Every finding on record at Diversicare of Tupelo

Based on observations, interviews, record review, and facility policy review, the facility failed to maintain an effective pest control program to prevent and control roaches in the facility for two (2) of 2 days of survey. Findings Include: Record review of the facility policy titled Pest Control, with an effective date of 9/1/2014, revealed, It is the policy of this center to maintain an effective pest control program .During an observation on 8/18/2026 at 10:23 AM, a black bait trap was observed behind the toilet in the bathroom of Room B5. One (1) dead roach was observed on the bathroom floor in front of the toilet. During an interview, Resident #4 stated, Oh yeah, we got roaches in the bathroom.During an interview on 8/18/2026 at 10:30 AM, Resident #5 revealed that she had roaches in her bathroom. Observation of the bathroom revealed one (1) live roach crawling on the floor in front of the toilet. Resident #5 observed and confirmed the live roach.During an interview on 8/19/2026 at 9:15 AM, the Maintenance Supervisor stated that the facility had a contract with a pest control company for routine and as-needed pest control services. He stated that they came to the facility monthly and treated the kitchen and dining room. He confirmed that they could also be contacted for additional treatment when needed. The Maintenance Supervisor stated that when a pest was observed, staff were expected to report the sighting to a nurse or member of the administrative staff so a work order could be entered. Once notified of a work order, he would inspect the area, spray, and place bait traps. He stated that he contacted the pest control company when needed but did not contact them for every reported pest sighting. The Maintenance Supervisor stated that clutter, unclean rooms and improper food storage in resident rooms contributed to the facility's ongoing pest control problems. He stated that residents sometimes placed open food or dirty dishes in the dresser drawers and stated, We can't go in their drawers.During an interview on 8/19/2026 at 9:49 AM, Certified Nursing Assistant (CNA) #1 stated that roaches were an issue throughout the facility and stated, Yeah we got them, everyone knows we got them. CNA #1 stated that when she observed roaches, she attempted to kill them and reported the sightings to the nurse. She stated that she did not know what occurred after she reported the sightings. CNA #1 also stated that residents sometimes kept open food containers in their rooms.During an interview on 8/19/2026 at 10:00 AM, Registered Nurse (RN) #1 stated that pests were a problem in the facility and It gets reported all the time, but I don't feel like it gets took care of.During an interview on 8/19/2026 at 10:26 AM, the Director of Nursing (DON) confirmed that roaches were an ongoing issue in the facility. The DON stated that she believed food brought into the facility from outside contributed to the problem. She stated that the facility did not routinely educate residents or family members regarding proper food storage.During an observation on 8/19/2026 at 12:59 PM, at least ten (10) live roaches were observed crawling on the bathroom floor and baseboards in Room B5.During an observation on 8/19/2026 at 1:01 PM, one (1) live roach was observed crawling on the bathroom mirror in Room B7, with five (5) additional live roaches of various sizes observed crawling on the bathroom floor.During an interview on 8/19/2026 at 1:15 PM, CNA #1 confirmed the presence of roaches in room B5's bathroom. She also stated that she often observed roaches crawling on resident dressers and baseboards in Room B10.During an observation on 8/19/2026 at 1:36 PM, 2 small live roaches were observed crawling on the floor in Room B10. Food crumbs were observed on the floor. At that same time an interview and observation with the Housekeeping Supervisor confirmed the findings and stated that the facility had an ongoing problem with roaches.During an interview on 8/19/2026 at 4:05 PM, the Administrator confirmed that roaches were a problem in the facility. She stated that routine pest control visits had not been increased and that she calls pest control as needed.Resident #4Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/9/2026 revealed a Brief Interview for Mental Status (BIMS) summary score of 15, indicating that Resident #4 was cognitively intact.Resident #5Record review of MDS with ARD of 8/4/2026 revealed a BIMS summary score of 10, indicating that Resident #5 was moderately cognitively impaired.