1's hire date was 2/10/26 and her last day worked was 3/12/26. She was terminated on 3/13/26 due to the suspected drug diversion. The DON confirmed a background check and nursing license verification were completed for RN #1, and her nursing license was unencumbered, with no restrictions or disciplinary actions. On 3/31/26 at 2:00 PM, during an interview with the Administrator, he confirmed the facility identified missing controlled substances on 3/12/26 involving our (4) residents. He revealed the facility's expectation is that all narcotics are secured at all times and that staff follow strict key control and chain of custody procedures, which were not followed in this instance. He confirmed the facility immediately removed involved staff from duty, initiated an investigation, and reported the incident to the appropriate agencies. He revealed corrective actions were implemented, including staff education, increased audits, and QAPI review, to ensure ongoing compliance and prevent recurrence. He confirmed that on 3/16/26, the facility conducted an emergency QAPI meeting with the following in attendance: Medical Director, Administrator, Director of Nursing (DON), Infection Preventionist, Staff Development Coordinator, Social Services, Business Office Manager, Minimum Data Set (MDS) Coordinator, Medical Records, Maintenance, and Dietary Manager.Based on the facility's implementation of corrective actions completed on 3/16/26, the SA determined the deficiencies to be Past Non-Compliance (PNC) and the facility was in compliance prior to the SA's entrance on 3/30/26.Validation:The SA validated on 3/31/26 through interview and record review, that all corrective actions had been implemented as of 3/16/26 and the facility was in compliance, prior to the SA's entrance on 3/30/26. A review of the Audit-Weekly Count Audit revealed the DON is monitoring the accuracy of the narcotic count weekly.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide necessary care and services to protect residents from neglect when Resident #1 sustained a burn from hot coffee on 12/31/25 at approximately 3:40 PM and the facility failed to implement safeguards or supervision to protect other residents from exposure to the same hazard. Residents continued to have access to hot coffee in the dining room without supervision, temperature controls, or access restrictions until 1/12/26. Additionally, on the night shift beginning at 7:00 PM on 12/29/25, residents on Station B remained under the care of an impaired licensed nurse who was unable to safely perform nursing duties. Despite staff observations of impairment, the nurse remained responsible for resident care until approximately 3:00 AM on 12/30/25. Review of medication administration records revealed multiple medications were not documented as administered and others were documented late. Staff interviews confirmed medications were pulled by another nurse, but administration was not observed or verified. As a result, the facility could not verify that residents received medications as ordered and to the correct residents for four (4) of (4) sampled residents (Residents #1, #2, #3 #4) and placing all (29) residents residing on Station B at risk. The facility's failure to safeguard residents from known burn hazards and failure to intervene when an impaired nurse was providing care placed all residents who had access to hot coffee and all 29 residents residing on Station B at likelihood for serious injury or illness, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and substandard Quality of Care (SQC) that began on 12/29/25 at 7:00 PM when residents remained under the care of an impaired licensed nurse. The facility Administrator was notified of the IJ on 1/13/26 at 3:40 PM and was presented with the IJ template. The facility provided an acceptable Removal Plan on 1/13/26, in which they alleged all corrective actions to remove the IJ were completed on 1/13/26. The State Agency (SA) validated the Removal Plan on 1/14/26 and determined that the IJ was removed on 1/14/26, prior to exit. Therefore, the scope and severity for 42 CFR S483.12(a)(1) Freedom from Abuse, Neglect, and Exploitation (F600) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include:A review of the facility's policy Abuse Prevention Program, modified 8/2/2022 revealed .Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.Policy Interpretation and Implementation.6. Identify and assess all possible incidents of abuse. A record review of the facility's incident report, dated 12/31/25 at 3:40 PM, revealed the Incident Description included a Nursing Descriptions of Called to resident's room r/t (related to) resident had coffee spilled on left hip area and blisters noted.Resident alert to person. Stating it hurts, it hurts. The Injuries Observed at Time of Incident revealed a Burn to the Left thigh (front). Other Info included Resident was given coffee by another resident, and this resident spilled coffee on himself resulting in blisters forming to left hip area.A record review of the Progress Notes revealed Resident #1 had a Skin Issues note effective 12/31/25 at 4:40 PM for .New skin issue.Front left trochanter.Blister.acquired in-house.12/31/2025.Length (cm): 7.06 Width (cm): 7.56 . A record review of the facility's Counseling/Discipline Report, dated 1/8/26, revealed License Practical Nurse (LPN) #1, was discharged from the facility. The Date(s) of Violation(s) was 12/29 through 12/30 (2025). Policies violated included .Sleeping or appearing to be asleep. The Employee's Statement revealed I was ill-my temp (temperature) was 101 degrees and blood sugar had dropped to 67. I do not remember this.In a record review of the facility's investigation revealed, on 12/30/25 the Director of Nurses (DON) received a call at 1:30 AM from the nurse on station one. (LPN #2). She stated, the nurse on station 2 isn't able to complete her med (medication) pass, she keeps falling asleep, I don't know what's going on with her. She advised her to send the nurse to the hospital. She said, I can't be left here with both sides to do meds for 60 people. The DON advised her to call the scheduler to see if she was able to get a nurse to come in and send the nurse on station 2 home. She was able to get a nurse to come at 3:00 AM. After the DON reviewed the camera footage of the incident that took place, she phoned LPN #1 and did not receive a return call from LPN #1. According to the camera footage, the DON observed the nurse at the nurse's station for about 2 hours. She pushed the cart into the hallway outside of the nurse's station. At this point, she stared at the computer for a long time and swayed around almost falling. LPN #1 appeared to be under the influence of something. She was stumbling around, staring at the med cart fumbling through the cart looking for meds, would pull a med card and just stare at it for minutes. At one point, she fell asleep at the med cart, in the dining room, with her head resting on the cart, the cart started to roll away, and she woke up. There was a resident in the dining room during this time, and he witnessed this incident. The aides came to her several times and woke her up, asking if she was OK. An aide put a chair behind her after she almost fell down, sleeping on the cart. She did not complete her med pass; she only gave meds to 2 residents. A record review of a signed statement by Certified Nurse Assistant (CNA) #1, dated 12/30/25 at 2:30 PM, revealed, .around 8pm, she started falling asleep standing up. She started crying really loud and moaning. She went back and forth to the bathroom a lot. She fell asleep on the counter in the nurse's station.At one point she fell asleep with the med cart open.Around 11:40 PM, we went and got the nurse from Station 1, and she tried to help with med pass.couldn't stay awake to pull meds or pass them. She almost fell down at the table. Her boyfriend/husband came to pick her up at 3:30 AM.The resident's kept calling us to get their meds, we kept having to wake her up to tell her that residents were needing meds. A record review of a signed statement by CNA #2, dated 12/30/25 at 4:00 PM, revealed, When came in for our shift (LPN #1) was fine. Then she came up to me in the dining room and said she didn't feel good. Then she started crying and was half out of it. She was at the cart, leaned over with her eyes closed. Her legs were giving out, so I put a chair behind her. No one got their meds, everyone kept calling us for their meds. She kept going to sleep mid conversation. I wondered if she was 'high as hell'. She went to the bathroom a bunch of times for a long time. She kept falling asleep while she was trying to sign the narc (narcotics) book.We tried to get her to in an ambulance.but she refused.She was crying so loud I was having a hard time doing my charting. A record review of the facility's Medication Admin Audit Report for Station B with Documentation Type: Missed for 12/29/25 through 12/30/25 revealed 25 residents had medications with no administration time.A record review of the facility's Medication Admin Audit Report for Station B with Documentation Type: Late - 1.0 hours(s) for 12/29/25 through 12/30/25 revealed 5 residents had medications that were administered late. A record review of the facility's daily staffing schedule for 12/29/25 at Building 1 revealed LPN #1 was assigned to Station 2 for the 7P-7A (7:00 PM to 7:00 AM) shift on 12/29/25. A record review of the facility's Time Punch Report revealed on 12/29/25, LPN #1 punched in on 12/29/25 at 7:00 PM and punched out on 12/30/25 at 3:00 AM. LPN #2 punched in on 12/29/25 at 6:30 PM and punched out on 12/30/25 at 7:14 AM. LPN #3 punched in on 12/30/25 at 3:45 AM and punched out on 12/30/25 at 2:45 PM. On 1/12/26 at 7:00 AM, during an interview, the facility's Medical Provider revealed Resident #1 sustained a thermal injury to the left thigh as a result of hot coffee being spilled onto the resident's leg causing a 2nd degree burn. Additionally, the Medical Provider stated he was unaware that an impaired nurse had been responsible for 29 residents on 12/30/25.On 1/12/26 at 7:20 AM, during an observation, there was a coffee machine located in the dining area accessible to residents. The machine was labeled out of service; however, the machine remained plugged in and operational. The State Agency obtained coffee from the machine without staff assistance or intervention and the coffee was hot. Residents were present in the dining area at the time of the observation, and no staff were observed supervising or restricting resident access to the coffee machine. No physical barriers were in place to prevent resident use of the machine despite the posted signage. On 1/12/26 at 7:30 AM, during an interview the Director of Nursing (DON), she confirmed that on 12/31/25 at approximately 3:40 PM, a resident provided hot coffee to Resident #1, which spilled onto the resident's left thigh and resulted in blistering to the affected area. The DON confirmed that nursing staff cleansed the area, measured the wound, applied a dressing, and notified the medical provider. The DON reported she did not become aware of the coffee burn incident until she returned to the facility on 1/2/26. She confirmed that upon becoming aware of the incident, no immediate corrective or preventive measures were implemented to reduce the risk of other residents sustaining burns from hot liquids. The DON explained that the incident was reviewed by facility leadership and determined to be accidental in nature, as staff were aware of how the incident occurred, and therefore leadership did not identify the need for additional interventions at that time. The DON confirmed that following the incident on 12/31/25, the facility continued to allow resident access to the coffee machines and did not restrict access, modify the coffee service process, or implement supervision or temperature-control measures. She acknowledged that no actions were taken between 12/31/25 and 1/6/26 to prevent similar incidents involving other residents. The DON further confirmed that on 1/6/26, the facility removed resident access to the coffee machines and began using coffee carafes as a safety measure. She acknowledged that this intervention was not implemented earlier and confirmed that the delay occurred because leadership did not initially consider the incident to pose an ongoing safety risk to other residents. The DON confirmed that she was aware that LPN #1 was impaired on 12/30/25 at approximately 1:30 AM, when LPN #2 informed her of the situation. She confirmed that she did not feel as if it was neglect because the following day, the residents were not identified as having experienced a change in condition, hospitalization, or medication-related harm. She explained that she did not consider the situation to meet the definition of neglect, as she verbally confirmed that all scheduled medications were administered to residents. The DON agreed she was aware on 12/30/25 at 1:30 AM, LPN #1 was impaired but remained on duty until 3:00 AM, the residents continued to request medications, and LPN #1 remained responsible for the residents care. On 1/12/26 at 10:47 AM, during an interview with LPN #2, she confirmed that on 12/29/25 at approximately 11:30 PM, she was informed by Certified Nurse Aides (CNAs) working on the opposite unit (Station 2) that the nurse assigned to that unit appeared impaired and was requesting assistance because residents were asking for their scheduled medications. LPN #2 explained that she went to Station 2 to provide limited assistance due to concerns about the nurse's condition. She confirmed that she accessed the medication cart and pulled medications for the impaired nurse; however, she did not administer the medications herself. LPN #2 reported that the impaired nurse remained responsible for administering the medications to the residents on that unit because the impaired nurse was familiar with the residents and their medication routines. LPN #2 acknowledged that she did not document the medications on the Medication Administration Record (MAR) and did not accompany or observe the impaired nurse during medication administration. She confirmed that she did not visually verify that the correct medications were administered to the correct residents and did not perform any checks to ensure medications were given as ordered. She explained that she assumed the medications were administered correctly based on the impaired nurse's familiarity with the residents. LPN #2 further confirmed that she did not take possession of the narcotic keys for Station 2. She explained that she declined to take the keys because she did not want to assume responsibility for both her assigned residents and the residents on the impaired nurse's unit. She acknowledged that as a result, she did not have oversight of controlled medication administration on Station 2 during that time. LPN #2 confirmed that after pulling the medications, she returned to her assigned unit and continued caring for her own residents. She acknowledged that no follow-up verification was completed to confirm that all medications were administered, documented, or administered accurately to the appropriate residents on Station 2 during that medication pass.On 1/12/26 at 11:50 AM, in an interview, the Administrator acknowledged awareness of an incident occurring on the 12/29/25 PM shift involving LPN #1 who was observed falling asleep while assigned to administer medications and was unable to safely complete medication administration duties. The Administrator confirmed he was aware that the nurse remained on duty until a replacement nurse arrived, which was approximately 8 hours later. He was not aware there was no documentation indicating that medications were administered, and he had been told that the residents had received their medications. Additionally, the Administrator confirmed that he was not made aware of the resident coffee burn that occurred on 12/31/25 until the facility stand-up meeting on 1/6/26. He acknowledged that the Director of Nursing did not notify him of the incident prior to that date. When asked why he was not informed earlier, the Administrator explained that no one at the facility brought the incident to his attention and indicated that, due to the holiday period, communication may have been missed. He confirmed that under normal circumstances, incidents involving resident injuries are communicated to him. The Administrator confirmed that once he became aware of the burn on 1/6/26, leadership discussed modifying the coffee service process; however, he acknowledged that he did not personally verify that corrective measures were implemented or consistently followed after that date. He confirmed there was no documented follow-up or monitoring to ensure resident access to hot coffee had been restricted. The Administrator was informed by the State Agency (SA) that upon arrival to the facility on 1/12/26 at approximately 7:30 AM, the SA was able to obtain hot coffee directly from the coffee machine located in the dining area, despite signage placed on the machine indicating it was out of service. The Administrator acknowledged this information and did not express surprise or provide an explanation as to why the coffee machine remained operational. He confirmed that he was not aware the coffee machine was still accessible to residents on the date of the SA's visit. The facility discussed that after the coffee is prepared for the residents, dietary staff was to unplug the coffee machines, but upon the SA arrival they must not have unplug the coffee machines. The Administrator further acknowledged that the facility did not fully implement or enforce the intervention to remove resident access to the coffee machines until the SA was present in the facility on 1/12/26. He confirmed that between the date of the incident on 12/31/25 and the SA's arrival on 1/12/26, residents continued to have access to hot coffee, and no system was in place to ensure the intervention discussed on 1/6/26 was being followed.On 1/12/26 at 12:15 PM, during an interview with CNA #1, confirmed that she was working on 12/29/25 through 12/30/25 and that she noticed LPN #1 was falling asleep, crying out loud, moaning, and leaning over the medication cart with her eyes closed. She notified the nurse on the opposite unit because residents were complaining that they were not receiving their medications.Resident #1 A record review of the admission Record revealed the facility admitted Resident #1 on 10/20/23 with diagnoses including Dementia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated his cognition was severely impaired.A record review of the Emergency Department Encounter, dated 1/6/26 revealed the Chief Complaint as .Patient brought in from (proper name of nursing home), family requesting patient be checked for everything.Patient has burn on left hip area that is being treated with wound care.since 12/31.HPI (History of Present Illness).presents to the emergency room with complaint of burn.patient was burned at the nursing home from a coffee spill a week ago.A record review of the Order Summary Report with active orders as of 1/13/26, revealed Resident #1 had a Physician's Order, dated 10/20/23, for Donepezil Hydrocholoride (HCL) Tablet 5 mg (milligram) Give 1 tablet by mouth at bedtime. 10/20/23).A record review of the Medication Administration Record (MAR) for December 2025 revealed there was no documentation indicating Resident #1 received the 12/29/25 8:30 PM dose of Donepezil HCL. Resident #2A record of the admission Record revealed the facility admitted Resident #2 on 9/8/25 with diagnoses including Cerebral Infarction.A record review of the Quarterly MDS with an ARD of 12/10/25 revealed Resident #2 had a BIMS score of 15 which indicated he was cognitively intact.A record review of the Order Summary Report with active orders as of 12/31/25, revealed Resident #2 had Physician's Orders for Crestor Oral Tablet 20 MG Give 1 tablet by mouth at bedtime for hyperlipidemia (dated 9/8/25), Latanoprost Ophthalmic Solution 0.005% Instill 1 drop in both eyes at bedtime for glaucoma (dated 9/8/25), Novolog Solution 100 UNIT/ML (milliliter), subcutaneously before meals and at bedtime for Diabetes Mellitus, (dated 9/8/25), and Trazodone HCL Oral Tablet 150 MG Give 1 tablet by mouth at bedtime for insomnia (dated 9/8/25). A record review of the Medication Administration Record (MAR) for December 2025 revealed there was no documentation indicating Resident #2 receiving the scheduled medications for 8:00 PM or 9:30 PM on 12/29/25.On 1/12/26 at 2:00 PM, during an interview with Resident #2, he reported he was awake and seated in the dining room at the time LPN #1 was responsible for medication administration. Resident #2 described observing the nurse appeared impaired, noting she was unable to safely perform medication administration. Resident #2 reported that he did not receive his scheduled medications on 12/29/25 and that he would have been afraid to accept medications from LPN #1 due to concerns that she may administer the incorrect medications. Resident #3 A record review of the admission Record revealed the facility admitted Resident #3 on 3/21/25 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction.A record review of the Quarterly MDS with an ARD 12/10/25 revealed Resident #3 had a BIMS score of 15, which indicated his cognition was intact. A record review of the Order Summary Report with active orders as of 12/31/25, revealed Resident #3 had Physician's Orders for Accucheck AC (before meals) and HS (at bedtime) for Diabetes (dated 3/21/25), Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for neuropathy, Guaifenesin Oral Tablet 400 MG Give 3 tablets by mouth two times a day for cough to equal 1200 MG, (dated 5/15/25), Keppra Oral Tablet 1000 MG Give 1.5 tablet by mouth two times a day for seizure activity take 1.5 tablets to equal dose of 1500 MG (dated 3/21/25), and Lacosamide Oral Tablet 100 MG by mouth two times a day for seizures (dated 10/9/25). A record review of the Medication Administration Record (MAR) for December 2025 revealed there was no documentation indicating Resident #3 receiving any of his 12/29/25 8:30 PM medications. On 1/12/26 at 2:15 PM, during an interview with Resident #3, the resident reported he was in his room, and the nurse was responsible for medication administration, did not give him his medication nor check is accucheck. Resident #3 asked his CNA for his medications, but she responded something was wrong with the nurse. Resident #4 A record review of the admission Record revealed the facility admitted Resident #4 on 7/1/25 with diagnoses including Senile Degeneration of Brain and Dementia. A record review of the Quarterly MDS with an ARD of 12/24/25 for revealed Resident #4 had a BIMS score of 9, which indicated her cognition was moderately impaired. A record review of the Order Summary Report with active orders as of 12/31/25, revealed Resident #4 had Physician's Orders for Clonidine HCL Oral Tablet 0.2 MG Give 1 tablet by mouth at bedtime for Hypertension (dated 7/1/25), Duloxetine HCL Capsule Delayed Release Particles 60 MG Give 1 capsule by mouth two times a day for depression (dated 7/1/25), and Gabapentin Oral Tablet 600 MG Give 1 tablet by mouth two times a day for Neuropathy (dated 7/1/25). A record review of the Medication Administration Record (MAR) for December 2025 revealed there was no documentation indicating Resident #4 receiving any of her 12/29/25 8:30 PM medications. On 1/13/26 at 9:17 AM, during an interview LPN #3 confirmed that LPN #2 and CNA #1 phoned him many times during 12/30/25 early morning, revealing that LPN #1 was acting strange, impaired, that she was very sick. He confirmed that he reported to work on 12/30/25 clocking in about 3:30 AM. When he relieved the nurse she, was unable to count the narcotics with him and LPN #2 had to perform the count. LPN #1 was very drowsy, unable to give report and stumbling as she walked. The facility submitted the following acceptable Removal Plan on 1/13/26: On 1/13/2026 at 3:55pm the Immediate Jeopardy Templates for F600, F725, F609, F610, F838, F689 were provided to the Administrator. On 12/31/2025, Resident #1 sustained a burn from hot coffee at approximately 3:40pm. The facility failed to implement safeguards or supervision to protect other residents from exposure to the same hazard. Residents continued to have access to hot coffee in the Dining Room without supervision, temperature controls, or access restrictions. The facility failed to implement a thorough investigation and report to the State Agency. On 12/29/25, on the 7:00pm-7:00am shift, the residents on Station 1 remained under the care of an impaired licensed nurse who was unable to safely perform nursing duties. Medication Administration records showed multiple medications were not documented as administered or documented as given late. On 12/29/25, the 7:00pm-7:00am shift, there was no designated Charge Nurse after the scheduled charge nurse called in sick. Therefore, no nurse was designated to assume responsibility to supervise staff, coordinate care, or respond to unsafe conditions. This resulted in the Director of Nursing (DON) not being notified until 1:30 AM which allowed for the impaired nurse to stay in the facility until 3:30 AM. The facility failed to ensure the facility assessment dated [DATE] was updated appropriately and adequately identified staffing and supervisory needs by shift and failed to ensure individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments. The staffing plan did not include contingency planning for absence of supervisory nursing staff and did not ensure onsite licensed supervision when the scheduled charge nurse was absent. 1. On 1/12/26, coffee machines were removed out of service by the Maintenance Director. Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit. 2.Coffee Temperature logs were created and started on 1/13/2026 that indicate the staff member who tested the temperature of the coffee, the time and date. These logs will be turned into the Administrator daily. 3.Training for ALL staff, prior to their next scheduled shift beginning on 1/13/2026. Beginning on 1/13/26, no staff will be allowed to work until completion of training, provided by the Administrator, DON, and Staff Development Nurse.Accidents and Supervision including implementing immediate interventions. Abuse and Neglect Reporting and Investigation. Hot Liquids Policy. Notification of Administrator and Director of Nursing (DON) of unusual occurrences, High Risk Events and timely notification. Charge Nurse Delegation and Duties to include the assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse. If assigned charge nurse calls off, the off-going charge nurse will notify the DON for the next assignment. The DON and Administrator's phone numbers are posted on the Facility Assignment Grid. In the event that the charge nurse is impaired, the DON and Administrator will be contacted. Updated Facility Assignment Grid to include assignment for designated charge nurse. Medication Administration Documentation.1.On 1/12/26, all Residents were evaluated for Safety with Hot Liquids by the DON, Resident Care Coordinators #1 and # 2, Registered Nurses (RN) #1, #2, and #3.2.Administrator and DON were inserviced on 1/13/26 by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.3.The Facility Assessment was updated on 1/13/2026 by the Administrator to include a contingency plan for absence of supervisory nursing staff and adequately identified staffing needs by shift and building. 4.The facility's Assignment Grid was updated on 1/13/26 to reflect who the Charge Nurse would be each shift.5.The Scheduler and the Staff Development nurse were inserviced by the DON on 1/13/26 on the new Assignment Grid and Charge Nurse Delegation. The Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be. 6.On 1/13/26 all Resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found. 7.Emergency Quality Assessment and Assurance Committee Meeting held on 1/13/26. Attending the meeting was the Administrator, DON, Infection Preventionist, Minimum Data Set (MDS) Nurse, Social Services Director and Social Services Assistance, Medical Records, Admissions Coordinator, Dietary Manager, Housekeeping Supervisor, Maintenance Supervisor, Human Resources and Central Supply. The Medical Director was present via telephone. The Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy were reviewed with no changes recommended or made. Summary of incident was discussed with actions taken including training and monitoring. 8.The Attorney General Office and the Mississippi Board of Nursing were notified on 1/12/26 by the Administrator of incident involving LPN #1. LPN #2 was reported to the Agency that she works for and is not allowed to work at this facility.The facility alleges that all corrective actions to remove the immediacy were completed on 1/13/26 and IJ removed on 1/14/26. Validation: The SA validated the removal plan through observations, interviews, and record reviews on 1/13/26 and the immediacy was removed on 1/14/26 prior to exit.

Based on observation, interviews, record review, and facility policy review, the facility failed to immediately report allegations of neglect to the State Agency for two (2) of (2) events reviewed. The facility's Administrator became aware on 1/6/26 that Resident #1 had sustained a burn from hot coffee on 12/31/25 and residents continued to have access to hot coffee without safeguards in place to prevent additional injuries until 1/12/26. The facility also failed to report to the SA when the Administrator became aware on 12/30/25 that an impaired licensed nurse had remained responsible for resident care from 7:00 PM on 12/29/25 until approximately 3:00 AM on 12/30/25 and medication administration could not be verified as accurate and timely. The facility's failure to report suspected neglect delayed regulatory oversight and corrective intervention, allowing unsafe conditions to continue, placing residents who had access to hot coffee and all (29) residents residing on Station B at likelihood for serious injury or illness, serious harm, serious impairment, or death.The situation was determined to be Immediate Jeopardy (IJ) that began on 12/29/25 at 7:00 PM when the impaired nurse remained responsible for resident care. The facility Administrator was notified of the IJ on 1/13/26 at 3:40 PM and was presented with the IJ template. The facility provided an acceptable Removal Plan on 1/13/26, in which they alleged all corrective actions to remove the IJ were completed on 1/13/26.The State Agency (SA) validated the Removal Plan on 1/14/26 and determined that the IJ was removed on 1/14/26, prior to exit. Therefore, the scope and severity for 42 CFR S483.12(c)(1) Reporting of Alleged Violations (F609) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include:A review of the facility's policy Abuse Investigation and Reporting revised 8/2/22 revealed .All reports of resident.neglect.shall be promptly reported to local, state and federal agencies (as defined by current regulation) and thoroughly investigated by facility management.Reporting 1. All alleged violations involving.neglect.will be reported by the facility Administrator, or his/her designee.2. An alleged violation of.neglect.will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse A record review of the facility's incident report, dated 12/31/25 at 3:40 PM, revealed the Incident Description included a Nursing Descriptions of Called to resident's room r/t (related to) resident had coffee spilled on left hip area and blisters noted.Resident alert to person. Stating it hurts, it hurts. The Injuries Observed at Time of Incident revealed a Burn to the Left thigh (front). Other Info included Resident was given coffee by another resident, and this resident spilled coffee on himself resulting in blisters forming to left hip area. There was no documentation indicating interventions to prevent re-occurrence being initiated.A record review of the Progress Notes revealed Resident #1 had a Skin Issues note effective 12/31/25 at 4:40 PM for .New skin issue.Front left trochanter.Blister.acquired in-house.12/31/2025.Length (cm): 7.06 Width (cm): 7.56 . A record review of the facility's Counseling/Discipline Report, dated 1/8/26, revealed License Practical Nurse (LPN) #1, was discharged from the facility. The Date(s) of Violation(s) was 12/29 through 12/30 (2025). Policies violated included .Sleeping or appearing to be asleep. The Employee's Statement revealed I was ill-my temp (temperature) was 101 degrees and blood sugar had dropped to 67. I do not remember this.In record review of the facility's investigation revealed, on 12/30/25 the Director of Nurses (DON) received a call at 1:30 AM from the nurse on station one. (LPN #2). She stated the nurse on station 2 isn't able to complete her med (medication) pass, she keeps falling asleep, I don't know what's going on with her. She advised her to send the nurse to the hospital. She said I can't be left here with both sides to do meds for 60 people the DON advised her to call the scheduler to see if she was able to get a nurse to come in and send the nurse on station 2 home. She was able to get a nurse to come at 3:00 AM. After the DON reviewed the camera footage of the incident that took place, she phoned LPN #1 and did not receive a return call from LPN #1. According to the camera footage, the DON observed the nurse at the nurse's station for about 2 hours. She pushed the cart into the hallway outside of the nurse's station. At this point, she stared at the computer for a long time and swayed around almost falling. LPN #1 appeared to be under the influence of something. She was stumbling around, staring at the med cart fumbling through the cart looking for meds, would pull a med card and just stare at it for minutes. At one point, she fell asleep at themed cart, in the dining room, with her head resting on the cart, the cart started to roll away, and she woke up. There was a resident in the dining room during this time, and he witnessed this incident. The aides came to her several times and woke her up, asking if she was OK. An aide put a chair behind her after she almost fell down, sleeping on the cart. She did not complete her med pass, she only gave meds to 2 residents. The [NAME] record review of a signed statement by Certified Nurse Assistant (CNA) #1, dated 12/30/25 at 2:30 PM, revealed, .around 8pm, she started falling asleep standing up. She started crying really loud and moaning. She went back and forth to the bathroom a lot. She fell asleep on the counter in the nurse's station.At one point she fell asleep with the med cart open.Around 11:40 we went and got the nurse from Station 1, and she tried to help with med pass.couldn't stay awake to pull meds or pass them. She almost fell down at the table. Her boyfriend/husband came to pick her up at 3:30.The resident's kept calling us to get their meds, we kept having to wake her up to tell her that residents were needing meds. A record review of a signed statement by CNA #2, dated 12/30/25 at 4:00 PM, revealed, When came in for our shift (LPN #1) was fine. Then she came up to me in the dining room and said she didn't feel good. Then she started crying and was half out of it. She was at the cart, leaned over with her eyes closed. Her legs were giving out, so I put a chair behind her. No one got their meds, everyone kept calling us for their meds. She kept going to sleep mid conversation. I wondered if she was 'high as hell'. She went to the bathroom a bunch of times for a long time. She kept falling asleep while she was trying to sign the narc (narcotics) book.We tried to get her to in an ambulance.but she refused.She was crying so loud I was having a hard time doing my charting. A record review of the facility's Medication Admin Audit Report for Station B with Documentation Type: Missed for 12/29/25 through 12/30/25 revealed 25 residents had medications with no administration time.A record review of the facility's Medication Admin Audit Report for Station B with Documentation Type: Late - 1.0 hours(s) for 12/29/25 through 12/30/25 revealed 5 residents had medications that were administered late. During an observation on 1/12/26 at 7:20 AM, there was a coffee machine located in the dining area accessible to residents. The machine was labeled out of service; however, the machine remained plugged in and operational. The State Agency obtained coffee from the machine without staff assistance or intervention and the coffee was hot. Residents were present in the dining area at the time of the observation, and no staff were observed supervising or restricting resident access to the coffee machine. No physical barriers were in place to prevent resident use of the machine despite the posted signage. During an interview on 1/12/26 at 7:30 AM, the Director of Nursing (DON) confirmed that on 12/31/25 at approximately 3:40 PM, a resident gave a cup of hot coffee to Resident #1, at which time the coffee spilled onto the resident's left thigh, resulting in blistering to the affected area. The DON reported that following the incident, nursing staff cleansed the affected area, measured the wound, applied a dressing, and notified the medical provider. She stated she was not aware of the coffee burn until she returned to the facility on 1/2/26 and confirmed there were no immediate interventions put in place to safeguard other residents who drink coffee. The DON reported the facility did not remove the coffee machines, but instead added signs on 1/6/26 (6 days after the burn) to not use the coffee machines, at which point they began using coffee carafes (a container, usually made of glass or stainless steel that holds and serves coffee). She was unaware that the coffee machines were still operational and being used as of 1/12/26 (13 days after the burn), despite the signage on the machines. Additionally, the DON confirmed that she was aware that LPN #1 was impaired on 12/30/25 at approximately 1:30 AM, when LPN #2 informed her of the situation. She verbally confirmed with LPN #2 that the residents received their medications but did not verify administration by interviewing residents or reviewing the Medication Audit Report for Missed or Late medications. The DON confirmed she was aware that although LPN #1 was impaired, she remained on duty for approximately eight (8) hours in which she was responsible for resident care and medication administration. During an interview on 1/12/26 at 11:50 AM, the Administrator acknowledged awareness of an incident occurring on the 12/29/25 PM shift involving LPN #1 who was observed falling asleep while assigned to administer medications and was unable to safely complete medication administration duties. The Administrator confirmed he was aware that the nurse remained on duty until a replacement nurse arrived, which was approximately 8 hours later. He was not aware there was no documentation indicating that medications were administered, and he had been told that the residents had received their medications. The Administrator also acknowledged awareness that Resident #1 sustained a burn injury after hot coffee spilled onto the resident's leg while at the facility. He explained that although the incident occurred on 12/31/25, he was not aware of it until 1/6/26, which was six (6) days after the incident occurred. He reported that signs were placed on the coffee machine on 1/6/26 indicating not to use and he was unaware that the machines were still being as of 1/12/26, despite there being signage. The Administrator confirmed there were no immediate interventions put into place to safeguard other residents who drink coffee. He explained that he believed both incidents to not be reportable events because he did not consider either issue to be neglect.On 1/13/26 at 9:17 AM, during an interview with LPN #3, he confirmed that LPN #2 and CNA #1 phoned him many times during 12/30/25 early morning, revealing that LPN #1 was acting strange, impaired, and that she was very sick. He confirmed that he reported to work on 12/30/25 and had clocked in at approximately 3:30 AM. When he relieved LPN #1, she was unable to count the narcotics with him and LPN #2 had to perform the count. LPN #1 was very drowsy, unable to give report and stumbling as she walked. The facility submitted the following acceptable Removal Plan on 1/13/26: On 1/13/2026 at 3:55pm the Immediate Jeopardy Templates for F600, F725, F609, F610, F838, F689 were provided to the Administrator. On 12/31/2025, Resident #1 sustained a burn from hot coffee at approximately 3:40pm. The facility failed to implement safeguards or supervision to protect other residents from exposure to the same hazard. Residents continued to have access to hot coffee in the Dining Room without supervision, temperature controls, or access restrictions. The facility failed to implement a thorough investigation and report to the State Agency. On 12/29/25, on the 7:00pm-7:00am shift, the residents on Station 1 remained under the care of an impaired licensed nurse who was unable to safely perform nursing duties. Medication Administration records showed multiple medications were not documented as administered or documented as given late. On 12/29/25, the 7:00pm-7:00am shift, there was no designated Charge Nurse after the scheduled charge nurse called in sick. Therefore, no nurse was designated to assume responsibility to supervise staff, coordinate care, or respond to unsafe conditions. This resulted in the Director of Nursing (DON) not being notified until 1:30am which allowed for the impaired nurse to stay in the facility until 3:30am. The facility failed to ensure the facility assessment dated [DATE] was updated appropriately and adequately identified staffing and supervisory needs by shift and failed to ensure individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments. The staffing plan did not include contingency planning for absence of supervisory nursing staff and did not ensure onsite licensed supervision when the scheduled charge nurse was absent. 1. On 1/12/26, coffee machines were removed out of service by the Maintenance Director. Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit. 2.Coffee Temperature logs were created and started on 1/13/2026 that indicate the staff member who tested the temperature of the coffee, the time and date. These logs will be turned into the Administrator daily. 3.Training for ALL staff, prior to their next scheduled shift beginning on 1/13/2026. Beginning on 1/13/26, no staff will be allowed to work until completion of training, provided by the Administrator, DON, and Staff Development Nurse.Accidents and Supervision including implementing immediate interventions. Abuse and Neglect Reporting and Investigation. Hot Liquids Policy. Notification of Administrator and Director of Nursing (DON) of unusual occurrences, High Risk Events and timely notification. Charge Nurse Delegation and Duties to include the assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse. If assigned charge nurse calls off, the off-going charge nurse will notify the DON for the next assignment. The DON and Administrator's phone numbers are posted on the Facility Assignment Grid. In the event that the charge nurse is impaired, the DON and Administrator will be contacted. Updated Facility Assignment Grid to include assignment for designated charge nurse. Medication Administration Documentation.1.On 1/12/26, all Residents were evaluated for Safety with Hot Liquids by the DON, Resident Care Coordinators #1 and # 2, Registered Nurses (RN) #1, 2, and 3.2.Administrator and DON were inserviced on 1/13/26 by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.3.The Facility Assessment was updated on 1/13/2026 by the Administrator to include a contingency plan for absence of supervisory nursing staff and adequately identified staffing needs by shift and building. 4.The facility's Assignment Grid was updated on 1/13/26 to reflect who the Charge Nurse would be each shift.5.The Scheduler and the Staff Development nurse were inserviced by the DON on 1/13/26 on the new Assignment Grid and Charge Nurse Delegation. The Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be. 6.On 1/13/26 all Resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found. 7.Emergency Quality Assessment and Assurance Committee Meeting held on 1/13/26. Attending the meeting was the Administrator, DON, Infection Preventionist, Minimum Data Set (MDS) Nurse, Social Services Director and Social Services Assistance, Medical Records, Admissions Coordinator, Dietary Manager, Housekeeping Supervisor, Maintenance Supervisor, Human Resources and Central Supply. The Medical Director was present via telephone. The Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy were reviewed with no changes recommended or made. Summary of incident was discussed with actions taken including training and monitoring. 8.The Attorney General Office and the Mississippi Board of Nursing were notified on 1/12/26 by the Administrator of incident involving LPN #1. LPN #2 was reported to the Agency that she works for and is not allowed to work at this facility.The facility alleges that all corrective actions to remove the immediacy were completed on 1/13/26 and IJ removed on 1/14/26. Validation: The SA validated the removal plan through observations, interviews, and record reviews on 1/13/26 and the immediacy was removed on 1/14/26 prior to exit.