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from sexual abuse for one (1) of 32 initial pool residents. Resident #14 Findings Include:Review of the facility policy titled Abuse Policy, unrevised, revealed under Policy Statement: It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin, and misappropriation of resident/patient property .Record review revealed the facility reported an allegation of abuse to the State Agency on 1/10/26 at 11:30 AM after a staff member witnessed Resident #56 touching Resident #14 inappropriately. The residents were immediately separated and Resident #56 denied the allegation, and an investigation was initiated.An observation of Resident #56 on 1/11/26 at 3:45 PM revealed he was sitting in his wheelchair outside his room doorway with a Certified Nurse Aide (CNA) sitting nearby. Resident #56 stated he had behaviors and that staff were watching him.An interview with Licensed Practical Nurse (LPN) #6 on 1/12/26 at 9:16 AM revealed Resident #56 touched Resident #14's breast over the weekend and had been placed on one-to-one supervision for observation.Record review of Resident #56's Progress Notes dated 1/10/26 revealed, Staff reported to this nurse that resident touched another resident breast. Resident stated that he did it because he loves her.Record review of Resident #56's Progress Notes dated 1/10/26 revealed the Social Worker spoke with Resident #56 regarding the allegations. The entry documented that Resident #56 did not deny the touching and told the Social Worker, That's what a man does when he is in love.An observation of Resident #14 on 1/12/26 at 10:34 AM revealed she was ambulatory and standing at the entrance of another resident's room. She was easily directed to her room and Resident #14 displayed a flat affect and responded to simple questions; however, her responses were inconsistent and suggested she did not fully understand or recall what was being asked. When questioned about the touching incident, she stated she did not remember and could not recall any part of the event.An interview with Resident #56 on 1/13/26 at 8:41 AM revealed that on 1/10/26 he was sitting at the dining table talking with Resident #14. He stated, I accidentally touched her on the breast. He reported Resident #14 told him, I love you, and stated he had been talking with her for a day or two prior to the incident and was attracted to her. He stated staff moved him back to his dining table afterward and began watching him. He acknowledged he had been attracted to other female residents before but had not touched them.An interview with Social Services (SS) on 1/13/26 at 8:53 AM revealed she spoke with Resident #56 on the date of the incident. She stated Resident #56 told her, That's what men do when they are in love. She stated he was cognitive and was educated about respecting other residents' personal space. SS reported Resident #14 was unable to recall the incident.An interview with the Director of Nursing on 1/13/26 at 2:04 PM revealed the incident occurred in the dining area and was witnessed by a CNA. She stated the residents were separated and Resident #56 was placed on one-to-one staff observation until psychiatric services could evaluate him.An interview with CNA #4 on 1/13/26 at 2:18 PM revealed she was walking toward the dining room when she noticed a dietary employee observing something occurring between Resident #56 and Resident #14. CNA #4 stated she entered the dining room and observed Resident #56 touching Resident #14's breast on the outside of her shirt while both residents sat at a dining table. CNA #4 reported she told him she was going to report the incident, and he replied, I don't care. She reported the incident to the nurse.An interview with Dietary Staff #1 on 1/14/26 at 11:19 AM revealed she saw both residents sitting together in the dining room and observed Resident #56 stroking Resident #14's face and rubbing her hair. She stated there were no staff present in the dining room at that time. She stated CNA #4 noticed the interaction and entered the room to check. Dietary Staff #1 stated she returned to her duties and did not personally witness the breast touching.Record review of Resident #56's Psychiatric Telemedicine Visit dated 1/10/26 revealed under Subjective: Earlier today, staff reported the patient inappropriately touched a female resident by rubbing her, which he acknowledges doing 'to see her reaction,' though he expected 'nothing' from it. He stated he likes the resident.During an interview on 1/14/26 at 3:28 PM with the Director of Nursing, she stated she was aware that all residents have the right to be free from abuse and that the facility was responsible for protecting residents from such conduct.Record review of the admission Record revealed the facility admitted Resident #14 on 12/26/25 with medical diagnoses including Unspecified Dementia, Unspecified Severity, with Mood Disturbance.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/25 revealed under section C, a Brief Interview for Mental Status (BIMS) score of 11, indicating Resident #14 was moderately cognitively impaired.Record review of the admission Record revealed the facility admitted Resident #56 on 1/27/24 with medical diagnoses including Epilepsy, Anxiety Disorder, and Unspecified Mood Disorder.Record review of the MDS with an ARD of 1/5/26 revealed under section C, a BIMS score of 15, indicating Resident #56 was cognitively intact.