Based on observation, interviews, record review, and facility policy review, the facility failed to conduct thorough and timely investigations and failed to implement corrective actions to prevent further neglect for two (2) of (2) events reviewed. Resident #1 sustained a burn on 12/31/25 at approximately 3:40 PM; however, the facility failed to determine the root cause of the injury or implement safeguards to prevent additional residents from exposure to the same hazard, and residents continued to have access to hot coffee without supervision, temperature controls, or access restrictions until 1/12/26. Additionally, residents remained under the care of an impaired licensed nurse from 7:00 PM on 12/29/25 until approximately 3:00 AM on 12/30/25. Medication administration could not be verified as accurate and timely. However, the facility failed to immediately investigate how long the nurse had been impaired, whether medications were administered correctly, or what system failures allowed unsafe care to continue without supervision.The facility's failure to conduct thorough investigations and implement corrective actions to prevent recurrence allowed unsafe conditions to continue and placed residents who had access to hot coffee and all (29) residents residing on Station B at likelihood for serious injury or illness, serious harm, serious impairment, or death.The situation was determined to be Immediate Jeopardy (IJ) that began on 12/29/25 at 7:00 PM when the impaired nurse remained responsible for resident care. The facility Administrator was notified of the IJ on 1/13/26 at 3:40 PM and was presented with the IJ template. The facility provided an acceptable Removal Plan on 1/13/26, in which they alleged all corrective actions to remove the IJ were completed on 1/13/26.The State Agency (SA) validated the Removal Plan on 1/14/26 and determined that the IJ was removed on 1/14/26, prior to exit. Therefore, the scope and severity for 42 CFR S483.12(c)(3) Investigate/Prevent Further Potential Abuse, Neglect, or Exploitation (F610) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.Findings include:A review of the facility's policy Abuse Investigation and Reporting revised 8/2/22 revealed .All reports of resident.neglect.shall be.thoroughly investigated by facility management.Role of the Administrator: 1. If an incident or suspected incident of resident.neglect.is reported, the Administrator or designee will lead the investigation. 4. The Administrator or designee will ensure that any further potential.neglect.is prevented.Investigative Process: 1. The individual conducting the investigation will.a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident.d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate).g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident.i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident 2. The following guidelines will be used when conducting interviews.3. Upon conclusion of the investigation, the Administrator or designee will document the results f the investigation.A record review of the facility's incident report, dated 12/31/25 at 3:40 PM, revealed the Incident Description included a Nursing Descriptions of Called to resident's room r/t (related to) resident had coffee spilled on left hip area and blisters noted.Resident alert to person. Stating it hurts, it hurts. The Injuries Observed at Time of Incident revealed a Burn to the Left thigh (front). Other Info included Resident was given coffee by another resident, and this resident spilled coffee on himself resulting in blisters forming to left hip area. There was no documentation indicating interventions to prevent re-occurrence being initiated.A record review of the Progress Notes revealed Resident #1 had a Skin Issues note effective 12/31/25 at 4:40 PM for .New skin issue.Front left trochanter.Blister.acquired in-house.12/31/2025.Length (cm): 7.06 Width (cm): 7.56 . A record review of the facility's Counseling/Discipline Report, dated 1/8/26, revealed License Practical Nurse (LPN) #1, was discharged from the facility. The Date(s) of Violation(s) was 12/29 through 12/30 (2025). Policies violated included .Sleeping or appearing to be asleep. The Employee's Statement revealed I was ill-my temp (temperature) was 101 degrees and blood sugar had dropped to 67. I do not remember this.In record review of the facility's investigation revealed, on 12/30/25 the Director of Nurses (DON) received a call at 1:30 AM from the nurse on station one. (LPN #2). She stated the nurse on station 2 isn't able to complete her med (medication) pass, she keeps falling asleep, I don't know what's going on with her. She advised her to send the nurse to the hospital. She said I can't be left here with both sides to do meds for 60 people the DON advised her to call the scheduler to see if she was able to get a nurse to come in and send the nurse on station 2 home. She was able to get a nurse to come at 3:00 AM. After the DON reviewed the camera footage of the incident that took place, she phoned LPN #1 and did not receive a return call from LPN #1. According to the camera footage, the DON observed the nurse at the nurse's station for about 2 hours. She pushed the cart into the hallway outside of the nurse's station. At this point, she stared at the computer for a long time and swayed around almost falling. LPN #1 appeared to be under the influence of something. She was stumbling around, staring at the med cart fumbling through the cart looking for meds, would pull a med card and just stare at it for minutes. At one point, she fell asleep at themed cart, in the dining room, with her head resting on the cart, the cart started to roll away, and she woke up. There was a resident in the dining room during this time, and he witnessed this incident. The aides came to her several times and woke her up, asking if she was OK. An aide put a chair behind her after she almost fell down, sleeping on the cart. She did not complete her med pass, she only gave meds to 2 residents. The [NAME] record review of a signed statement by Certified Nurse Assistant (CNA) #1, dated 12/30/25 at 2:30 PM, revealed, .around 8pm, she started falling asleep standing up. She started crying really loud and moaning. She went back and forth to the bathroom a lot. She fell asleep on the counter in the nurse's station.At one point she fell asleep with the med cart open.Around 11:40 we went and got the nurse from Station 1, and she tried to help with med pass.couldn't stay awake to pull meds or pass them. She almost fell down at the table. Her boyfriend/husband came to pick her up at 3:30.The resident's kept calling us to get their meds, we kept having to wake her up to tell her that residents were needing meds. A record review of a signed statement by CNA #2, dated 12/30/25 at 4:00 PM, revealed, When came in for our shift (LPN #1) was fine. Then she came up to me in the dining room and said she didn't feel good. Then she started crying and was half out of it. She was at the cart, leaned over with her eyes closed. Her legs were giving out, so I put a chair behind her. No one got their meds, everyone kept calling us for their meds. She kept going to sleep mid conversation. I wondered if she was 'high as hell'. She went to the bathroom a bunch of times for a long time. She kept falling asleep while she was trying to sign the narc (narcotics) book.We tried to get her to in an ambulance.but she refused.She was crying so loud I was having a hard time doing my charting. A record review of the facility's Medication Admin Audit Report for Station B with Documentation Type: Missed for 12/29/25 through 12/30/25 revealed 25 residents had medications with no administration time.A record review of the facility's Medication Admin Audit Report for Station B with Documentation Type: Late - 1.0 hours(s) for 12/29/25 through 12/30/25 revealed 5 residents had medications that were administered late. During an observation on 1/12/26 at 7:20 AM, there was a coffee machine located in the dining area accessible to residents. The machine was labeled out of service; however, the machine remained plugged in and operational. The State Agency obtained coffee from the machine without staff assistance or intervention and the coffee was hot. Residents were present in the dining area at the time of the observation, and no staff were observed supervising or restricting resident access to the coffee machine. No physical barriers were in place to prevent resident use of the machine despite the posted signage. In an interview on 1/12/26 at 7:30 AM, the Director of Nursing (DON) confirmed that on 12/31/25 at approximately 3:40 PM, a resident gave a cup of hot coffee to Resident #1 and Resident #1 then spilled it onto his left thigh, resulting in blistering. She reported nursing staff cleansed the affected area, measured the wound, applied a dressing, and notified the medical provider. The DON stated she was not aware of the coffee burn until she returned to the facility on 1/2/26 and confirmed there were no immediate interventions implemented to safeguard other residents who drink coffee until 1/6/26. She reported that the facility did not remove the coffee machines but added signs on 1/6/26 instructing staff and residents not to use the coffee machines, and began using coffee carafes instead. She stated she was not aware the coffee machines remained operational and were still being used as of 1/12/26, despite the signage instructing not to use them. The DON did not describe completing interviews with residents who drink coffee, review of the procedure to check coffee temperatures or environmental risks related to access to hot liquids to prevent recurrence. The DON also confirmed she was notified on 12/30/25 at approximately 1:30 AM by LPN #2 that LPN #1 appeared impaired while on duty and responsible for resident care and medication administration. She reported she verbally confirmed with LPN #2 that residents had received their medications but did not verify medication administration by reviewing Medication Administration Records, reviewing the Medication Audit Report for missed or late medications, or interviewing residents. She also did not describe reviewing all events leading up to and following the incident to determine root cause or to prevent recurrence. The DON confirmed she was aware that although LPN #1 was impaired, the nurse remained on duty and responsible for resident care until approximately 3:00 AM. In an interview on 1/12/26 at 11:50 AM, the Administrator acknowledged awareness of the incident occurring on the 12/29/25 evening shift involving LPN #1 who was observed falling asleep while assigned to administer medications and was unable to safely complete medication administration duties. He confirmed the nurse remained on duty until a replacement nurse arrived approximately eight (8) hours later. However, he stated he was told residents had received their medications and did not review Medication Administration Records, Medication Audit Reports, or other documentation to verify whether medications were administered accurately and timely. The Administrator also acknowledged awareness that Resident #1 sustained a burn injury after hot coffee spilled onto the resident's leg, stating the incident occurred on 12/31/25 but he was not aware of it until 1/6/26, six (6) days after the incident occurred. He reported signs were placed on the coffee machines on 1/6/26 instructing not to use the machines and stated he was not aware the coffee machines remained operational and were still being used as of 1/12/26, despite the signage. He confirmed there were no immediate interventions implemented to safeguard other residents who drink coffee or to assess environmental risks related to access to hot liquids immediately following the incident on 12/31/25. The Administrator did not describe initiating a formal investigation that included interviewing residents who drink coffee, interviewing residents who were under the care of the impaired nurse, reviewing documentation related to medication administration, or identifying root causes and corrective actions to prevent recurrence for either incident.The facility submitted the following acceptable Removal Plan on 1/13/26: On 1/13/2026 at 3:55pm the Immediate Jeopardy Templates for F600, F725, F609, F610, F838, F689 were provided to the Administrator. On 12/31/2025, Resident #1 sustained a burn from hot coffee at approximately 3:40pm. The facility failed to implement safeguards or supervision to protect other residents from exposure to the same hazard. Residents continued to have access to hot coffee in the Dining Room without supervision, temperature controls, or access restrictions. The facility failed to implement a thorough investigation and report to the State Agency. On 12/29/25, on the 7:00pm-7:00am shift, the residents on Station 1 remained under the care of an impaired licensed nurse who was unable to safely perform nursing duties. Medication Administration records showed multiple medications were not documented as administered or documented as given late. On 12/29/25, the 7:00pm-7:00am shift, there was no designated Charge Nurse after the scheduled charge nurse called in sick. Therefore, no nurse was designated to assume responsibility to supervise staff, coordinate care, or respond to unsafe conditions. This resulted in the Director of Nursing (DON) not being notified until 1:30am which allowed for the impaired nurse to stay in the facility until 3:30am. The facility failed to ensure the facility assessment dated [DATE] was updated appropriately and adequately identified staffing and supervisory needs by shift and failed to ensure individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments. The staffing plan did not include contingency planning for absence of supervisory nursing staff and did not ensure onsite licensed supervision when the scheduled charge nurse was absent. 1. On 1/12/26, coffee machines were removed out of service by the Maintenance Director. Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit. 2.Coffee Temperature logs were created and started on 1/13/2026 that indicate the staff member who tested the temperature of the coffee, the time and date. These logs will be turned into the Administrator daily. 3.Training for ALL staff, prior to their next scheduled shift beginning on 1/13/2026. Beginning on 1/13/26, no staff will be allowed to work until completion of training, provided by the Administrator, DON, and Staff Development Nurse.Accidents and Supervision including implementing immediate interventions. Abuse and Neglect Reporting and Investigation. Hot Liquids Policy. Notification of Administrator and Director of Nursing (DON) of unusual occurrences, High Risk Events and timely notification. Charge Nurse Delegation and Duties to include the assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse. If assigned charge nurse calls off, the off-going charge nurse will notify the DON for the next assignment. The DON and Administrator's phone numbers are posted on the Facility Assignment Grid. In the event that the charge nurse is impaired, the DON and Administrator will be contacted. Updated Facility Assignment Grid to include assignment for designated charge nurse. Medication Administration Documentation.1.On 1/12/26, all Residents were evaluated for Safety with Hot Liquids by the DON, Resident Care Coordinators #1 and # 2, Registered Nurses (RN) #1, 2, and 3.2.Administrator and DON were inserviced on 1/13/26 by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.3.The Facility Assessment was updated on 1/13/2026 by the Administrator to include a contingency plan for absence of supervisory nursing staff and adequately identified staffing needs by shift and building. 4.The facility's Assignment Grid was updated on 1/13/26 to reflect who the Charge Nurse would be each shift.5.The Scheduler and the Staff Development nurse were inserviced by the DON on 1/13/26 on the new Assignment Grid and Charge Nurse Delegation. The Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be. 6.On 1/13/26 all Resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found. 7.Emergency Quality Assessment and Assurance Committee Meeting held on 1/13/26. Attending the meeting was the Administrator, DON, Infection Preventionist, Minimum Data Set (MDS) Nurse, Social Services Director and Social Services Assistance, Medical Records, Admissions Coordinator, Dietary Manager, Housekeeping Supervisor, Maintenance Supervisor, Human Resources and Central Supply. The Medical Director was present via telephone. The Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy were reviewed with no changes recommended or made. Summary of incident was discussed with actions taken including training and monitoring. 8.The Attorney General Office and the Mississippi Board of Nursing were notified on 1/12/26 by the Administrator of incident involving LPN #1. LPN #2 was reported to the Agency that she works for and is not allowed to work at this facility.The facility alleges that all corrective actions to remove the immediacy were completed on 1/13/26 and IJ removed on 1/14/26. Validation: The SA validated the removal plan through observations, interviews, and record reviews on 1/13/26 and the immediacy was removed on 1/14/26 prior to exit.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the resident environment remained free of accident hazards when Resident #1 sustained a burn with blisters from hot coffee on 12/31/25 at approximately 3:40 PM and the facility failed to implement environmental controls or supervision to prevent other residents from exposure to the same hazard. Despite staff knowledge that hot coffee posed a burn risk, coffee pots remained accessible to residents in the dining room without supervision, temperature controls, or access restrictions until 1/12/26. This deficient practice affected one (1) of four (4) sampled residents (Resident #1) with the potential to affect all residents who drink hot coffee.The facility's failure to provide adequate supervision resulted in Resident #1 sustaining a burn with blisters and placed all residents who had access to hot coffee at likelihood for serious injury, serious harm, serious impairment, or death.The situation was determined to be Immediate Jeopardy (IJ) that began on 12/31/25 when Resident #1 sustained a burn from hot coffee. The facility Administrator was notified of the IJ on 1/13/26 at 3:40 PM and was presented with the IJ template. The facility provided an acceptable Removal Plan on 1/13/26, in which they alleged all corrective actions to remove the IJ were completed on 1/13/26.The State Agency (SA) validated the Removal Plan on 1/14/26 and determined that the IJ was removed on 1/14/26, prior to exit. Therefore, the scope and severity for 42 CFR S483.25(d)(2) Accidents/Hazards (F689) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.Findings include: A review of the facility's policy Safety of Hot Liquids created 7/25/22 revealed .Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions.Policy Interpretation and Implementation.3. Appropriate interventions will be implemented to minimize the risk from burns. Such interventions may include: a. maintaining a hot liquids serving temperature of not more than 140 degrees Fahrenheit.f. staff supervision or assistance with hot beverages.4. General safety precautions when serving hot liquids include, but are not limited to.d. Regulate temperature of hot liquids to which residents have direct access. A record review of the facility's policy Safety and Supervision of Residents revised 8/2/22 revealed, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation.1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes.3. When accident hazards are identified, The Quality Assurance Performance Improvement (QAPI)/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible.Individualized, Resident-Centered Approach to Safety.2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision.4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Documenting interventions A record review of the facility's incident report, dated 12/31/25 at 3:40 PM, revealed the Incident Description included a Nursing Descriptions of Called to resident's room r/t (related to) resident had coffee spilled on left hip area and blisters noted.Resident alert to person. Stating it hurts, it hurts. The Injuries Observed at Time of Incident revealed a Burn to the Left thigh (front). Other Info included Resident was given coffee by another resident, and this resident spilled coffee on himself resulting in blisters forming to left hip area.A record review of a handwritten statement signed by Certified Nurse Aide (CNA) #3 on 1/7/26 revealed that on 12/31/25 after 3:00 PM, revealed she and two (2) other CNAs were in the dining room and Resident #1 was sitting by the Christmas tree asleep. Another resident walked past Resident #1 and approximately 15 seconds she heard Resident #1 yelling, hey help me this hot. CNA #3, along with the other 2 CNAs, took the resident to his room and noticed that his left side was red. The wound care nurse was notified and came to check on the resident because he had spilled coffee on himself. A record review of the Progress Notes revealed Resident #1 had a Skin Issues note effective 12/31/25 at 4:40 PM for .New skin issue.Front left trochanter.Blister.acquired in-house.12/31/2025.Length (cm): 7.06 Width (cm): 7.56 . A record review of the facility's Hot/Cold Holding Temperature Log which was identified as Coffee logs revealed there were no coffee temperatures recorded prior to 1/6/26. The facility's Medical Director revealed on 1/12/26 at 7:00 AM, during an interview, that Resident #1 sustained a thermal injury to the left thigh as a result of hot coffee being spilled onto the resident's leg causing a 2nd degree burn. An observation on 1/12/26 at 7:20 AM, revealed there was a coffee machine located in the dining area accessible to residents. The machine was labeled out of service; however, the machine remained plugged in and operational. The State Agency obtained coffee from the machine without staff assistance or intervention and the coffee was hot. Residents were present in the dining area at the time of the observation, and no staff were observed supervising or restricting resident access to the coffee machine. No physical barriers were in place to prevent resident use of the machine despite the posted signage. The Director of Nursing (DON) revealed on 1/12/26 at 7:30 AM during an interview, that on 12/31/25 at approximately 3:40 PM, a resident provided hot coffee to Resident #1, which spilled onto the resident's left thigh and resulted in blistering to the affected area. The DON confirmed that nursing staff cleansed the area, measured the wound, applied a dressing, and notified the medical provider. The DON reported she did not become aware of the coffee burn incident until she returned to the facility on 1/2/26. She confirmed that upon becoming aware of the incident, no immediate corrective or preventive measures were implemented to reduce the risk of other residents sustaining burns from hot liquids. The DON explained that the incident was reviewed by facility leadership and determined to be accidental in nature, as staff were aware of how the incident occurred, and therefore leadership did not identify the need for additional interventions at that time. The DON confirmed that following the incident on 12/31/25, the facility continued to allow resident access to the coffee machines and did not restrict access, modify the coffee service process, or implement supervision or temperature-control measures. She acknowledged that no actions were taken between 12/31/25 and 1/6/26 to prevent similar incidents involving other residents. The DON further confirmed that on 1/6/26, the facility placed signs on the machines and began pouring the coffee into carafes as a safety measure. She acknowledged that this intervention was not implemented earlier and confirmed that the delay occurred because leadership did not initially consider the incident to pose an ongoing safety risk to other residents. The Administrator revealed on 1/12/26 at 11:50 AM, in an interview, that he was not made aware of the resident coffee burn that occurred on 12/31/25 until the facility stand-up meeting on 1/6/26. He acknowledged that the Director of Nursing did not notify him of the incident prior to that date. When asked why he was not informed earlier, the Administrator explained that no one at the facility brought the incident to his attention and indicated that, due to the holiday period, communication may have been missed. He confirmed that under normal circumstances, incidents involving resident injuries are communicated to him. The Administrator confirmed that once he became aware of the burn on 1/6/26, leadership discussed modifying the coffee service process by using the coffee machines to make the coffee and then pouring the coffee into coffee carafes. He acknowledged that he did not personally verify that corrective measures were implemented or consistently followed after that date. He confirmed there was no documented follow-up or monitoring to ensure resident access to hot coffee had been restricted. The Administrator was informed by the State Agency (SA) that upon arrival to the facility on 1/12/26 at approximately 7:30 AM, the SA was able to obtain hot coffee directly from the coffee machine located in the dining area, despite signage placed on the machine indicating it was out of service. The Administrator acknowledged this information and did not provide an explanation as to why the coffee machine remained operational. The facility discussed that after the coffee is prepared for the residents, dietary staff was to unplug the coffee machines, but upon the SA arrival they must not have unplugged the coffee machines. The Administrator further acknowledged that the facility did not fully implement or enforce the intervention to remove resident access to the coffee machines until the SA was present in the facility on 1/12/26. He confirmed that between the date of the incident on 12/31/25 and the SA's arrival on 1/12/26, residents continued to have access to hot coffee, and no system was in place to ensure the intervention discussed on 1/6/26 was being followed.On 1/12/26 at 2:00 PM, during an interview with Resident #2, he reported that residents continued to receive coffee from the coffee machines until the SA entered the facility. He explained that around the 1st of January, after the holidays, staff were expected to unplug the machines throughout the day; however, he observed that this did not consistently occur. Resident #2 reported that residents were still able to obtain coffee from the machines because they remained plugged in and usable. On 1/12/26 at 3:00 PM, the SA observed a sign on back of the dietary door revealing, Attention!!!! Every 2 hours whom ever the Aide is. Are to refill the coffee kettle pots on each side! Plug coffee machine in let it heat up and refill the kettle pot every 2 hours and then un plug the coffee machines! The coffee is to hot in the machine for the residents. Signed by: Dietary Manager. There was no date indicating when the sign was placed. On 1/13/26 at 11:00 PM, during an interview with the Dietary Manager, she confirmed that following the coffee-related burn injury on 12/31/25, the facility continued to use the coffee machines until 1/6/26. She confirmed that on 1/6/26, the facility still used the coffee machines to make the coffee but then transitioned the coffee to a coffee dispensary device. She explained there were Do Not Use signage on the coffee machines and provided in-services to dietary staff regarding testing coffee temperatures. She further confirmed that the coffee machines were not shut down and removed from the building until 1/12/26, after the SA entry.Resident #1 A record review of the admission Record revealed the facility admitted Resident #1 on 10/20/23 with diagnoses including Dementia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated his cognition was severely impaired.A record review of the Emergency Department Encounter, dated 1/6/26 revealed the Chief Complaint as .Patient brought in from (proper name of nursing home), family requesting patient be checked for everything.Patient has burn on left hip area that is being treated with wound care.since 12/31.HPI (History of Present Illness).presents to the emergency room with complaint of burn.patient was burned at the nursing home from a coffee spill a week ago.Resident #2A record of the admission Record revealed the facility admitted Resident #2 on 9/8/25 with diagnoses including Cerebral Infarction.A record review of the Quarterly MDS with an ARD of 12/10/25 revealed Resident #2 had a BIMS score of 15 which indicated he was cognitively intact.The facility submitted the following acceptable Removal Plan on 1/13/26: On 1/13/2026 at 3:55pm the Immediate Jeopardy Templates for F600, F725, F609, F610, F838, F689 were provided to the Administrator. On 12/31/2025, Resident #1 sustained a burn from hot coffee at approximately 3:40pm. The facility failed to implement safeguards or supervision to protect other residents from exposure to the same hazard. Residents continued to have access to hot coffee in the Dining Room without supervision, temperature controls, or access restrictions. The facility failed to implement a thorough investigation and report to the State Agency. On 12/29/25, on the 7:00pm-7:00am shift, the residents on Station 1 remained under the care of an impaired licensed nurse who was unable to safely perform nursing duties. Medication Administration records showed multiple medications were not documented as administered or documented as given late. On 12/29/25, the 7:00pm-7:00am shift, there was no designated Charge Nurse after the scheduled charge nurse called in sick. Therefore, no nurse was designated to assume responsibility to supervise staff, coordinate care, or respond to unsafe conditions. This resulted in the Director of Nursing (DON) not being notified until 1:30am which allowed for the impaired nurse to stay in the facility until 3:30am. The facility failed to ensure the facility assessment dated [DATE] was updated appropriately and adequately identified staffing and supervisory needs by shift and failed to ensure individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments. The staffing plan did not include contingency planning for absence of supervisory nursing staff and did not ensure onsite licensed supervision when the scheduled charge nurse was absent. 1. On 1/12/26, coffee machines were removed out of service by the Maintenance Director. Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit. 2.Coffee Temperature logs were created and started on 1/13/2026 that indicate the staff member who tested the temperature of the coffee, the time and date. These logs will be turned into the Administrator daily. 3.Training for ALL staff, prior to their next scheduled shift beginning on 1/13/2026. Beginning on 1/13/26, no staff will be allowed to work until completion of training, provided by the Administrator, DON, and Staff Development Nurse.Accidents and Supervision including implementing immediate interventions. Abuse and Neglect Reporting and Investigation. Hot Liquids Policy. Notification of Administrator and Director of Nursing (DON) of unusual occurrences, High Risk Events and timely notification. Charge Nurse Delegation and Duties to include the assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse. If assigned charge nurse calls off, the off-going charge nurse will notify the DON for the next assignment. The DON and Administrator's phone numbers are posted on the Facility Assignment Grid. In the event that the charge nurse is impaired, the DON and Administrator will be contacted. Updated Facility Assignment Grid to include assignment for designated charge nurse. Medication Administration Documentation.1.On 1/12/26, all Residents were evaluated for Safety with Hot Liquids by the DON, Resident Care Coordinators #1 and # 2, Registered Nurses (RN) #1, 2, and 3.2.Administrator and DON were inserviced on 1/13/26 by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.3.The Facility Assessment was updated on 1/13/2026 by the Administrator to include a contingency plan for absence of supervisory nursing staff and adequately identified staffing needs by shift and building. 4.The facility's Assignment Grid was updated on 1/13/26 to reflect who the Charge Nurse would be each shift.5.The Scheduler and the Staff Development nurse were inserviced by the DON on 1/13/26 on the new Assignment Grid and Charge Nurse Delegation. The Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be. 6.On 1/13/26 all Resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found. 7.Emergency Quality Assessment and Assurance Committee Meeting held on 1/13/26. Attending the meeting was the Administrator, DON, Infection Preventionist, Minimum Data Set (MDS) Nurse, Social Services Director and Social Services Assistance, Medical Records, Admissions Coordinator, Dietary Manager, Housekeeping Supervisor, Maintenance Supervisor, Human Resources and Central Supply. The Medical Director was present via telephone. The Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy were reviewed with no changes recommended or made. Summary of incident was discussed with actions taken including training and monitoring. 8.The Attorney General Office and the Mississippi Board of Nursing were notified on 1/12/26 by the Administrator of incident involving LPN #1. LPN #2 was reported to the Agency that she works for and is not allowed to work at this facility.The facility alleges that all corrective actions to remove the immediacy were completed on 1/13/26 and IJ removed on 1/14/26. Validation: The SA validated the removal plan through observations, interviews, and record reviews on 1/13/26 and the immediacy was removed on 1/14/26 prior to exit.

Based on interviews, record review, and facility policy review, the facility failed to ensure sufficient licensed nursing supervision and coordination of care when no licensed nurse was designated to serve as charge nurse for the night shift beginning at 7:00 PM on 12/29/25. The scheduled charge nurse called in sick, and no replacement charge nurse was designated. As a result, no licensed nurse was assigned responsibility to supervise staff, coordinate care, or respond to unsafe conditions. During this shift, residents on Station B remained under the care of an impaired licensed nurse who was unable to safely perform nursing duties, and leadership was not notified until approximately 1:30 AM on 12/30/25, with the impaired nurse not replaced until approximately 3:00 AM for one (1) of seven (7) shifts reviewed. The facility's failure to ensure a designated licensed charge nurse was present to supervise staff and coordinate resident care resulted in unsafe nursing care continuing for over eight (8) hours, including inability to verify timely and accurate medication administration, and placed all (29) residents residing on Station B at likelihood for serious injury, serious harm, serious impairment, or death.The situation was determined to be Immediate Jeopardy (IJ) that began on 12/29/25 at 7:00 PM when no charge nurse was designated and residents remained under the care of an impaired licensed nurse. The facility Administrator was notified of the IJ on 1/13/26 at 3:40 PM and was presented with the IJ template. The facility provided an acceptable Removal Plan on 1/13/26, in which they alleged all corrective actions to remove the IJ were completed on 1/13/26.The State Agency (SA) validated the Removal Plan on 1/14/26 and determined that the IJ was removed on 1/14/26, prior to exit. Therefore, the scope and severity for 42 CFR S483.35 Sufficient Nursing Staff (F725) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.Findings include: A review of the facility's policy Nursing Services and Sufficient Staff created 8/2/24 revealed .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.Policy Explanation and Compliance Guidelines.3. The facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. A record review of the facility's Counseling/Discipline Report, dated 1/8/26, revealed License Practical Nurse (LPN) #1, was discharged from the facility. The Date(s) of Violation(s) was 12/29 through 12/30 (2025). Policies violated included .Sleeping or appearing to be asleep. The Employee's Statement revealed I was ill-my temp (temperature) was 101 degrees and blood sugar had dropped to 67. I do not remember this.In record review of the facility's investigation revealed, on 12/30/25 the Director of Nurses (DON) received a call at 1:30 AM from the nurse on station one. (LPN #2). She stated the nurse on station 2 isn't able to complete her med (medication) pass, she keeps falling asleep, I don't know what's going on with her. She advised her to send the nurse to the hospital. She said I can't be left here with both sides to do meds for 60 people the DON advised her to call the scheduler to see if she was able to get a nurse to come in and send the nurse on station 2 home. She was able to get a nurse to come at 3:00 AM. After the DON reviewed the camera footage of the incident that took place, she phoned LPN #1 and did not receive a return call from LPN #1. According to the camera footage, the DON observed the nurse at the nurse's station for about 2 hours. She pushed the cart into the hallway outside of the nurse's station. At this point, she stared at the computer for a long time and swayed around almost falling. LPN #1 appeared to be under the influence of something. She was stumbling around, staring at the med cart fumbling through the cart looking for meds, would pull a med card and just stare at it for minutes. At one point, she fell asleep at themed cart, in the dining room, with her head resting on the cart, the cart started to roll away, and she woke up. There was a resident in the dining room during this time, and he witnessed this incident. The aides came to her several times and woke her up, asking if she was OK. An aide put a chair behind her after she almost fell down, sleeping on the cart. She did not complete her med pass, she only gave meds to 2 residents. A record review of a signed statement by Certified Nurse Assistant (CNA) #1, dated 12/30/25 at 2:30 PM, revealed, .around 8pm, she started falling asleep standing up. She started crying really loud and moaning. She went back and forth to the bathroom a lot. She fell asleep on the counter in the nurse's station.At one point she fell asleep with the med cart open.Around 11:40 we went and got the nurse from Station 1, and she tried to help with med pass.couldn't stay awake to pull meds or pass them. She almost fell down at the table. Her boyfriend/husband came to pick her up at 3:30.The resident's kept calling us to get their meds, we kept having to wake her up to tell her that residents were needing meds. A record review of a signed statement by CNA #2, dated 12/30/25 at 4:00 PM, revealed, When came in for our shift (LPN #1) was fine. Then she came up to me in the dining room and said she didn't feel good. Then she started crying and was half out of it. She was at the cart, leaned over with her eyes closed. Her legs were giving out, so I put a chair behind her. No one got their meds, everyone kept calling us for their meds. She kept going to sleep mid conversation. I wondered if she was 'high as hell'. She went to the bathroom a bunch of times for a long time. She kept falling asleep while she was trying to sign the narc (narcotics) book.We tried to get her to in an ambulance.but she refused.She was crying so loud I was having a hard time doing my charting. A record review of the facility's Medication Admin Audit Report for Station B with Documentation Type: Missed for 12/29/25 through 12/30/25 revealed 25 residents had medications with no administration time.A record review of the facility's Medication Admin Audit Report for Station B with Documentation Type: Late - 1.0 hours(s) for 12/29/25 through 12/30/25 revealed 5 residents had medications that were administered late. A record review of the facility's daily staffing schedule for 12/29/25 at Building 1 revealed LPN #1 was assigned to Station 2 for the 7P-7A (7:00 PM to 7:00 AM) shift on 12/29/25. Further review revealed the Supervisor 7P-7A name was marked through with vacation written in. There was no indication there was a charge nurse assigned to replace the staff member that was marked through on the schedule.A record review of the facility's Time Punch Report revealed on 12/29/25, LPN #1 punched in on 12/29/25 at 7:00 PM and punched out on 12/30/25 at 3:00 AM. LPN #2 punched in on 12/29/25 at 6:30 PM and punched out on 12/30/25 at 7:14 AM. LPN #3 punched in on 12/30/25 at 3:45 AM and punched out on 12/30/25 at 2:45 PM. On 1/12/26 at 7:30 AM, during an interview with the Director of Nursing (DON), she confirmed awareness that on 12/29/25 during the PM shift, LPN #1 was observed to be impaired and falling asleep while assigned to administer medications and provide resident care. The DON confirmed that at the time of the incident, there was no designated charge nurse providing direct supervision on the unit or responding to the unsafe conditions caused by the impaired nurse. She acknowledged that despite concerns regarding the nurse's ability to safely perform assigned duties, the nurse remained responsible for resident care and medication administration until a replacement nurse arrived, which was approximately eight (8) hours later. The DON confirmed the facility did not immediately remove the nurse from duty and acknowledged the absence of active supervisory oversight during the period the nurse remained impaired and responsible for resident care.On 1/12/26 at 11:50 AM, during an interview with the Administrator, he acknowledged awareness of an incident occurring on the 12/29/25 PM shift involving a licensed nurse who was observed falling asleep while assigned to administer medications and was unable to safely complete medication administration duties. The Administrator confirmed the nurse remained on duty until a replacement nurse arrived, which was approximately eight (8) hours later. The Administrator also acknowledged that the facility did not have a supervisor scheduled for the shift to oversee staff supervision, resident care, and unsafe conditions.On 1/13/26 at 10:00 AM, an interview with CNA #1 confirmed that during the incident involving an impaired nurse on 12/29/25, medications were not administered as ordered and staff relied on informally notifying the nurse on the other unit as there was no defined supervisor on duty to address the unsafe conditions.On 1/13/26 at 10:40 AM, during an interview with Registered Nurse (RN) #1, she confirmed she was not aware that the facility did not have a designated charge nurse assigned during the shift in which LPN #1 was observed to be impaired. She confirmed she could not identify a staff member assigned to provide charge nurse oversight or supervision at that time. The facility submitted the following acceptable Removal Plan on 1/13/26: On 1/13/2026 at 3:55pm the Immediate Jeopardy Templates for F600, F725, F609, F610, F838, F689 were provided to the Administrator. On 12/31/2025, Resident #1 sustained a burn from hot coffee at approximately 3:40pm. The facility failed to implement safeguards or supervision to protect other residents from exposure to the same hazard. Residents continued to have access to hot coffee in the Dining Room without supervision, temperature controls, or access restrictions. The facility failed to implement a thorough investigation and report to the State Agency. On 12/29/25, on the 7:00pm-7:00am shift, the residents on Station B remained under the care of an impaired licensed nurse who was unable to safely perform nursing duties. Medication Administration records showed multiple medications were not documented as administered or documented as given late. On 12/29/25, the 7:00pm-7:00am shift, there was no designated Charge Nurse after the scheduled charge nurse called in sick. Therefore, no nurse was designated to assume responsibility to supervise staff, coordinate care, or respond to unsafe conditions. This resulted in the Director of Nursing (DON) not being notified until 1:30am which allowed for the impaired nurse to stay in the facility until 3:30am. The facility failed to ensure the facility assessment dated [DATE] was updated appropriately and adequately identified staffing and supervisory needs by shift and failed to ensure individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments. The staffing plan did not include contingency planning for absence of supervisory nursing staff and did not ensure onsite licensed supervision when the scheduled charge nurse was absent. 1. On 1/12/26, coffee machines were removed out of service by the Maintenance Director. Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit. 2.Coffee Temperature logs were created and started on 1/13/2026 that indicate the staff member who tested the temperature of the coffee, the time and date. These logs will be turned into the Administrator daily. 3.Training for ALL staff, prior to their next scheduled shift beginning on 1/13/2026. Beginning on 1/13/26, no staff will be allowed to work until completion of training, provided by the Administrator, DON, and Staff Development Nurse.Accidents and Supervision including implementing immediate interventions. Abuse and Neglect Reporting and Investigation. Hot Liquids Policy. Notification of Administrator and Director of Nursing (DON) of unusual occurrences, High Risk Events and timely notification. Charge Nurse Delegation and Duties to include the assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse. If assigned charge nurse calls off, the off-going charge nurse will notify the DON for the next assignment. The DON and Administrator's phone numbers are posted on the Facility Assignment Grid. In the event that the charge nurse is impaired, the DON and Administrator will be contacted. Updated Facility Assignment Grid to include assignment for designated charge nurse. Medication Administration Documentation.1.On 1/12/26, all Residents were evaluated for Safety with Hot Liquids by the DON, Resident Care Coordinators #1 and # 2, Registered Nurses (RN) #1, 2, and 3.2.Administrator and DON were inserviced on 1/13/26 by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.3.The Facility Assessment was updated on 1/13/2026 by the Administrator to include a contingency plan for absence of supervisory nursing staff and adequately identified staffing needs by shift and building. 4.The facility's Assignment Grid was updated on 1/13/26 to reflect who the Charge Nurse would be each shift.5.The Scheduler and the Staff Development nurse were inserviced by the DON on 1/13/26 on the new Assignment Grid and Charge Nurse Delegation. The Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be. 6.On 1/13/26 all Resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found. 7.Emergency Quality Assessment and Assurance Committee Meeting held on 1/13/26. Attending the meeting was the Administrator, DON, Infection Preventionist, Minimum Data Set (MDS) Nurse, Social Services Director and Social Services Assistance, Medical Records, Admissions Coordinator, Dietary Manager, Housekeeping Supervisor, Maintenance Supervisor, Human Resources and Central Supply. The Medical Director was present via telephone. The Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy were reviewed with no changes recommended or made. Summary of incident was discussed with actions taken including training and monitoring. 8.The Attorney General Office and the Mississippi Board of Nursing were notified on 1/12/26 by the Administrator of incident involving LPN #1. LPN #2 was reported to the Agency that she works for and is not allowed to work at this facility.The facility alleges that all corrective actions to remove the immediacy were completed on 1/13/26 and IJ removed on 1/14/26. Validation: The SA validated the removal plan on 1/13/26 and the immediacy was removed on 1/14/26 prior to exit.