Based on staff interview, record review, and facility policy review, the facility failed to notify the State Long-Term Care Ombudsman of a resident's transfer to the hospital, which did not ensure compliance with required notification procedures for resident transfers for one (1) of four (4) hospitalizations reviewed. Resident #46 Findings Include:Record review of facility policy titled, Transfer and discharge date d 11/1/16, revealed 4. Before (Proper name of facility removed) transfers or discharges the Resident, it shall notify the Resident and the Resident's Representative of the basis for the transfer or discharge in a language and manner they understand; and will also notify the State Long-Term Care Ombudsman . Record review of Resident #46's Order Details revealed an order dated 11/21/25 to send to (Proper name of hospital removed) ER (Emergency Room) for AMS (Altered Mental Status). Record review of the Emergency Transfer Log for the Office of the State Long-Term Care Ombudsman for the month of November 2025, revealed Resident #46 was not listed for his 11/21/25 transfer. During an interview on 1/13/25 at 4:05 PM, the Administrator revealed that she was responsible for the completion and submission of the Emergency Transfer Log for the Office of the State Long-Term Care Ombudsman. She acknowledged that this log provided the Ombudsman with the information on residents transferred to the hospital. She confirmed she failed to place Resident #46's name on the November log for his 11/21/25 admission. Record review of Resident #46's admission Record revealed he was admitted by the facility on 10/24/23 with diagnoses of Gastro-esophageal Reflux Disease and Chronic Obstructive Pulmonary Disease. Record review of Resident #46's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was intact cognitively.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement the comprehensive care plan for two (2) of 28 residents sampled. (Resident #39 and Resident #58) Findings include: Review of facility policy titled Care Plans with effective date: October 2021, revealed, Policy.Care plans are developed by the interdisciplinary team and revied as needed according to resident and patient status or change. Record review of Resident #39's Medication Administration Record (MAR) for January 2026, revealed Resident #39 was currently on an anticoagulant Eliquis five (5) milligram (mg) tablet by mouth (PO) two times a day as of 10/15/25. There was no monitoring for signs/symptoms of bleeding. Record review of Resident #39's Care Plan Risk for complications related to anticoagulant. with review date 10/23/2025, revealed, .Observe for sign and symptoms (S/S) of bleeding example (i.e.) tarry stools, blood in urine, bruising, petechiae. During an interview on 1/12/2026 at 3:41 PM, the Director of Nursing (DON) confirmed there is not an order to monitor for bleeding every (q) shift. She stated her expectations were that any resident on an anticoagulant should have an order on the MAR to monitor for s/s of bleeding. She verbalized the resident was at risk for bleeding because she is taking an anticoagulant. Record review of the admission Record revealed Resident #39 was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Unspecified Systolic (Congestive) Heart Failure, and Paroxysmal Atrial Fibrillation. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/2025 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident # 58 Record review of Resident #58's Care Plan Report revealed an ADL self-care performance deficit related to other failure to thrive including, provide all the effort with the following tasks as this resident is dependent: oral hygiene, toileting hygiene, shower/bathe self . On 1/11/2026 at 4:00 PM, during initial rounds, Resident #58 stated she had received her baths; however, she stated she had not had her hair washed in approximately two weeks and stated she would like her hair washed. On 1/12/2026 at 4:33 PM, during an interview and observation Registered Nurse (RN) #1 was interviewed at the resident's bedside and confirmed the resident's hair appeared unwashed. During an interview on 1/13/2026 at 1:30 PM, the MDS Coordinator confirmed that hair washing is included as part of the resident's ADL care plan. When asked to identify the frequency or specific days the resident was scheduled to have her hair washed, the MDS Coordinator stated it was to occur on the resident's bath or shower days. The MDS Coordinator further stated the purpose of the care plan is to guide staff how to best provide care for the residents. Record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses that included Cognitive Communication Deficit. Record review of the quarterly MDS with an ARD of 10/20/2025 revealed a BIMS score of 07, indicating mildly impaired cognition.

Based on observation, interviews, record review, and facility policy review, the facility failed to revise the comprehensive care plan, following a fall, on one (1) of 28 residents sampled. (Resident #83) Findings include:Review of facility policy titled Care Plans with effective date: October 2021, revealed, Policy.Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change .During observation and interview on 1/11/2026 at 3:43 PM, Resident #83 was lying in bed. She was observed to have old, facial bruising. Resident #83 stated she had a fall in her room, but it was a long time ago. She stated, It's almost healed now. Observed that her bed was not in low position during observation. Record review of Post Fall Review with effective date 1/1/2026, revealed, .Date and time of fall: 12/31/2025 21:06 (9:06 PM) .Interventions/recommendations post fall .Recommendations/Interventions .Bed in low position .Care Plan/Kardex updated with new interventions: No .Record review of Resident #83's Risk for Falls care plan with revision date 10/3/2025, revealed, no interventions listed for resident's bed to be in low position.During an interview on 1/13/2026 at 3:09 PM, the Director of Nursing (DON) confirmed that the intervention for bed in low position was not added to the care plan or to the Kardex. She stated, it seems like we did something different with her mattress. She stated that all the beds were supposed to be left in low position. She further stated that the care plan was to be used as a guide on how to provide care for the residents and that the intervention was intended to lessen the possibility of injury should she fall again. Record review of the admission Record revealed Resident #83 was admitted to the facility on [DATE] with medical diagnoses that included Peripheral Vascular Disease, Unspecified. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/6/2026 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 02, indicating the resident had severely impaired cognition.

Based on observation, staff interview, resident interview, record review, and facility policy review, the facility failed to ensure a resident who required assistance received activities of daily living (ADL) care, including grooming and personal hygiene services such as hair washing, in accordance with the resident's assessed needs, for one (1) of 29 residents. (Resident #58) Findings Include: Review of facility policy titled Activities of Daily Living (ADLs), with an effective date of August 2021, revealed the facility policy is to ensure activities of daily living are provided in accordance with accepted standards of practice, the resident's care plan, and reasonable accommodation of the resident's choices and preferences. The policy further identified hygiene activities of daily living to include bathing, dressing, grooming, and oral care. During an interview on 1/11/2026 at 4:00 PM, Resident #58 stated she has received her baths but hasn't had her hair washed in approximately two weeks; she stated she would like her hair washed. During an interview and observation on 1/12/2026 at 4:33 PM, Registered Nurse (RN) #1 was interviewed at the resident's bedside and confirmed the resident's hair appeared unwashed. During an interview on 1/14/2026 at 9:36 AM, Certified Nursing Assistant (CNA) #5 stated she was not familiar with the resident and the past couple weeks she did not wash her hair because she did not want to cause her pain. CNA #5 further stated that now that she knows the resident, she will wash the resident's hair on Mondays, Wednesdays, and Fridays, which are the resident's scheduled shower days. On 1/14/26 at 10:00 AM, the Director of Nursing (DON) stated that the expectations are for the resident's hair to be washed by the CNAs on scheduled shower days. Record review of the admission Record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses that included Cognitive Communication Deficit. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/20/2025 revealed a Brief Interview for Mental Status (BIMS) score of 07, indicating severly impaired cognition.