Based on interviews and record review the facility failed to ensure the facility assessment dated [DATE] was updated appropriately and failed to identify staffing and supervisory needs by shift and failed to ensure individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments. The facility assessment did not include contingency planning for absence of supervisory nursing staff and did not ensure onsite licensed supervision when the scheduled charge nurse was absent. On the night shift beginning at 7:00 PM on 12/29/25, the scheduled charge nurse called in sick, and no replacement charge nurse was designated. As a result, there was not a licensed nurse assigned the responsibility to supervise staff, coordinate care, or respond to unsafe conditions. Residents on Station B remained under the care of an impaired licensed nurse who was unable to safely perform nursing duties until approximately 3:00 AM on 12/30/25. This deficient practice affected four (4) of (4) sampled residents (Residents #1, #2, #3, and #4).The facility's failure to ensure the facility assessment accurately identified staffing, supervisory, and coordination of care needs by shift resulted in unsafe nursing care continuing without supervisory intervention, inability to verify timely and accurate medication administration, and placed all residents residing on Station B at likelihood for serious injury, serious harm, serious impairment, or death.The situation was determined to be Immediate Jeopardy (IJ) that began on 12/29/25 at 7:00 PM when no supervisory licensed nurse was designated and residents remained under the care of an impaired licensed nurse. The facility Administrator was notified of the IJ on 1/13/26 at 3:40 PM and was presented with the IJ template. The facility provided an acceptable Removal Plan on 1/13/26, in which they alleged all corrective actions to remove the IJ were completed on 1/13/26.The State Agency (SA) validated the Removal Plan on 1/14/26 and determined that the IJ was removed on 1/14/26, prior to exit. Therefore, the scope and severity for 42 CFR S483.71(c)(2)(3)(5) Facility Assessment (F838) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include:Record review of a typed statement on facility letterhead dated January 19, 2026, revealed To Whom it May Concern, (Proper name of facility) does not have a Facility Assessment Policy. A review of the facility's policy Nursing Services and Sufficient Staff created 8/2/24 revealed .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.Policy Explanation and Compliance Guidelines.3. The facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. A record review of the facility's policy Staffing, revised 7/21/22 revealed, .Our facility provides adequate staffing to meet needed care and services for our resident population.Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. A review of the facility assessment, dated 11/21/2024, revealed the assessment identified residents requiring medication administration, supervision, and safety monitoring. The assessment was not updated annually as required. It also did not identify staffing and supervisory needs by shift and did not include safeguards or contingency planning for absence of required nursing staff, including supervisory staff.A record review of the facility's Counseling/Discipline Report, dated 1/8/26, revealed License Practical Nurse (LPN) #1, was discharged from the facility. The Date(s) of Violation(s) was 12/29 through 12/30 (2025). Policies violated included .Sleeping or appearing to be asleep. The Employee's Statement revealed I was ill-my temp (temperature) was 101 degrees and blood sugar had dropped to 67. I do not remember this.In record review of the facility's investigation revealed, on 12/30/25 the Director of Nurses (DON) received a call at 1:30 AM from the nurse on station one. (LPN #2). She stated the nurse on station 2 isn't able to complete her med (medication) pass, she keeps falling asleep, I don't know what's going on with her. She advised her to send the nurse to the hospital. She said I can't be left here with both sides to do meds for 60 people the DON advised her to call the scheduler to see if she was able to get a nurse to come in and send the nurse on station 2 home. She was able to get a nurse to come at 3:00 AM. After the DON reviewed the camera footage of the incident that took place, she phoned LPN #1 and did not receive a return call from LPN #1. According to the camera footage, the DON observed the nurse at the nurse's station for about 2 hours. She pushed the cart into the hallway outside of the nurse's station. At this point, she stared at the computer for a long time and swayed around almost falling. LPN #1 appeared to be under the influence of something. She was stumbling around, staring at the med cart fumbling through the cart looking for meds, would pull a med card and just stare at it for minutes. At one point, she fell asleep at themed cart, in the dining room, with her head resting on the cart, the cart started to roll away, and she woke up. There was a resident in the dining room during this time, and he witnessed this incident. The aides came to her several times and woke her up, asking if she was OK. An aide put a chair behind her after she almost fell down, sleeping on the cart. She did not complete her medication pass; she only gave meds to 2 residents. A record review of a signed statement by Certified Nurse Assistant (CNA) #1, dated 12/30/25 at 2:30 PM, revealed, .around 8pm, she started falling asleep standing up. She started crying really loud and moaning. She went back and forth to the bathroom a lot. She fell asleep on the counter in the nurse's station.At one point she fell asleep with the med cart open.Around 11:40 we went and got the nurse from Station 1, and she tried to help with med pass.couldn't stay awake to pull meds or pass them. She almost fell down at the table. Her boyfriend/husband came to pick her up at 3:30.The resident's kept calling us to get their meds, we kept having to wake her up to tell her that residents were needing meds. A record review of a signed statement by CNA #2, dated 12/30/25 at 4:00 PM, revealed, When came in for our shift (LPN #1) was fine. Then she came up to me in the dining room and said she didn't feel good. Then she started crying and was half out of it. She was at the cart, leaned over with her eyes closed. Her legs were giving out, so I put a chair behind her. No one got their meds, everyone kept calling us for their meds. She kept going to sleep mid conversation. I wondered if she was 'high as hell'. She went to the bathroom a bunch of times for a long time. She kept falling asleep while she was trying to sign the narc (narcotics) book.We tried to get her to in an ambulance.but she refused.She was crying so loud I was having a hard time doing my charting. A record review of the facility's Medication Admin Audit Report for Station B with Documentation Type: Missed for 12/29/25 through 12/30/25 revealed 25 residents had medications with no administration time.A record review of the facility's Medication Admin Audit Report for Station B with Documentation Type: Late - 1.0 hours(s) for 12/29/25 through 12/30/25 revealed 5 residents had medications that were administered late. A record review of the facility's daily staffing schedule for 12/29/25 at Building 1 revealed LPN #1 was assigned to Station 2 for the 7P-7A (7:00 PM to 7:00 AM) shift on 12/29/25. A record review of the facility's Time Punch Report revealed on 12/29/25, LPN #1 punched in on 12/29/25 at 7:00 PM and punched out on 12/30/25 at 3:00 AM. LPN #2 punched in on 12/29/25 at 6:30 PM and punched out on 12/30/25 at 7:14 AM. LPN #3 punched in on 12/30/25 at 3:45 AM and punched out on 12/30/25 at 2:45 PM. On 1/13/26 at 10:00 AM, during an interview, CNA #1 reported she was not aware of any contingency plan for staff call offs. CNA #1 confirmed that during the incident involving an impaired nurse on 12/29/25, medications were not administered as ordered and staff relied on informally notifying the nurse on the other unit as there was no defined supervisor on duty to address the unsafe conditions because the charge nurse had called-in.On 1/13/26 at 10:20 AM, during an interview with the DON she explained the facility assessment identifies general resident care needs and that includes medication administration. While reviewing the assessment, she was unable to determine a contingency plan regarding staffing needs when there is a call off by staff, so that the residents received continuity of care when staffing changes occurred. On 1/13/26 at 11:00 AM, during an interview with the Administrator, he acknowledged awareness of the incident involving an impaired licensed nurse who was unable to safely administer medications on 12/29/25 and the absence of a designated charge nurse on the shift. He confirmed the current facility assessment was dated 11/13/24 and that it should have been updated annually. When asked how the facility assessment is used to guide staffing decisions and contingency planning, he explained staffing decisions are generally based on census and daily schedules and was unable to identify how the facility assessment is used to determine supervisory coverage needed or continuity of care when staffing changes occur. Resident #1 A record review of the admission Record revealed the facility admitted Resident #1 on 10/20/23 with diagnoses including Dementia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated his cognition was severely impaired.A record review of the Order Summary Report with active orders as of 1/13/26, revealed Resident #1 had a Physician's Order, dated 10/20/23, for Donepezil Hydrocholoride (HCL) Tablet 5 mg (milligram) Give 1 tablet by mouth at bedtime. 10/20/23).A record review of the Medication Administration Record (MAR) for December 2025 revealed there was no documentation indicating Resident #1 received the 12/29/25 8:30 PM dose of Donepezil HCL. Resident #2A record of the admission Record revealed the facility admitted Resident #2 on 9/8/25 with diagnoses including Cerebral Infarction.A record review of the Quarterly MDS with an ARD of 12/10/25 revealed Resident #2 had a BIMS score of 15 which indicated he was cognitively intact.A record review of the Order Summary Report with active orders as of 12/31/25, revealed Resident #2 had Physician's Orders for Crestor Oral Tablet 20 MG Give 1 tablet by mouth at bedtime for hyperlipidemia (dated 9/8/25), Latanoprost Ophthalmic Solution 0.005% Instill 1 drop in both eyes at bedtime for glaucoma (dated 9/8/25), Novolog Solution 100 UNIT/ML (milliliter), subcutaneously before meals and at bedtime for Diabetes Mellitus, (dated 9/8/25), and Trazodone HCL Oral Tablet 150 MG Give 1 tablet by mouth at bedtime for insomnia (dated 9/8/25). A record review of the Medication Administration Record (MAR) for December 2025 revealed there was no documentation indicating Resident #2 receiving the scheduled medications for 8:00 PM or 9:30 PM on 12/29/25.Resident #3 A record review of the admission Record revealed the facility admitted Resident #3 on 3/21/25 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction.A record review of the Quarterly MDS with an ARD 12/10/25 revealed Resident #3 had a BIMS score of 15, which indicated his cognition was intact. A record review of the Order Summary Report with active orders as of 12/31/25, revealed Resident #3 had Physician's Orders for Accucheck AC (before meals) and HS (at bedtime) for Diabetes (dated 3/21/25), Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for neuropathy, Guaifenesin Oral Tablet 400 MG Give 3 tablets by mouth two times a day for cough to equal 1200 MG, (dated 5/15/25), Keppra Oral Tablet 1000 MG Give 1.5 tablet by mouth two times a day for seizure activity take 1.5 tablets to equal dose of 1500 MG (dated 3/21/25), and Lacosamide Oral Tablet 100 MG by mouth two times a day for seizures (dated 10/9/25). A record review of the Medication Administration Record (MAR) for December 2025 revealed there was no documentation indicating Resident #3 receiving any of his 12/29/25 8:30 PM medications. Resident #4 A record review of the admission Record revealed the facility admitted Resident #4 on 7/1/25 with diagnoses including Senile Degeneration of Brain and Dementia. A record review of the Quarterly MDS with an ARD of 12/24/25 for revealed Resident #4 had a BIMS score of 9, which indicated her cognition was moderately impaired. impaired. A record review of the Order Summary Report with active orders as of 12/31/25, revealed Resident #4 had Physician's Orders for Clonidine HCL Oral Tablet 0.2 MG Give 1 tablet by mouth at bedtime for Hypertension (dated 7/1/25), Duloxetine HCL Capsule Delayed Release Particles 60 MG Give 1 capsule by mouth two times a day for depression (dated 7/1/25), and Gabapentin Oral Tablet 600 MG Give 1 tablet by mouth two times a day for Neuropathy (dated 7/1/25). A record review of the Medication Administration Record (MAR) for December 2025 revealed there was no documentation indicating Resident #4 receiving any of her 12/29/25 8:30 PM medications. The facility submitted the following acceptable Removal Plan on 1/13/26: On 1/13/2026 at 3:55pm the Immediate Jeopardy Templates for F600, F725, F609, F610, F838, F689 were provided to the Administrator. On 12/31/2025, Resident #1 sustained a burn from hot coffee at approximately 3:40pm. The facility failed to implement safeguards or supervision to protect other residents from exposure to the same hazard. Residents continued to have access to hot coffee in the Dining Room without supervision, temperature controls, or access restrictions. The facility failed to implement a thorough investigation and report to the State Agency. On 12/29/25, on the 7:00pm-7:00am shift, the residents on Station B remained under the care of an impaired licensed nurse who was unable to safely perform nursing duties. Medication Administration records showed multiple medications were not documented as administered or documented as given late. On 12/29/25, the 7:00pm-7:00am shift, there was no designated Charge Nurse after the scheduled charge nurse called in sick. Therefore, no nurse was designated to assume responsibility to supervise staff, coordinate care, or respond to unsafe conditions. This resulted in the Director of Nursing (DON) not being notified until 1:30am which allowed for the impaired nurse to stay in the facility until 3:30am. The facility failed to ensure the facility assessment dated [DATE] was updated appropriately and adequately identified staffing and supervisory needs by shift and failed to ensure individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments. The staffing plan did not include contingency planning for absence of supervisory nursing staff and did not ensure onsite licensed supervision when the scheduled charge nurse was absent. 1. On 1/12/26, coffee machines were removed out of service by the Maintenance Director. Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit. 2.Coffee Temperature logs were created and started on 1/13/2026 that indicate the staff member who tested the temperature of the coffee, the time and date. These logs will be turned into the Administrator daily. 3.Training for ALL staff, prior to their next scheduled shift beginning on 1/13/2026. Beginning on 1/13/26, no staff will be allowed to work until completion of training, provided by the Administrator, DON, and Staff Development Nurse.Accidents and Supervision including implementing immediate interventions. Abuse and Neglect Reporting and Investigation. Hot Liquids Policy. Notification of Administrator and Director of Nursing (DON) of unusual occurrences, High Risk Events and timely notification. Charge Nurse Delegation and Duties to include the assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse. If assigned charge nurse calls off, the off-going charge nurse will notify the DON for the next assignment. The DON and Administrator's phone numbers are posted on the Facility Assignment Grid. In the event that the charge nurse is impaired, the DON and Administrator will be contacted. Updated Facility Assignment Grid to include assignment for designated charge nurse. Medication Administration Documentation.1.On 1/12/26, all Residents were evaluated for Safety with Hot Liquids by the DON, Resident Care Coordinators #1 and # 2, Registered Nurses (RN) #1, 2, and 3.2.Administrator and DON were inserviced on 1/13/26 by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.3.The Facility Assessment was updated on 1/13/2026 by the Administrator to include a contingency plan for absence of supervisory nursing staff and adequately identified staffing needs by shift and building. 4.The facility's Assignment Grid was updated on 1/13/26 to reflect who the Charge Nurse would be each shift.5.The Scheduler and the Staff Development nurse were inserviced by the DON on 1/13/26 on the new Assignment Grid and Charge Nurse Delegation. The Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be. 6.On 1/13/26 all Resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found. 7.Emergency Quality Assessment and Assurance Committee Meeting held on 1/13/26. Attending the meeting was the Administrator, DON, Infection Preventionist, Minimum Data Set (MDS) Nurse, Social Services Director and Social Services Assistance, Medical Records, Admissions Coordinator, Dietary Manager, Housekeeping Supervisor, Maintenance Supervisor, Human Resources and Central Supply. The Medical Director was present via telephone. The Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy were reviewed with no changes recommended or made. Summary of incident was discussed with actions taken including training and monitoring. 8.The Attorney General Office and the Mississippi Board of Nursing were notified on 1/12/26 by the Administrator of incident involving LPN #1. LPN #2 was reported to the Agency that she works for and is not allowed to work at this facility.The facility alleges that all corrective actions to remove the immediacy were completed on 1/13/26 and IJ removed on 1/14/26. Validation: The SA validated the removal plan on 1/13/26 and the immediacy was removed on 1/14/26 prior to exit.

Based on interviews, record review, and facility policy review, the facility failed to maintain complete and accurate medical records to document the services provided for four (4) of (4) sampled residents (Residents #1, #2, #3, and #4). Specifically, review of the Medication Administration Records (MARs) for the night shift of 12/29/25 revealed multiple medications were not documented as administered and medication administration could not be verified as accurate and timely.Findings include:A review of the facility's policy Administering Medications revised 8/2/22 revealed, Medications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation.10. The resident must be observed taking the medication.14.The nurse will document on the EMAR (Electronic Medication Administration Record) when the medication is administered to the resident.A record review of the facility's Medication Admin Audit Report for Station B with Documentation Type: Missed for 12/29/25 through 12/30/25 revealed 25 residents had medications with no administration time.A record review of the facility's Medication Admin Audit Report for Station B with Documentation Type: Late - 1.0 hours(s) for 12/29/25 through 12/30/25 revealed 5 residents had medications that were administered late. On 1/12/26 at 7:30 AM, during an interview with the Director of Nursing (DON), she confirmed the facility policy requires licensed nurses to document all medications administered, held, or not administered on the Medication Administration Record (MAR) at the time of administration. She confirmed the facility had an impaired nurse on 12/29/25 but she had been told by Licensed Practical Nurse (LPN) #2 that the residents' medications had been administered. She did not verify documentation of the medications at that time and was not aware that the residents' medications were not documented as administered. She explained that she expected staff to document medication at the time administered.On 1/12/26 at 10:47 AM, during an interview with LPN #2, she confirmed that she accessed the medication cart and pulled medications for LPN #1 who was impaired, however, she did not administer the medications herself. LPN #2 reported that she did not document the medications on the MARs and did not accompany or observe the impaired nurse during medication administration. She confirmed that she did not visually verify that the correct medications were administered to the correct residents and did not perform any checks to ensure medications were given as ordered. She explained that she assumed the medications were administered correctly based on the impaired nurse's familiarity with the residents. She reported that no follow-up verification was completed to confirm that all medications were administered, documented, or administered accurately to the appropriate residents on Station 2 during that medication pass on 12/29/25.Resident #1 A record review of the admission Record revealed the facility admitted Resident #1 on 10/20/23 with diagnoses including Dementia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated his cognition was severely impaired.A record review of the Order Summary Report with active orders as of 1/13/26, revealed Resident #1 had a Physician's Order, dated 10/20/23, for Donepezil Hydrocholoride (HCL) Tablet 5 mg (milligram) Give 1 tablet by mouth at bedtime. 10/20/23).A record review of the Medication Administration Record (MAR) for December 2025 revealed there was no documentation indicating Resident #1 received the 12/29/25 8:30 PM dose of Donepezil HCL. Resident #2A record of the admission Record revealed the facility admitted Resident #2 on 9/8/25 with diagnoses including Cerebral Infarction.A record review of the Quarterly MDS with an ARD of 12/10/25 revealed Resident #2 had a BIMS score of 15 which indicated he was cognitively intact.A record review of the Order Summary Report with active orders as of 12/31/25, revealed Resident #2 had Physician's Orders for Crestor Oral Tablet 20 MG Give 1 tablet by mouth at bedtime for hyperlipidemia (dated 9/8/25), Latanoprost Ophthalmic Solution 0.005% Instill 1 drop in both eyes at bedtime for glaucoma (dated 9/8/25), Novolog Solution 100 UNIT/ML (milliliter), subcutaneously before meals and at bedtime for Diabetes Mellitus, (dated 9/8/25), and Trazodone HCL Oral Tablet 150 MG Give 1 tablet by mouth at bedtime for insomnia (dated 9/8/25). A record review of the Medication Administration Record (MAR) for December 2025 revealed there was no documentation indicating Resident #2 receiving the scheduled medications for 8:00 PM or 9:30 PM on 12/29/25.Resident #3 A record review of the admission Record revealed the facility admitted Resident #3 on 3/21/25 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction.A record review of the Quarterly MDS with an ARD 12/10/25 revealed Resident #3 had a BIMS score of 15, which indicated his cognition was intact. A record review of the Order Summary Report with active orders as of 12/31/25, revealed Resident #3 had Physician's Orders for Accucheck AC (before meals) and HS (at bedtime) for Diabetes (dated 3/21/25), Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for neuropathy, Guaifenesin Oral Tablet 400 MG Give 3 tablets by mouth two times a day for cough to equal 1200 MG, (dated 5/15/25), Keppra Oral Tablet 1000 MG Give 1.5 tablet by mouth two times a day for seizure activity take 1.5 tablets to equal dose of 1500 MG (dated 3/21/25), and Lacosamide Oral Tablet 100 MG by mouth two times a day for seizures (dated 10/9/25). A record review of the Medication Administration Record (MAR) for December 2025 revealed there was no documentation indicating Resident #3 receiving any of his 12/29/25 8:30 PM medications. Resident #4 A record review of the admission Record revealed the facility admitted Resident #4 on 7/1/25 with diagnoses including Senile Degeneration of Brain and Dementia. A record review of the Quarterly MDS with an ARD of 12/24/25 for revealed Resident #4 had a BIMS score of 9, which indicated her cognition was moderately impaired. impaired. A record review of the Order Summary Report with active orders as of 12/31/25, revealed Resident #4 had Physician's Orders for Clonidine HCL Oral Tablet 0.2 MG Give 1 tablet by mouth at bedtime for Hypertension (dated 7/1/25), Duloxetine HCL Capsule Delayed Release Particles 60 MG Give 1 capsule by mouth two times a day for depression (dated 7/1/25), and Gabapentin Oral Tablet 600 MG Give 1 tablet by mouth two times a day for Neuropathy (dated 7/1/25). A record review of the Medication Administration Record (MAR) for December 2025 revealed there was no documentation indicating Resident #4 receiving any of her 12/29/25 8:30 PM medications.

Based on record review and staff interviews, the facility failed to complete a required Significant Change PASRR (Preadmission Screening and Resident Review) for 1 (one) of 23 (twenty-three) sampled residents (resident #113) after the initiation of an antipsychotic medication. The facility's failure to complete the Significant Change PASRR prevented the appropriate evaluation of the resident's mental health needs and compliance with federal PASRR requirements. A record review of the Level I PASARR dated July 9, 2019, was completed prior to admission. A review of the admission Record revealed Resident #113 was admitted to the facility on [DATE], with a diagnosis of chronic systolic heart failure. A subsequent review of the admission Record revealed the resident was diagnosed with unspecified psychosis not due to a substance or known physiological condition on May 15, 2025.A review of the Significant Change in Status Minimum Data Set (MDS) with an Assessment Reference ARD) of September 19, 2025, revealed Section C documented a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. The same Significant Change MDS, Section I, documented active diagnoses of anxiety disorder, depression, and psychotic disorder (other than schizophrenia).A review of the facility's Resident Assessment - Coordination with PASARR Program Policy, revised June 1, 2023, revealed the Social Services Director is responsible for tracking residents' PASARR screening status and referring residents to the appropriate authority. The policy further revealed any resident who exhibits newly evident or possible serious mental disorder is to be promptly referred to the state mental health or intellectual disability authority for a Level II PASARR review, including residents who receive a new order for antipsychotic or psychotropic medication when not previously taking such medications prior to admission.A review of psychiatry visit notes dated December 28, 2024, and September 14, 2025, reflected the resident was prescribed antipsychotic medication. A record review of the resident's physician orders revealed Vraylar 1.5 mg (milligrams) prescribed on January 25, 2024, and an increased dose of Vraylar 6 mg ordered on April 6, 2025, for treatment of psychosis.On December 17, 2025, at 11:29 AM, during an interview, the Social Services Director, stated that Resident #113 receives psychiatric services and was last seen by Psychiatrist, on October 25, 2025.On December 17, 2025, at 2:50 PM, during an interview, the Director of Nursing stated that the psychiatric nurse practitioner was terminated in October 2025, and the facility was actively seeking a replacement provider. She further stated that, in the interim, the Medical Director and nurse practitioner were seeing residents with lower BIMS scores until a new psychiatric provider was obtained.On December 18, 2025, at 10:30 AM, during an interview, the Social Services Director stated that Resident #113 did not have a PASARR Level II completed due to failure to submit the referral. She further stated that she was unaware that a Level II PASARR submission was required.On December 18, 2025, at 11:21 AM, during a follow-up interview and medication review with the Social Services Director, it was confirmed that Resident #113 had been prescribed psychotropic medication since December 2024 and that no Significant Change PASARR Level II referral had been submitted.On December 18, 2025, at 1:46 PM, during an interview, the State Agent informed the Administrator of the failure to complete a PASARR Level II evaluation following the resident's psychotropic medication use and documented mental health diagnoses. The Administrator stated that his expectation is for staff to follow PASARR policy requirements.

Based on interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan with appropriate interventions for a resident diagnosed with a urinary tract infection (UTI) for one (1) of 23 sampled residents, Resident #7. Findings include:A review of the facility's policy Comprehensive Care Plans with revised date 8/24/22 revealed . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.A record review of the admission Record revealed the facility admitted Resident #7 on 07/31/2025 with diagnoses including Polyneuropathy. A record review of the Results Urine Culture which was lasted resulted on 12/10/2025, revealed Resident #7 had a urine culture that was positive for greater than 100 thousand counts for an Klebsiella pneumoniae (a type of bacteria).A record review of the Order Summary Report revealed Resident #7 had a Physician's Order, dated 12/10/2025, for Cefuroxime Axetil (an antibiotic medication) with instructions to Give 1 tablet by mouth two times a day for UTI.A record review of Resident #7's medical record revealed no comprehensive care plan with interventions was developed to address the diagnosis of a urinary tract infection (UTI) or to identify the resident as at risk for UTI.On 12/16/2025 at 2:45 PM, during an interview with Licensed Practical Nurse (LPN)#1, he confirmed that Resident #7 is currently being treated with antibiotics for UTI. On 12/17/25 at 1:00 PM, during an interview with Registered Nurse (RN) #2, she explained care plans were updated when a resident had a new medication or a change in condition and were also reviewed and updated during quarterly and annual reviews.On 12/17/25 at 1:45 PM, during an interview with RN #3, she confirmed a urine culture for Resident #7 was positive with greater than 100,000 colony counts for an organism, and the resident was started on antibiotic therapy for seven (7) days for a diagnosis of Urinary Tract Infection (UTI). She confirmed Resident #7 did not have a care plan addressing the UTI diagnosis or a care plan identifying the resident as at risk for UTI.On 12/18/25 at 12:03 PM, during an interview with the Director of Nursing (DON), she explained the purpose of the care plan was to guide staff on how to care for the resident. She indicated that if a resident had a current Urinary Tract Infection (UTI) and was receiving antibiotic therapy, she would expect a care plan to be developed to inform staff of the resident's condition and identify appropriate interventions to be implemented during care.