Based on observations, staff and resident interviews, record review, and facility policy review, the facility failed to ensure adequate supervision and monitoring for one (1) of 28 residents reviewed following expressions of suicidal ideation, despite receiving post-emergency room recommendations for psychiatric follow-up. (Resident #8) Findings include:Review of facility policy titled, Behavioral Health Services with no date revealed, Each.resident must receive.the necessary behavioral health care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.Interview with Resident #8 on 01/11/26 at 3:45 PM the resident stated that she had been to the emergency room (ER) recently and that she wanted to see a psychiatrist and had not seen one yet.Review of the ER records revealed Resident #8 presented to ER with mood instability and insomnia on 01/10/26. Documentation indicated the resident experienced crying spells and moodiness, with fleeting thoughts of self-harm without plan, intent, or access to means. The resident declined psychiatric admission and stated inpatient care was not necessary. She expressed a desire for outpatient psychiatric follow-up with psychiatrist who visits the facility. The physician documented, Patient appears stable; I do not feel the patient is a risk to herself as she has not endorsed any suicidal ideation at this time. She is in assisted living facility and can receive care from her psychiatrist there for medication adjustment . Documentation further revealed, .Patient states she has been feeling depressed and anxious and wanted to see a psychiatrist, but the (facility name removed) nurses 'wouldn't listen to her' so she made a comment about being suicidal. Upon admission to the ER, patient stated she was not actively suicidal and never had a plan .During an interview on 1/13/2026 at 11:22 AM, Licensed Practical Nurse (LPN) #5 stated Resident #8 returned from the ER at approximately 12:19 AM on 1/11/2026 with no new orders. She stated she confirmed with Emergency Medical Services (EMS) that the resident had not received medication while at the ER; therefore, she administered the resident's nighttime medications and assisted her to bed. She stated the ER did not provide a referral or follow-up orders.During an interview on 1/13/2026 at 11:13 AM, Social Services stated she spoke with Resident #8; however, no documentation was present to support that interaction. She further stated she made a referral on Monday, 1/12/2026, with (Proper Name) Health Services. She stated (Proper Name) Health Services provides weekly visits and that the Master Social Worker (MSW) was in the facility that day and scheduled to see the resident. She stated this behavior was new for Resident #8 and she completed a PHQ9 assessment (questionnaire to screen for depression) upon admission and again in November 2025, and neither assessment indicated concerns. She also stated the resident had experienced multiple room changes due to incompatibility with roommates. Review of the ER document titled [NAME] Telepsychiatry Consult Note dated 1/10/2026, revealed the following recommendations: Medication recommendations: Review and adjust the current antidepressant regimen by facility psychiatric provider. Consider initiation or titration of a non-benzodiazepine anxiolytic appropriate for geriatric patients. Consider sleep-focused pharmacologic intervention (e.g., low-dose trazodone or mirtazapine, if clinically appropriate and not contraindicated). Avoid benzodiazepines if possible given age-related risks unless clearly indicated and closely monitored. 2. Non-Medication/therapeutic recommendations: Urgent psychiatric follow-up at assisted living facility; recommend expedited evaluation rather than routine monthly rounding. Facility staff monitor mood, anxiety, and sleep patterns closely. Encourage daughter's involvement in advocacy and care coordination. Environmental modifications at facility to reduce anxiety triggers (noise reduction, door-open accommodations due to claustrophobia).During an interview on 1/13/2026 at 3:03 PM, the Director of Nursing (DON) confirmed resident was sent to ER as the facility's intervention when the resident stated that she wanted to harm herself. She stated, Since the hospital sent her back to us, we look at that as she's safe to come back to the facility .like an 'all clear' to us. That is why we did not put any additional interventions or monitoring into place.Record review of the admission Record revealed Resident #8 was admitted to the facility on [DATE] with medical diagnoses that included Urinary Tract Infection, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Bipolar Disorder, current episode hypomanic, Other Bipolar Disorder, Depression, and Anxiety. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2025 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