Based on observation, interview, and facility policy review, the facility failed to store medications in a safe and secure manner for two (2) of four (4) medication carts reviewed.Findings included:A review of the facility policy, Storage of Medications, revised 8/2/22, revealed, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation.7. Compartments (including, but not limited to.carts.containing drugs and biologicals shall be locked when not in use.carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.On 12/17/25 at 8:05 AM, during an observation of medication pass in Building One with Licensed Practical Nurse (LPN) #1, the medication cart was observed left unattended and unlocked on the resident hallway while LPN #1 went to the medication room. The medication cart remained unattended and unlocked from 8:15 AM to 8:20 AM.On 12/17/25 at 8:21 AM, during an interview with LPN #1, he confirmed that the medication cart was left unlocked while he went to the medication room. He explained that the cart contained medications for multiple residents and acknowledged that a resident could have accessed the cart while he was away. On 12/17/25 at 8:30 AM, an observation of the contents of the medication cart revealed multiple medications stored on the cart, including over-the-counter medications such as aspirin, vitamins, acetaminophen (Tylenol), eye drops, and prescription blood pressure medications.On 12/17/25 at 10:33 AM, during an interview with the Director of Nursing (DON), she explained that medication carts are required to remain locked at all times when not in use in accordance with facility policy. She stated the purpose of locking the cart is to protect residents from accessing medications not intended for them and confirmed staff had received training multiple times related to medication cart security.On 12/17/25 from 2:50 PM to 3:03 PM, during an observation in Building Two, a medication cart was observed left unattended and unlocked on the resident hallway.On 12/17/25 at 3:04 PM, during an interview with LPN #2, she confirmed the medication cart was unlocked and then locked the cart. She explained that she left the cart unlocked while responding to an event involving a resident on the other side of the building. She acknowledged that medication carts should remain locked to prevent residents from accessing medications not prescribed to them.

Based on record review, staff interview, and facility policy review, the facility failed to ensure an advance directive, specifically a durable Power of Attorney (POA), was available and readily retrievable by facility staff for one (1) of 32 residents reviewed for advance directives. (Resident #100). This deficient practice had the potential to affect all residents who had a durable POA. Findings Include: A review of the facility's policy, Residents' Rights Regarding Treatment and Advanced Directives, revised 11/1/22, revealed, Policy: It is the policy of this facility to support and facilitate a resident's right to .formulate an advance directive. Definitions: Advance Directive is a written instruction, such as a . durable power of attorney for health care .Policy Explanation and Compliance Guidelines .3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart . Record review of the Acknowledgement of Advance Directives Decisions, Rights, and Information, signed 2/9/24, which was located in the electronic health record and signed by the Resident Representative (RR), indicated Resident #100 had a Living Will. Upon review of the medical record, there was no copy of an advance directive or POA located in the medical chart. On 5/20/24 at 1:15 PM, in an interview and record review with Registered Nurse (RN) #1, she stated advance directives are in the resident's electronic chart and reviewed the electronic health record for Resident #100. She acknowledged there was no advance directive located under the Misc (Miscellaneous) tab of the electronic chart. She confirmed there were no paper charts or other areas of the nurse's station where advance directives would be kept. She commented that if a resident had an advance directive, she thought it would be listed under the Special Instructions which was readily viewable by all staff. She confirmed there were no instructions listed on the special instructions section for Resident #100. On 5/20/24 at 1:45 PM, in an interview with the Director of Nursing (DON), she revealed Resident #100 did not have a living will but clarified the RR had provided a POA to the facility and he had incorrectly checked the Living Will while electronically signing the admission paperwork. The DON explained the POA could be viewed on the Administration Side of the electronic health record and not the Clinical Side, which meant the POA could not be viewed by nurses or clinical staff. The DON provided a paper copy of Resident #100's POA and advised she would have the POA scanned into the Misc tab on the electronic medical record. On 5/20/24 at 1:56 PM, in an interview with the Admission Coordinator, she explained she was responsible for discussing advance directives with residents and the RR upon admission to the facility. She stated if a resident had a POA, she kept a copy in a binder. She further explained the binder was in an office that was locked after hours and on weekends, and was located in Building 2, which was a separate building from Building 1. The Admissions Coordinator confirmed POAs were not readily retrievable by facility staff. A record review of the Admission Record revealed the facility admitted Resident #100 on 2/22/24 and she had current diagnoses including Hemiplegia and Hemiparesis.

Based on staff interview, record review, and facility policy review, the facility failed to revise comprehensive care plan interventions related to oxygen therapy (Resident #3), pain management (Resident #103), and trauma-informed care (Resident #62) for three (3) of 21 sampled residents. Findings include: A review of the facility's policy, Comprehensive Care Plans, revised 8/24/22, revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .Definitions . Trauma-Informed care is an approach to delivering care that involves understanding, recognizing, and responding to effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans .Policy Explanation and Compliance Guidelines .3. The comprehensive care plan will describe .a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effort of the trigger on the resident . Resident #3 A record review of the comprehensive care plan with a date initiated of 5/1/2024 revealed Problem The resident has COPD (Chronic obstructive pulmonary disease) .Interventions .Oxygen Settings: O2 via nasal cannula @ 2L continuously . Further review revealed a Problem of The resident has oxygen therapy r/t (related to) Ineffective gas exchange with Interventions of Oxygen settings: O2 via NC 2/L .PRN (as needed). A record review of the Order Summary Report, with active orders as of 5/21/24, revealed Resident #3 had a Physician's Order, dated 3/20/24, for O2 (Oxygen) at 2L/min (liters per minute), TITRATE TO KEEP O2 SATS (Saturation) > 92%. A record review of the Admission Record revealed the facility admitted Resident #3 on 1/6/22 and she had current diagnoses including Chronic Obstructive Pulmonary Disease (COPD). On 5/21/24 at 2:30 PM, in an interview with Registered Nurse (RN) #5, she confirmed Resident #3 had a physician's order to titrate her oxygen which meant it should be applied as needed to keep her oxygen saturation above 92%. On 5/21/24 at 2:51 PM, in an interview with RN #2, she confirmed the comprehensive care plan for Resident #3 had conflicting oxygen orders because one care plan indicated the oxygen was used continuously and the other care plan indicated the oxygen was to be used as needed. She explained the staff had been auditing care plan and reconciling them with orders and this care revision could have been missed. She stated she expected the facility staff to follow the care plan and to advise the care plan nurse if there were conflicting interventions. Resident #103 A record review of the comprehensive care plan with a date initiated of 3/29/204, revealed Problem The resident has acute/chronic pain r/t (related to) Disease process CANCER .Interventions .Fentanyl Patch 72 HR 25 MCG/HR (Micrograms/Hour) Q72H (every 72 hours) for Pain . There was no care plan intervention addressing the Physician's Order for morphine sulfate. A record review of the Order Summary Report, with active orders as of 5/22/24, revealed Resident #103 had a Physician's Order, dated 4/18/24, for Fentanyl Transdermal Patch 72 Hour 75 MCG/HR (micrograms/hour) and an order dated 5/17/24 for Morphine Sulfate .10 MG (milligrams)/0.5 ml (milliliters) q (every) 4 hours for pain. A record review of the Admission Record revealed the facility admitted Resident #103 on 3/8/24 and she had current medical diagnoses including Malignant Neoplasm of the Ovary, Colon, and Rectum. On 5/22/24 at 9:50 AM, in an interview with RN #2, she explained she was the Minimum Data Set (MDS) nurse. She stated the facility ran a report every day and reviewed all new physician orders that were written. The care plan nurse then revised the care plan for residents based on the physician's orders. On 5/22/24 at 10:03 AM, in an interview with Licensed Practical Nurse (LPN #1), she explained that she was responsible for updating or revising the care plans. She confirmed Resident #103's care plan was not revised to include recent physician orders to increase the Fentanyl patch to 75 mcg and to add morphine sulfate. She stated the staff tried to review care plans periodically to ensure they accurately reflected the resident's care and physician's orders. On 5/22/24 at 10:30 AM, in an interview with the Director of Nursing (DON), she stated she expected resident care plans to be accurate and match the resident's orders and confirmed care plans were used by staff to provide care to the residents. Resident #62 A record review of the comprehensive care plan for Resident #62, undated, revealed Problem The resident has potential for psychosocial well-being r/t (related to) hx (history) of PTSD . The care plan was not revised to include interventions to identify triggers and prevent re-traumatization of the resident. Record review of the Admission Record revealed the facility admitted Resident #62 on 11/13/2023 and he had a diagnosis of Post Traumatic Stress Disorder (PTSD) with an onset date of 11/13/2023. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/22/23, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated his cognition was moderately impaired. Further review of Section I for Active Diagnoses revealed he had a diagnosis of PTSD. On 05/23/24 at 9:45 AM, an interview with Licensed Practical Nurse (LPN) #1, she confirmed the care plan was not revised for Resident #62 related to the diagnosis of PTSD, including information regarding the resident's triggers. She reviewed the electronic medical record and stated she would review her information and revise the residents care plan. On 05/23/24 at 9:50 AM, during an interview with the Social Services (SS) Designee, confirmed that a care plan with interventions would be helpful for staff to know how to care for the resident to avoid re-traumatization. On 05/23/24 at 9:55 AM, in an interview with the Director of Nursing (DON), she stated she expected the facility to revise comprehensive care plans related to residents with PTSD to include the triggers for residents. She also stated that she expected the care plan to contain interventions to prevent re-traumatization of the residents. 37415

Based on observation, staff interviews, and facility policy review, the facility failed to discard expired foods and failed to label opened foods with a use-by date for one (1) of three (3) kitchen observations. Findings include: A review of the facility's policy, Food Safety Requirements, revised [DATE], revealed, .Food will be stored .in accordance with professional standards for food safety .Policy Interpretation and Implementation .1. Food safety will be followed throughout the facility's entire food handling process .b. Storage of food in a manner that helps prevent deterioration or contamination of the food .3. Facility will inspect all food .and ensure timely and proper storage .c. Refrigerated storage .Practices to maintain safe refrigerated storage include .iv. labeling, dating, and monitoring refrigerated food . On [DATE] at 8:00 AM, during the initial tour of the kitchen with the Dietary Manager (DM) #1 of Building 1, revealed an opened gallon of buttermilk in the Cook's Refrigerator with a manufacturer's expiration date of ,d+[DATE]. DM #1 confirmed the buttermilk was expired. On [DATE] at 8:00 AM, during the initial tour of the kitchen with DM #2, the walk-in refrigerator had clear containers of olives that did not have an opened or use-by date and an opened container of sour cream with no opened or use-by date. DM #2 confirmed the containers of olives and sour cream did not have a use-by date. On [DATE] at 10:12 AM, in an interview with DM #1 and DM #2, they stated it was everyone's responsibility to ensure opened foods were labeled with a use-by date and expired foods were discarded, but it was ultimately their responsibility to oversee that it was done.

Based on observation, staff interview, and record review, the facility failed to store an O2 (Oxygen) nasal cannula and a nebulizer mask in a designated container and failed to change or discard a disposable humidifier water bottle timely for one (1) of two (2) residents reviewed for oxygen therapy. Resident #3 Findings include: Record review of the facility's policy, Oxygen Administration, revised 8/2/22, revealed Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration . However, the policy did not address O2 and Nebulizer tubing storage or changing the disposable water humidifier bottle. On 5/20/24 at 9:13 AM, Resident #3 was observed sleeping in bed. She was not wearing oxygen and there was an O2 concentrator located next to the bed and bedside table. There was a nasal cannula tubing wrapped around the concentrator and not stored in a bag. The disposable humidifier water bottle attached to the concentrator had a handwritten date of 12/21/23, was half full, and was attached to a nasal cannula tubing that was dated 5/16/24. There was a nebulizer machine on the bedside table and the mask was hanging down the side of the bedside table and not stored in a designated bag or container. A record review of the Admission Record revealed the facility admitted Resident #3 on 1/6/22 and she had current diagnoses including Chronic Obstructive Pulmonary Disease (COPD). A record review of the Order Summary Report, with active orders as of 5/21/24, revealed Resident #3 had a Physician's Order, dated 3/20/24, for O2 (Oxygen) at 2L/min (liters per minute), TITRATE TO KEEP O2 SATS (Saturation) > 92% and a Physician's Order, dated 11/20/23 for Ipratropium-Albuterol Solution 0.5-2.5 .1 vial inhale orally every 12 hours as needed . On 5/21/24 at 2:10 PM, an interview with Licensed Practical Nurse (LPN) #2 revealed Resident #3 was not currently using oxygen because it was ordered as needed and LPN #2 stated the resident had not needed to wear it recently. He stated that he did not look at the oxygen water humidifier bottle or how the tubing was stored because the night shift staff were responsible for changing those out weekly. On 5/21/24 at 2:30 PM, in an interview and observation in Resident #3's room with Registered Nurse (RN) #5, she confirmed the O2 nasal cannula and nebulizer mask were not stored in a designated container and stated they should have been stored in a bag. She also verified the O2 concentrator water humidifier bottle was dated 12/21/23 and thought it should be changed weekly. On 5/22/24 at 10:30 AM, in an interview with the Director of Nursing (DON), she stated she expected oxygen nasal cannula tubing and nebulizer masks to be stored appropriately and for staff to change or discard oxygen humidifier bottles timely.

Based on interviews, record review, and facility policy review, the facility failed to ensure triggers and resident specific interventions were identified and initiated for a resident with Post Traumatic Stress Disorder (PTSD) for one (1) of 21 sampled residents. Resident #62 Findings include: A review of the facility's policy, Trauma Informed Care, revised 6/1/23, revealed, .It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re -traumatization .Policy Explanation and Compliance Guidelines .2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools .4. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other care professionals .to develop and implement individualized care plan interventions. 5. The facility will identify triggers which may re-traumatize residents with the history of trauma. Trigger- specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan .9. In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident . Record review of the Admission Record revealed the facility admitted Resident #62 on 11/13/2023 and he had a diagnosis of PTSD with an onset date of 11/13/2023. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/22/23, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated his cognition was moderately impaired. Further review of Section I for Active Diagnoses revealed he had a diagnosis of PTSD. A record review of the Life History document, dated 11/14/23, indicated Resident #62 had experienced physical, mental abuse, trauma, traumatic experience are significant fears in the past and resident .attempted to commit suicide a few years ago . A record review of the facility's .Trauma Screening Questionnaire, dated 11/15/23, revealed in Section 3 Resident has been evaluated and treated related to history of PTSD. A review of the medical record revealed there was no documentation that indicated Resident #62 was evaluated to identify triggers and resident specific interventions regarding his history of PTSD. In an interview on 5/23/24 at 8:30 AM, Certified Nurse Aide (CNA) #2 stated Resident #62 was admitted to the facility in November and she was not sure what type of previous trauma the resident had or what things might trigger the resident to cause re-traumatization. She said that any information regarding how to care for the resident was located on the Kardex (summary of resident information). CNA #2 went to a kiosk in the hallway, signed in, and reviewed Resident #62's information. She confirmed there was no information regarding the resident's triggers that may cause re-traumatization. In an interview on 5/23/24 at 8:40 AM, with Licensed Practical Nurse (LPN) #3, she confirmed Resident #62 was admitted in November 2023 and she was not aware of any triggers that may cause re-traumatization to the resident. She stated that behavior interventions would be on the resident's care plan, and she signed in on the computer to review the care plan. She confirmed there was nothing in place as to what triggers the resident. During an interview on 5/23/24 at 9:50 AM, with the Social Services Director (SSD), she confirmed the facility had not provided trauma informed care for Resident #62 because they were not aware of the triggers that could cause re-traumatization. The SSD stated Resident #62 had previously been hospitalized at the Veteran's Administration (VA) hospital. The resident's sister had signed him in and advised he had previously suffered from a nervous breakdown. The SSD reported Resident #62 had a diagnosis of PTSD when he left the VA hospital. She confirmed she completed a trauma screen on the resident which revealed the resident had a history of PTSD. The SSD said the resident's sister did not know what triggered the resident because previously he lived alone. The SSD confirmed she had not attempted to obtain information from the VA hospital regarding his history of PTSD and the triggers that could cause re-traumatization. During an interview on 5/23/24 at 9:55 AM, the Director of Nursing (DON), stated she expected the facility to provide trauma informed care for residents with PTSD so they would know what the triggers were for residents to prevent re-traumatization. During an interview on 05/23/24 at 10:14 AM, with the facility's Administrator, stated that he expected a resident who had PTSD to receive trauma informed care to ensure that a resident was not re-traumatized.

Based on observation, staff interview, and facility policy review, the facility failed to discard expired stock medications for one (1) of five (5) medication storage areas reviewed. Nurses Station-Building 1 Findings include: Review of the facility policy, Medication Storage, revised 7/17/23, revealed, .It is the policy of this facility to ensure all medications housed on our premises will be stored in the in the pharmacy and/or medication rooms according to the manufacturer's recommendations .Policy Explanation and Compliance Guidelines .8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective or deteriorated medications with worn illegible or missing labels. On 05/20/24 at 9:16 AM, during an observation, there were expired medications in the medication storage area of the nurses' station in Building 1. The expired stock medications were Magnesium 750 milligrams (mg), which had an expiration date of 12/2023, Folic Acid 1 mg with an expiration date of 1/2024, and Aspirin 325 mg with an expiration date of 1/2024. On 05/20/24 at 10:14 AM, during an interview and observation with Registered Nurse (RN) # 1, she confirmed the Magnesium, Folic Acid, and Aspirin were expired and should not be in the stock medication area. She stated it was the cart nurses' responsibility to discard any expired medications from the medication carts and medication storage areas. On 05/21/24 at 10:14 AM, in an interview with the Director of Nursing (DON), she confirmed it was the responsibility of cart nurses to discard expired medications from the medication carts and from the medication storage areas. She stated she expected the nurses to follow up and check for expired medications in facility stock and carts. She explained that using expired medications could be a potential hazard as the efficacy of the medication could have changed.

Based on observation, staff interview, and facility policy review, the facility failed to provide hand hygiene for residents prior to meals for one (1) of four (4) dining rooms observed. Dining Room C. Findings include: A record review of the facility's policy, Handwashing/Hand Hygiene revised 8/2/22, revealed, .This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation .5. Residents .will be encouraged to practice hand hygiene .7. Use an alcohol-based hand rub .or .soap .and water for the following situations .o. Before and after eating or handling food . On 5/20/24 at 10:51 AM, during an observation of Dining Room C, the facility staff did not offer to assist residents with washing or sanitizing their hands. There were four (4) Certified Nurse Aides (CNAs) and one (1) Licensed Practical Nurse (LPN) present. On 5/20/24 at 11:44 AM, during an observation, three (3) residents were assisted to the dining room table in Dining Room C by therapy staff. The residents were not offered assistance with washing or sanitizing their hands prior to the meal being served. On 5/20/24 at 11:48 AM, during an interview with the Director of Nursing (DON), she was in Dining Room C and observed the three (3) residents who came from therapy to the dining room table and staff did not offer assistance with washing or sanitizing their hands. The DON explained CNAs were responsible for assisting the residents with hand hygiene before meals. On 05/20/24 at 12:35 PM, an interview with CNA #1, she confirmed the staff did not offer to assist residents with hand hygiene in Dining Room C prior to serving lunch. On 05/20/24 at 12:40 PM, during an interview with the Physical Therapy Assistant (PTA), she reported the (3) residents that came into the dining room had just ended therapy prior to lunch. She confirmed the therapy staff do not assist residents in washing their hands before going to the dining room. She stated, Residents like to stay in the therapy room as long as they can before going to lunch.

Based on interviews, record review, and facility policy review, the facility failed to notify the Physician or the Resident Representative (RR) when a resident was observed to have bruising, edema, and pain to her left thigh and vaginal area, until the following day when she was diagnosed with a femoral fracture for one (1) of six (6) sampled residents. Resident #1. Findings include: A review of the facility's policy, Notification of Change in a Resident's Condition or Status, revised 8/2/22, revealed, Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .Policy Interpretation and Implementation .1. The nurse will notify the resident's Attending Physician or physician on call when there has been .b. discovery of injuries of an unknown source .4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source . A record review of the facility's investigation which included the,Alleged Abuse Incident Report dated 11/3/23, revealed on 10/28/23 at approximately 1:45 PM, License Practical Nurse (LPN) #1 reported to Registered Nurse (RN) #2 Supervisor that Resident #1 had bruising to the left thigh and vaginal area with swelling and pain. On 10/29/23 at approximately 7:30 AM, the assigned RN/Supervisor #1 observed Resident #1 bruising to the left thigh and groin area, with swelling and pain, notified her physician, and transferred Resident #1 to the local emergency room (ER). Record review of a handwritten statement from Certified Nursing Assistant (CNA) #1, dated 10/29/23, revealed on 10/28/23 at about 1:30 PM, that CNA #1 noticed a large bruise on Resident #1's vagina and she informed LPN #1. CNA #1 and LPN #1 discovered another bruise on the bottom of her labia. A record review of the Progress Notes revealed a Nurses Note, dated 10/28/23 at 1:45 PM, signed by LPN #1, revealed, alerted to resident's room. upon exam bruising was noted to vaginal area, and left thigh. painful to touch. Swelling noted to upper left thigh. shift supervisor notified of resident's condition . There was no documentation indicating the RR or the Physician were notified of the bruising or pain on 10/28/23. A record review of the Progress Notes revealed a Nurses Note, dated 10/29/23 at 8:21 AM, signed by RN #1, revealed, Alerted by (Proper Name) LPN #1 about bruising on resident's vagina and left hip. While putting resident's head of bed down to view the area, the resident began to cry out in pain. (Proper Name) Director of Nursing (DON) notified of situation. Dr. (Proper Name) aware. New orders given to send to ER for further evaluation. A record review of the hospital record, with an admitted [DATE], revealed, Resident #1 was presented to the hospital with a left leg injury. Emergency Department (ED) workup was significant for left proximal femur fracture. The Physical Exam revealed Resident #1 had diffuse bruising at various stages of healing to left lower extremity and expected tenderness to left lower extremity. The Assessment/Plan revealed the ED nursing staff filed an elder abuse report and pain medications were ordered. On 2/6/24 at 11:17 AM, during a phone interview with LPN #1, he confirmed that on 10/28/23, around 1:00 PM, he was called to Resident #1's room by CNA #1 and was made aware of the residents bruising of the left groin and vaginal area. He stated Resident #1 was non-verbal, had facial grimacing, and was in pain. LPN #1 confirmed he did not notify the Medical Provider or the RR regarding the resident's bruises or pain on 10/28/23. On 2/6/23 at 11:27 AM, during a phone conversation with RN #2, she confirmed that on 10/28/23 after lunch, LPN #1 informed her of Resident #1 bruising to the left groin area. RN #2 confirmed she did not assess the resident. She passed the situation off to the night shift but could not remember the nurse's name. RN #2 confirmed that she did not notify the physician or the RR on 10/28/23 about the resident's condition. On 2/7/24 at 10:11 AM, during an interview with the DON, she confirmed that the physician and the RR should have been notified of Resident #1's bruises and pain. She explained it was the facility's policy to notify the Medical Director and the RR of any changes with the residents and she expected the nursing staff to follow the facility's policy. On 2/7/24 at 2:49 PM, in an interview with the Administrator, he confirmed that on 10/28/23 the facility did not follow the facility's policy regarding notification of a change in a resident's condition. The Administrator stated that he expected the facility staff to follow the policy and notify the physician and the RR. During an interview on 2/8/24 at 12:00 PM, with the Medical Director, he confirmed the facility did not contact him or provide him with any information on Resident #1's bruising of the left leg and perineal area on 10/28/23. He said he expected the facility to notify him of any change in a resident's condition. Record review of the Admission Record revealed the facility admitted Resident #1 on 6/14/2016 and she had current diagnoses including Alzheimer's Disease and Vascular Dementia. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 8/30/23, revealed Resident #1 required a staff interview for mental status and her cognition was severely impaired. Based on the facility's implementation of corrective actions on 11/2/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC). The deficiency was corrected as of 11/3/23, before the SA's entrance on 2/5/24. Validation: On 2/8/23, the SA validated through staff interviews, record review, and facility policy review the facility began an investigation on 10/29/23. The SA validated through staff interview and record review of the sign in sheet and meeting minutes that an emergency Quality Assurance Performance Improvement (QAPI) meeting with all required staff was held on 10/31/23 at 9:15 AM. The DON, Medical Provider, and Social Services Director attended the QAPI meeting to discuss the situation regarding abuse and neglect, including investigation and reporting of abuse and neglect. The QAPI members also discussed ethics and communication, perineal care, notification of changes, mechanical lift and transfer safety, care plans, and Kardex following the incident. The QAPI meeting concluded that the Plan of Correction was to in-service all staff, suspend the CNA, and conduct body audits on all residents. The QA Committee reviewed all related policies and procedures with no changes recommended. The SA validated through staff interview and record review of the in-service sign-in sheets that in-services with all staff conducted by the Administrator and the DON began on 10/29/23 regarding abuse and neglect, investigating and reporting abuse and neglect, ethics, communication, perineal care, notification of changes, mechanical lift and transfer safety, care plan, and Kardex. No staff were allowed to work until they received the in-service training. The SA validated through staff interview and record review that the DON conducted Resident mechanical lift/transfer assessments on all residents on 11/1/23 and ensured all were up-to-date and care planned accordingly. The SA validated through staff interview and record review that on 11/1/23 through 11/2/23, the DON completed new pain assessments for all residents and updated the care plan accordingly. The SA validated through staff interview and record review that the DON completed body audits on 10/29/23 through 10/31/23 on all current residents. The SA validated through staff interview and record review, for monitoring purposes, all nurses and CNAs completed a lift skill observation. The SA validated through staff interview and record review, for monitoring purposes, Transfer Audits were completed by the nurse two (2) times per day until 12/31/23. The SA validated through staff interview and record review, for monitoring purposes, weekly body audits are completed by nurses on all residents. The SA validated that the facility reported the incident to the SA and the Attorney General Office (AGO) on 10/29/23.

Based on interviews, record review, and facility policy review, the facility failed to protect the resident's right to be free from neglect as evidenced by Resident #1, who was observed to have bruising, edema, and pain to her left thigh and vaginal area, did not receive care or treatment until the following day when she was diagnosed with a femoral fracture for one (1) of six (6) sampled residents. Resident #1. Findings included: A review of the facility's policy, Abuse Prevention Program, reviewed July 2019, revealed, Policy Statement: Our residents have the right to be free from abuse, neglect . A review of the facility's policy, Compliance with Reporting Allegation of Abuse/Neglect/Exploitation, dated 10/10/22, revealed, .Compliance Guidelines .Identification: The facility will identify events, occurrences, patterns and trends that may constitute: a. Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . A record review of the facility's investigation which included the,Alleged Abuse Incident Report dated 11/3/23, revealed that on 10/28/23 at approximately 1:45 PM, License Practical Nurse (LPN) #1 reported to Registered Nurse (RN) #2 Supervisor that Resident #1 had bruising to the left thigh and vaginal area with swelling and pain. On 10/29/23 at approximately 7:30 AM, the assigned RN/Supervisor #1 observed Resident #1 bruising to the left thigh and groin area, with swelling and pain, notified her physician, and transferred Resident #1 to the local emergency room . Record review of a handwritten statement from Certified Nursing Assistant (CNA) #1, dated 10/29/23, revealed on 10/28/23 at about 1:30 PM, that CNA #1 noticed a large bruise on Resident #1's vagina and she informed LPN #1. CNA #1 and LPN #1 discovered another bruise on the bottom of her labia. A record review of the Progress Notes revealed a Nurses Note, dated 10/28/23 at 1:45 PM, signed by LPN #1, revealed, alerted to resident's room. upon exam bruising was noted to vaginal area, and left thigh. painful to touch. Swelling noted to upper left thigh. shift supervisor notified of resident's condition . Record review of a handwritten statement from LPN #1, undated, revealed on 10/28/23 at approximately 1:30 PM, he was called to Resident #1's room and was made aware of bruising to the groin/perineal care. There was old bruising noted to the vagina/major labia and inner left thigh. The resident was showing no signs or symptoms of distress or pain at this time. Shift supervisor was notified of the resident's condition. Report on resident's condition was given at shift change. On the following morning, 10/29/23, it was noted that the resident's left leg was visually displaced and that she was complaining of pain with movement. A record review of a handwritten statement from RN #2, dated 10/30/23, revealed LPN #1 told her that the CNA said Resident #1 had an injury and he was going to write a report. The resident had a bruise and hematoma that they noticed on Saturday afternoon (10/28/23) and RN #2 did not go down and look at it. A record view of the Progress Notes revealed a Nurses Note, dated 10/29/23 at 8:21 AM, signed by RN #1, revealed, Alerted by (Proper Name) LPN #1 about bruising on resident's vagina and left hip. While putting resident's head of bed down to view the area, the resident began to cry out in pain. (Proper Name) Director of Nursing (DON) notified of situation. Dr. (Proper Name) aware. New orders given to send to ER for further evaluation. A record review of the hospital records,including the History and Physical and Progress notes, with an admitted [DATE], revealed Resident #1 presented to the hospital with a left leg injury. Emergency Department (ED) workup was significant for left proximal femur fracture. The Physical Exam revealed Resident #1 had diffuse bruising at various stages of healing to left lower extremity and expected tenderness to left lower extremity. Patient withdraws to pain. The Assessment/Plan revealed the ED nursing staff filed an elder abuse report and pain medications were ordered. On 2/6/24 at 11:17 AM, during a phone conversation with LPN #1, he confirmed that on 10/28/23, around 1:00 PM, he was called to Resident #1's room by Certified Nurse Assistant (CNA) #1 and was made aware of the residents bruising of the left groin and vaginal area. He stated Resident #1 was non-verbal, had facial grimacing, and was in pain. LPN #1 notified RN #2, who was the facility supervisor of Resident #1's bruising, and she informed him to complete an incident report. LPN #1 confirmed that he did not follow up with RN #2 to ensure the resident was assessed by the RN on 10/28/23. On 10/29/23 at approximately 7:00 AM, LPN #1 reported the bruising to RN #1. RN #1 assessed the resident and immediately called the Medical Director, the Director of Nursing (DON), and the ambulance for transfer to the hospital. LPN #1 confirmed that he should have provided more care to Resident #1 on 10/28/23 but was following the chain of command. On 2/6/23 at 11:27 AM, during a phone conversation with RN #2, she confirmed that on 10/28/23 after lunch, LPN #1 informed her of Resident #1 bruising to the left groin area. RN #2 confirmed she did not assess the resident. She passed the situation off to the night shift but could not remember the nurse's name. RN #2 stated it was the facility's policy to report bruising of the vaginal area to the DON and Medical Director and that she did not report or assess the resident. On 2/6/24 at 11:35 AM, during a phone interview with CNA #1, she stated on 10/28/23 at approximately 1:30 PM, when changing Resident #1's brief, she observed a large orange and black bruise between her legs and groin area on the left side. The resident's leg was cocked out a little, which was not normal for the resident because she normally kept her legs closed together very tight. She stated that she notified LPN #1. On 2/6/24 at 11:41 AM, during a phone interview with RN #1, she confirmed on 10/29/23 at 7:24 AM, LPN #1 requested she assess Resident #1's peri-area related to bruising and swelling. She observed yellow and black bruising to her left groin and leg. RN #1 notified the DON, Medical Director, and called the local ambulance. The resident was transferred out of the facility by a local ambulance and brought to the local hospital. On 2/7/24 at 10:11 AM, during an interview with the DON, she confirmed that on 10/29/23 at approximately 8:00 AM, she received a call from RN #1 stating that Resident #1 had bruising to her left hip, pubic area, and upper pelvic area. The DON stated that on 10/29/23 at approximately 12:20 PM, she entered the facility and began her investigation. However, she did not observe the resident or the bruising because the resident had already been transferred to the hospital. The DON revealed the facility did not follow the abuse and neglect policy because the RN should have assessed the resident and reported her findings to the Medical Director and the DON on 10/28/24 when the bruising was observed by facility staff. On 2/7/24 at 2:49 PM, in an interview with the Administrator, he confirmed that on 10/28/23 the facility did not follow the abuse or neglect policy. He stated that Resident #1 should have been assessed by RN #2 on 10/28/23 and she should have reported the bruising to the Medical Director and the DON. On 2/8/24 at 12:00 PM, during an interview with the Medical Director, he confirmed the facility did not contact him or provide him with any information on Resident #1's bruising of the left leg and perineal area on 10/28/23. He said he expected the facility to notify him of any change in a resident's condition. Record review of the Admission Record revealed the facility admitted Resident #1 on 6/14/2016 and she had current diagnoses including Alzheimer's Disease and Vascular Dementia. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 8/30/23, revealed Resident #1 required a staff interview for mental status and her cognition was severely impaired. Based on the facility's implementation of corrective actions on 11/2/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC). The deficiency was corrected as of 11/3/23, before the SA's entrance on 2/5/24. Validation: On 2/8/23, the SA validated through staff interviews, record review, and facility policy review the facility began an investigation on 10/29/23. The SA validated through staff interview and record review of the sign in sheet and meeting minutes that an emergency Quality Assurance Performance Improvement (QAPI) meeting with all required staff was held on 10/31/23 at 9:15 AM. The DON, Medical Provider, and Social Services Director attended the QAPI meeting to discuss the situation regarding abuse and neglect, including investigation and reporting of abuse and neglect. The QAPI members also discussed ethics and communication, perineal care, notification of changes, mechanical lift and transfer safety, care plans, and Kardex following the incident. The QAPI meeting concluded that the Plan of Correction was to in-service all staff, suspend the CNA, and conduct body audits on all residents. The QA Committee reviewed all related policies and procedures with no changes recommended. The SA validated through staff interview and record review of the in-service sign-in sheets that in-services with all staff conducted by the Administrator and the DON began on 10/29/23 regarding abuse and neglect, investigating and reporting abuse and neglect, ethics, communication, perineal care, notification of changes, mechanical lift and transfer safety, care plan, and Kardex. No staff were allowed to work until they received the in-service training. The SA validated through staff interview and record review that the DON conducted Resident mechanical lift/transfer assessments on all residents on 11/1/23 and ensured all were up-to-date and care planned accordingly. The SA validated through staff interview and record review that on 11/1/23 through 11/2/23, the DON completed new pain assessments for all residents and updated the care plan accordingly. The SA validated through staff interview and record review that the DON completed body audits on 10/29/23 through 10/31/23 on all current residents. The SA validated through staff interview and record review, for monitoring purposes, all nurses and CNAs completed a lift skill observation. The SA validated through staff interview and record review, for monitoring purposes, Transfer Audits were completed by the nurse two (2) times per day until 12/31/23. The SA validated through staff interview and record review, for monitoring purposes, weekly body audits are completed by nurses on all residents. The SA validated that the facility reported the incident to the SA and the Attorney General Office (AGO) on 10/29/23.

Based on interviews, record review, and facility policy review, the facility failed to report an injury of unknown origin within two (2) hours when facility staff observed a Resident who had bruising, edema, and pain to her left thigh and vaginal area for one (1) of six (6) sampled residents. Resident #1 Findings include: A review of the facility policy, Abuse Investigation and Reporting, revised July 2019, revealed Policy Statement: .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) . A review of the facility's policy, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated 10/10/22, revealed, Policy: It is the policy of this facility to report all allegations of abuse .injuries of unknown sources .are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframe's .Compliance Guidelines .Identification: The facility will identify events, occurrences, patterns and trends that may constitute .4. Identification .d. Injuries of unknown source: Includes circumstances when both the following conditions are met; i. The source of the injury was not observed by any person or could not be explained by the resident. ii. The injury is suspicious because of the extent of the injury, location of the injury . A record review of the facility's investigation which included the,Alleged Abuse Incident Report dated 11/3/23, revealed that on 10/28/23 at approximately 1:45 PM, License Practical Nurse (LPN) #1 reported to Registered Nurse (RN) #2 Supervisor that Resident #1 had bruising to the left thigh and vaginal area with swelling and pain. On 10/29/23 at approximately 7:30 AM, the assigned RN/Supervisor #1 observed Resident #1 bruising to the left thigh and groin area, with swelling and pain, notified her physician, and transferred Resident #1 to the local emergency room . The Date of Alleged Incident documented as 10/28/23 and indicated the date and time of first report to the SA was 10/29/23 at 12:24 PM. Record review of a handwritten statement from Certified Nursing Assistant (CNA) #1, dated 10/29/23, revealed on 10/28/23 at about 1:30 PM, that CNA #1 noticed a large bruise on Resident #1's vagina and she informed LPN #1. She and LPN #1 discovered another bruise on the bottom of her labia. During a phone interview on 2/6/24 at 11:17 AM, LPN #1 confirmed on 10/28/23, around 1:00 PM, he was called to Resident #1's room by CNA #1 and was made aware of the residents bruising of the left groin and vaginal area. He stated Resident #1 was non-verbal, had facial grimacing, and was in pain. LPN #1 notified RN #2, who was the facility supervisor, of Resident #1's bruising, and she informed him to complete an incident report. He confirmed that he did not notify the Administrator or the DON of the resident's bruising, swelling, and pain. He stated he followed his chain of command. During a phone interview on 2/6/23 at 11:27 AM, RN #2 confirmed on 10/28/23 after lunch, LPN #1 informed her of Resident #1 bruising to the left groin area. RN #2 confirmed she did not assess the resident. She passed the situation off to the night shift but could not remember the nurse's name. RN #2 stated it was the facility's policy to report bruising of the vaginal area to the DON and Medical Director and that she did not report or assess the resident. On 2/7/24 at 10:11 AM, during an interview with the DON, she confirmed that the facility staff first observed the bruising on Resident #1's left groin and perineal area on 10/28/23, but they did not report the injury of unknown origin until 10/29/23 at approximately 8:00 AM, which was more than two (2) hours after the injuries were observed. On 2/7/24 at 2:49 PM, in an interview with the Administrator, he confirmed that on 10/28/23, Resident #1 sustained an injury. He stated that although the facility staff were aware, the DON or himself was not aware of the injury until 10/29/23. On 10/29/24 at approximately 11:30 AM, the DON notified him of the incident and then it was reported to the SA on 10/29/23 at 12:24 PM. He stated that it should have been reported within two (2) hours of it occurring on 10/28/23. Record review of the Admission Record revealed the facility admitted Resident #1 on 6/14/2016 and she had current diagnoses including Alzheimer's Disease and Vascular Dementia. Based on the facility's implementation of corrective actions on 11/2/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC). The deficiency was corrected as of 11/3/23, before the SA's entrance on 2/5/24. Validation: On 2/8/23, the SA validated through staff interviews, record review, and facility policy review the facility began an investigation on 10/29/23. The SA validated through staff interview and record review of the sign in sheet and meeting minutes that an emergency Quality Assurance Performance Improvement (QAPI) meeting with all required staff was held on 10/31/23 at 9:15 AM. The DON, Medical Provider, and Social Services Director attended the QAPI meeting to discuss the situation regarding abuse and neglect, including investigation and reporting of abuse and neglect. The QAPI members also discussed ethics and communication, perineal care, notification of changes, mechanical lift and transfer safety, care plans, and Kardex following the incident. The QAPI meeting concluded that the Plan of Correction was to in-service all staff, suspend the CNA, and conduct body audits on all residents. The QA Committee reviewed all related policies and procedures with no changes recommended. The SA validated through staff interview and record review of the in-service sign-in sheets that in-services with all staff conducted by the Administrator and the DON began on 10/29/23 regarding abuse and neglect, investigating and reporting abuse and neglect, ethics, communication, perineal care, notification of changes, mechanical lift and transfer safety, care plan, and Kardex. No staff were allowed to work until they received the in-service training. The SA validated through staff interview and record review that the DON conducted Resident mechanical lift/transfer assessments on all residents on 11/1/23 and ensured all were up-to-date and care planned accordingly. The SA validated through staff interview and record review that on 11/1/23 through 11/2/23, the DON completed new pain assessments for all residents and updated the care plan accordingly. The SA validated through staff interview and record review that the DON completed body audits on 10/29/23 through 10/31/23 on all current residents. The SA validated through staff interview and record review, for monitoring purposes, all nurses and CNAs completed a lift skill observation. The SA validated through staff interview and record review, for monitoring purposes, Transfer Audits were completed by the nurse two (2) times per day until 12/31/23. The SA validated through staff interview and record review, for monitoring purposes, weekly body audits are completed by nurses on all residents. The SA validated that the facility reported the incident to the SA and the Attorney General Office (AGO) on 10/29/23.

Based on interviews, record review, and facility policy review, the facility failed to implement care plan approaches or interventions related to pain and resident transfers for one (1) of six (6) residents reviewed for care plans. Resident #1. Findings Include: Record review of the facility's Comprehensive Care Plans policy, revised 8/24/22, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights .to meet a resident's medical, nursing .needs that are identified in the resident's comprehensive assessment .Policy Explanation and Compliance Guidelines .3. The comprehensive care plan will describe .a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Record review of the Order Summary Report with active orders as of 11/20/23, revealed Resident #1 had a Physician Order, dated 8/1/2019 for Acetaminophen Tablet 500 MG (milligrams) Give two (2) tablet by mouth every 6 hours as needed for .pain . Record review of the electronic Medication Administration Record (eMAR) for October 2023 revealed there was no documentation that Resident #1 received pain medication in October. A record review of the Comprehensive Care Plan for Resident #1 revealed a Problem of Resident is at risk for pain . with Interventions/Tasks initiated on 8/1/2019 of Administer pain medications per order .and a Problem of The resident has an ADL (Activities of Daily Living) self-care performance deficit .with interventions/Tasks initiated on 10/1/2019 of Transfer: The resident requires Total Mechanical Lift with 2 staff assistance for transfers. A record review of the Progress Notes revealed a Nurses Note, dated 10/28/23 at 1:45 PM, signed by Licensed Practical Nurse (LPN) #1, revealed, alerted to resident's room. upon exam bruising was noted to vaginal area, and left thigh. painful to touch . There was no documentation that pain was addressed in the nurses note. A record review of the hospital records, with an admitted [DATE], revealed, Resident #1 presented to the hospital with a left leg injury. Emergency Department (ED) workup was significant for left proximal femur fracture. The Physical Exam revealed Resident #1 had diffuse bruising at various stages of healing to left lower extremity and expected tenderness to left lower extremity. The Assessment/Plan revealed the ED nursing staff filed an elder abuse report and pain medications were ordered. On 2/6/24 at 11:17 AM, during a phone interview with LPN #1, he confirmed on 10/28/23 he did not follow Resident #1's care plan related to pain. LPN #1 stated Resident #1 demonstrated she was in pain because she had facial grimacing. LPN #1 stated he gave Resident #1 Acetaminophen, but he failed to provide any documentation regarding administering the medication. On 2/7/24 at 10:11 AM, during an interview with the Director of Nursing (DON), she confirmed that Certified Nursing Assistant (CNA) #2 did not follow the care plan when she transferred Resident #1 with the mechanical lift and did not have assistance from another staff member as per the video surveillance evidence. The DON confirmed care plan interventions were not implemented regarding pain when LPN #1 observed Resident #1 to be in pain on 10/28/23. The DON explained that care plans were in place for the staff to use to take care of the residents and she expected the staff at the facility to follow care plan interventions on the residents. On 2/8/24 at 11:19 AM, during an interview with Minimum Data Set (MDS)/RN, she confirmed that care plans provided a detailed and effective personalized outline of the care that is to be provided to the residents. It was her expectation that the staff follow the care plans on residents to ensure consistency in the nursing care of the residents. Record review of the Admission Record revealed the facility admitted Resident #1 on 6/14/2016 and she had current diagnoses including Alzheimer's Disease and Vascular Dementia. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 8/30/23, revealed Resident #1 required a staff interview for mental status and her cognition was severely impaired. Further review revealed she required extensive assistance with two person physical assist with transfers. Based on the facility's implementation of corrective actions on 11/2/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC). The deficiency was corrected as of 11/3/23, before the SA's entrance on 2/5/24. Validation: On 2/8/23, the SA validated through staff interviews, record review, and facility policy review the facility began an investigation on 10/29/23. The SA validated through staff interview and record review of the sign in sheet and meeting minutes that an emergency Quality Assurance Performance Improvement (QAPI) meeting with all required staff was held on 10/31/23 at 9:15 AM. The DON, Medical Provider, and Social Services Director attended the QAPI meeting to discuss the situation regarding abuse and neglect, including investigation and reporting of abuse and neglect. The QAPI members also discussed ethics and communication, perineal care, notification of changes, mechanical lift and transfer safety, care plans, and Kardex following the incident. The QAPI meeting concluded that the Plan of Correction was to in-service all staff, suspend the CNA, and conduct body audits on all residents. The QA Committee reviewed all related policies and procedures with no changes recommended. The SA validated through staff interview and record review of the in-service sign-in sheets that in-services with all staff conducted by the Administrator and the DON began on 10/29/23 regarding abuse and neglect, investigating and reporting abuse and neglect, ethics, communication, perineal care, notification of changes, mechanical lift and transfer safety, care plan, and Kardex. No staff were allowed to work until they received the in-service training. The SA validated through staff interview and record review that the DON conducted Resident mechanical lift/transfer assessments on all residents on 11/1/23 and ensured all were up-to-date and care planned accordingly. The SA validated through staff interview and record review that on 11/1/23 through 11/2/23, the DON completed new pain assessments for all residents and updated the care plan accordingly. The SA validated through staff interview and record review that the DON completed body audits on 10/29/23 through 10/31/23 on all current residents. The SA validated through staff interview and record review, for monitoring purposes, all nurses and CNAs completed a lift skill observation. The SA validated through staff interview and record review, for monitoring purposes, Transfer Audits were completed by the nurse two (2) times per day until 12/31/23. The SA validated through staff interview and record review, for monitoring purposes, weekly body audits are completed by nurses on all residents. The SA validated that the facility reported the incident to the SA and the Attorney General Office (AGO) on 10/29/23.

Based on record reviews, interviews, and facility policy review, the facility failed to ensure a resident was free of accidents and/or hazards when a staff member transferred a resident using a mechanical lift without two (2) people to assist for one (1) of six (6) sampled residents. Resident #1 Findings include: Record review of the facility's Safe Transfer and Lifting of Residents policy, revised 8/2/22, revealed, .In order to protect the safety and well-being of .residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .Policy Interpretation and Implementation .VI. Procedure for transferring resident with full body lift .f. Ensure 2nd person is assisting . A record review of the facility's investigation which included the,Alleged Abuse Incident Report dated 11/3/23, revealed that on 10/28/23 at approximately 1:45 PM, License Practical Nurse (LPN) #1 reported to Registered Nurse (RN) #2 Supervisor that Resident #1 had bruising to the left thigh and vaginal area with swelling and pain. On 10/29/23 at approximately 7:30 AM, the assigned RN/Supervisor #1 observed Resident #1 bruising to the left thigh and groin area, with swelling and pain, notified her physician, and transferred Resident #1 to the local emergency room . The investigation revealed during camera review, 10/28/23 at 6:42 AM, Certified Nursing Assistant (CNA) #2 pushed Resident #1 out of her room in a Geri-chair and her left leg was not crossed over her right as per her normal routine. A record review of the Progress Notes revealed a Nurses Note, dated 10/28/23 at 1:45 PM, signed by LPN #1, revealed, alerted to resident's room. upon exam bruising was noted to vaginal area, and left thigh. painful to touch. Swelling noted to upper left thigh. shift supervisor notified of resident's condition . Record review of a handwritten statement from LPN #1, undated, revealed on 10/28/23 at approximately 1:30 PM, he was called to Resident #1's room and was made aware of bruising to the groin/perineal care. There was old bruising noted to the vagina/major labia and inner left thigh. The resident was showing no signs or symptoms of distress or pain at this time. Shift supervisor was notified of the resident's condition. Report on resident's condition was given at shift change. On the following morning, 10/29/23, it was noted that the resident's left leg was visually displaced and that she was complaining of pain with movement. A record review of a handwritten statement from RN #2, dated 10/30/23, revealed LPN #1 told her that the CNA said Resident #1 had an injury and he was going to write a report. The resident had a bruise and hematoma that they noticed on Saturday afternoon (10/28/23) and RN #2 did not go down and look at it. A record view of the Progress Notes revealed a Nurses Note, dated 10/29/23 at 8:21 AM, signed by RN #1, revealed, Alerted by (Proper Name) LPN #1 about bruising on resident's vagina and left hip. While putting resident's head of bed down to view the area, the resident began to cry out in pain. (Proper Name) Director of Nurses(DON) notified of situation. Dr. (Proper Name) aware. New orders given to send to ER for further evaluation. A record review of the hospital records including the History and Physical and Progress Notes, with an admitted [DATE], revealed Resident #1 presented to the hospital with a left leg injury. Emergency Department (ED) workup was significant for left proximal femur fracture. The Physical Exam revealed Resident #1 had diffuse bruising at various stages of healing to left lower extremity and expected tenderness to left lower extremity. The Assessment/Plan revealed the ED nursing staff filed an elder abuse report and pain medications were ordered. Record review of the Employee Termination Report, dated 11/3/23, revealed CNA #2 was discharged from employment with the facility due to Violation of Lift Policy. On 2/6/24 at 11:17 AM, during a phone interview with LPN #1, he confirmed that on 10/28/23, around 1:00 PM, he was called to Resident #1's room by Certified Nurse Assistant (CNA) #1 and was made aware of the residents bruising of the left groin and vaginal area. He stated Resident #1 was non-verbal, had facial grimacing, and was in pain. LPN #1 notified RN #2, who was the facility supervisor, of Resident #1's bruising, and she informed him to complete an incident report. On 2/6/24 at 11:35 AM, during a phone interview with CNA #1, she stated on 10/28/23 at approximately 1:30 PM, when changing Resident #1's brief, she observed a large orange and black bruise between her legs and groin area on the left side. The resident's leg was cocked out a little, which was not normal for the resident because she normally kept her legs closed together very tight. She stated that she notified LPN #1. On 2/6/24 at 11:41 AM, during a phone interview with RN #1, she confirmed on 10/29/23 at 7:24 AM, LPN #1 requested she assess Resident #1's peri-area related to bruising and swelling. She observed yellow and black bruising to her left groin and leg. RN #1 notified the DON, Medical Director, and called the local ambulance. The resident was transferred out of the facility by a local ambulance and brought to the local hospital. On 2/7/24 at 10:11 AM, during an interview with the DON, she confirmed that on 10/28/23, Resident #1 had bruising of her left groin and peri-area with leg swelling. The DON stated the injury that Resident #1 sustained could have been caused by a CNA performing a transfer with mechanical lift by herself with no other staff assistance. The DON revealed that according to the video surveillance, CNA #2 entered and exited the resident's room alone, with the mechanical lift. The CNA was placed on suspension and terminated following the investigation. On 2/7/24 at 2:49 PM, in an interview with the Administrator, he confirmed he observed the video surveillance, and on 10/28/23, CNA #2 entered Resident #1's room at approximately 6:00 AM alone with the mechanical lift. CNA #2 exited about 15 minutes later with Resident #1. The Administrator stated the facility could not determine the exact cause of the injury following the investigation but that it was likely caused by the night shift CNA on 10/28/23. CNA #2 was suspended pending investigation and then terminated. Record review of the Admission Record revealed the facility admitted Resident #1 on 6/14/2016 and she had current diagnoses including Alzheimer's Disease and Vascular Dementia. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 8/30/23, revealed Resident #1 required a staff interview for mental status and her cognition was severely impaired. Based on the facility's implementation of corrective actions on 11/2/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC). The deficiency was corrected as of 11/3/23, before the SA's entrance on 2/5/24. Validation: On 2/8/23, the SA validated through staff interviews, record review, and facility policy review the facility began an investigation on 10/29/23. The SA validated through staff interview and record review of the sign in sheet and meeting minutes that an emergency Quality Assurance Performance Improvement (QAPI) meeting with all required staff was held on 10/31/23 at 9:15 AM. The DON, Medical Provider, and Social Services Director attended the QAPI meeting to discuss the situation regarding abuse and neglect, including investigation and reporting of abuse and neglect. The QAPI members also discussed ethics and communication, perineal care, notification of changes, mechanical lift and transfer safety, care plans, and Kardex following the incident. The QAPI meeting concluded that the Plan of Correction was to in-service all staff, suspend the CNA, and conduct body audits on all residents. The QAPI Committee reviewed all related policies and procedures with no changes recommended. The SA validated through staff interview and record review of the in-service sign-in sheets that in-services with all staff conducted by the Administrator and the DON began on 10/29/23 regarding abuse and neglect, investigating and reporting abuse and neglect, ethics, communication, perineal care, notification of changes, mechanical lift and transfer safety, care plan, and Kardex. No staff were allowed to work until they received the in-service training. The SA validated through staff interview and record review that the DON conducted Resident mechanical lift/transfer assessments on all residents on 11/1/23 and ensured all were up-to-date and care planned accordingly. The SA validated through staff interview and record review that on 11/1/23 through 11/2/23, the DON completed new pain assessments for all residents and updated the care plan accordingly. The SA validated through staff interview and record review that the DON completed body audits on 10/29/23 through 10/31/23 on all current residents. The SA validated through staff interview and record review, for monitoring purposes, all nurses and CNAs completed a lift skill observation. The SA validated through staff interview and record review, for monitoring purposes, Transfer Audits were completed by the nurse two (2) times per day until 12/31/23. The SA validated through staff interview and record review, for monitoring purposes, weekly body audits are completed by nurses on all residents. The SA validated that the facility reported the incident to the SA and the Attorney General Office (AGO) on 10/29/23.

Based on interview, record review, and facility policy review, the facility failed to ensure pain management was provided to a resident when the resident was observed with bruising, edema, and pain to the left thigh and vaginal area, and was subsequently diagnosed with a femoral fracture for (1) of six (6) residents reviewed for pain. Resident #1. Findings include: Record review of the facility's policy, Pain Assessment and Management, revised 8/2/22, revealed, .The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain .6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes . A record review of the facility's investigation which included the,Alleged Abuse Incident Report dated 11/3/23, revealed on 10/28/23 at approximately 1:45 PM, License Practical Nurse (LPN) #1 reported to Registered Nurse (RN) #2 Supervisor that Resident #1 had bruising to the left thigh and vaginal area with swelling and pain. A record review of the Progress Notes revealed a Nurses Note, dated 10/28/23 at 1:45 PM, authored by LPN #1, revealed, alerted to resident's room. upon exam bruising was noted to vaginal area, and left thigh. painful to touch . There was no documentation that pain was addressed in the nurses note. A record review of the hospital records which included the History and Physical and Progress Notes, with an admitted [DATE], revealed Resident #1 presented to the hospital with a left leg injury. Emergency Department (ED) workup was significant for left proximal femur fracture. The Physical Exam revealed Resident #1 had diffuse bruising at various stages of healing to left lower extremity and expected tenderness to left lower extremity. The Assessment/Plan revealed the ED nursing staff filed an elder abuse report and pain medications were ordered. Record review of the Order Summary Report with active orders as of 11/20/23, revealed Resident #1 had a Physician Order, dated 8/1/2019 for Acetaminophen Tablet 500 MG (milligrams) Give two (2) tablet by mouth every 6 hours as needed for .pain . Record review of the electronic Medication Administration Record (eMAR) for October 2023 revealed there was no documentation that Resident #1 received pain medication in October. Record review of the Order Summary Report with active orders as of 11/20/23 revealed a physician order dated 11/1/23 Morphine Sulfate (concentrate) solution 20 MG/ML (milliliter) give 0.5 ml by mouth every 2 hours as need for .PAIN. Record review of the November 2023 MAR revealed Resident #1 had documented pain levels 14 times that ranged from four (4) to eight (8) from 11/1/23 through 11/14/23 and had received Morphine Sulfate 14 times in November after her diagnosis of a left femur fracture on 10/29/23. On 2/6/24 at 11:17 AM, during a phone interview with LPN #1, he confirmed he was notified that Resident #1 had bruising to her left leg and groin area. LPN #1 stated Resident #1 demonstrated she was in pain because she had facial grimacing. LPN #1 stated he gave Resident #1 Acetaminophen, but he failed to provide any documentation regarding administering the medication. On 2/7/24 at 10:11 AM, during an interview with the Director of Nursing (DON), she confirmed that on 10/28/23, RN #2 should have assessed Resident #1 because she had demonstrated she was in pain due to her facial grimaces. She explained that Resident #1 rarely demonstrated pain. The DON confirmed Resident #1 was prescribed Acetaminophen Tablets and there was no documentation that it was administered in October 2023. She reported that RN #2 and LPN #1 did not follow the facility's policy on pain assessment and management for Resident #1 and she expected the staff to follow the policy. On 2/7/24 at 2:49 PM, in an interview with the Administrator, he confirmed that on 10/28/23, the facility did not follow the pain policy and should have medicated Resident #1 for pain. He expected the staff to follow the policy and procedures of the facility. On 2/8/24 at 12:00 PM, during an interview with the Medical Director, he confirmed the facility did not provide him with any information on Resident #1's pain on 10/28/23. He stated he expected the facility to notify him of residents' acute pain. Record review of the Admission Record revealed the facility admitted Resident #1 on 6/14/2016 and she had current diagnoses including Alzheimer's Disease and Vascular Dementia. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 8/30/23, revealed Resident #1 required a staff interview for mental status and her cognition was severely impaired. Based on the facility's implementation of corrective actions on 11/2/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC). The deficiency was corrected as of 11/3/23, before the SA's entrance on 2/5/24. Validation: On 2/8/23, the SA validated through staff interviews, record review, and facility policy review the facility began an investigation on 10/29/23. The SA validated through staff interview and record review of the sign in sheet and meeting minutes that an emergency Quality Assurance Performance Improvement (QAPI) meeting with all required staff was held on 10/31/23 at 9:15 AM. The DON, Medical Provider, and Social Services Director attended the QAPI meeting to discuss the situation regarding abuse and neglect, including investigation and reporting of abuse and neglect. The QAPI members also discussed ethics and communication, perineal care, notification of changes, mechanical lift and transfer safety, care plans, and Kardex following the incident. The QAPI meeting concluded that the Plan of Correction was to in-service all staff, suspend the CNA, and conduct body audits on all residents. The QA Committee reviewed all related policies and procedures with no changes recommended. The SA validated through staff interview and record review of the in-service sign-in sheets that in-services with all staff conducted by the Administrator and the DON began on 10/29/23 regarding abuse and neglect, investigating and reporting abuse and neglect, ethics, communication, perineal care, notification of changes, mechanical lift and transfer safety, care plan, and Kardex. No staff were allowed to work until they received the in-service training. The SA validated through staff interview and record review that the DON conducted Resident mechanical lift/transfer assessments on all residents on 11/1/23 and ensured all were up-to-date and care planned accordingly. The SA validated through staff interview and record review that on 11/1/23 through 11/2/23, the DON completed new pain assessments for all residents and updated the care plan accordingly. The SA validated through staff interview and record review that the DON completed body audits on 10/29/23 through 10/31/23 on all current residents. The SA validated through staff interview and record review, for monitoring purposes, all nurses and CNAs completed a lift skill observation. The SA validated through staff interview and record review, for monitoring purposes, Transfer Audits were completed by the nurse two (2) times per day until 12/31/23. The SA validated through staff interview and record review, for monitoring purposes, weekly body audits are completed by nurses on all residents. The SA validated that the facility reported the incident to the SA and the Attorney General Office (AGO) on 10/29/23.