Based on observation, staff interview, and record review, the facility failed to ensure catheter care was performed correctly for one (1) of six (6) residents with an indwelling urinary catheter. Resident #70. Findings Include: Record review of the facility's Peri Care Audit Tool (undated) revealed, 11. If Foley catheter present, must wash catheter tube first before starting the peri care. Washes from the meatus up the tube about 6 inches X2 (times two) with changing position of cloth. An observation of Resident #70's catheter care with Certified Nurse Aide (CNA) #4 on 1/12/26 at 3:40 PM revealed she prepared to provide catheter care and filled one pan with clean water. CNA #4 wet a washcloth and applied Dynacare shampoo and body wash directly to the cloth. She washed the resident's groin area first, then washed the shaft of the penis, and lastly washed the urinary meatus followed by the catheter. She did not rinse the washcloth with soap between cleaning the different areas of the groin area. An interview with Certified Nurse Aide (CNA) #4 on 1/12/26 at 3:54 PM confirmed that she did not use the correct catheter-cleaning sequence during Resident #70's care and acknowledged she did not rinse the soap. CNA #4 explained she was in a hurry and messed up. She acknowledged this could cause the resident to get a urinary tract infection. An interview with the Director of Nursing on 1/12/26 at 4:02 PM confirmed improper catheter-care sequence could cause Resident #70 an infection and that not rinsing soap could cause skin irritation. Record review of the admission Record revealed the facility admitted Resident #70 on 11/3/25 with medical diagnoses including Obstructive and Reflux Uropathy and Urinary Tract Infection. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 10, which indicated Resident #70 was moderately cognitively impaired. Section H indicated an indwelling catheter was marked.

Based on staff interview, facility record review, and facility policy review, the facility failed to ensure ongoing monitoring for adverse effects of a medication for one (1) of five (5) residents reviewed for medication review. (Resident #39). Findings include:Review of document on facility letterhead, dated 1/14/26, with the Administrator's signature, revealed, Standards of Practice.The expectation set forth by (facility proper name removed) management is that nurses comply with current standards of practice for residents needing anticoagulant monitoring.Record review of Resident #39's medical record revealed the resident was prescribed Eliquis five (5) milligram (mg) tablet by mouth (PO) two times a day on 10/15/2025; however, the record lacked evidence that nursing staff monitored for signs and symptoms (s/s) of bleeding.On 1/12/2026 at 3:41 PM, during an interview the Director of Nursing (DON) confirmed there was no order to monitor every (q) shift for bleeding. She stated her expectation was that any resident receiving an anticoagulant should have an order on the Medication Administration Record (MAR) to monitor for signs and symptoms of bleeding. She further stated the resident was at risk for bleeding due to anticoagulant use. Record review of the admission Record revealed Resident #39 was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Unspecified Systolic (Congestive) Heart Failure, and Paroxysmal Atrial Fibrillation. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/2025 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

Based on observation, staff interview, facility policy review, the facility failed to ensure infection prevention and control practices were consistently implemented in accordance with accepted standards of practice. Specifically, the facility failed to maintain oxygen equipment by not dating the oxygen tubing and oxygen humidifier water bottles for Residents #37 and #93 and failed to ensure staff followed Enhanced Barrier Precautions (EBP) by not wearing a gown during Foley catheter care for a resident requiring EBP (Resident #70). These failures affected three (3) of twenty nine sampled residents. Findings Include: Record review of the facility policy titled Oxygen Guideline with an effective date of 1/1/2022 revealed, Medical oxygen is classified by the Food and Drug Administration as a drug and therefore it is provided in accordance with a health care provider's order and in accordance with acceptable standards of practice. Review of the Infection Control Guide dated 2025 revealed under, System of Isolation for Infection Control: Enhanced Barrier Precautions should be considered when: Any resident with any: . Wound and/or indwelling medical devices (e.g., central lines, urinary catheter. It also revealed under Required: Gloves and gown don prior to the high-contact care activity. Resident #37 An observation on 1/11/26 at 3:45 PM revealed that Resident #37's oxygen tubing and the humidifier water bottle were not dated. A subsequent observation on 1/12/26 at 10:20 AM revealed that the oxygen tubing and humidifier water bottle remained undated. A record review of Resident #37's admission Record revealed the facility admitted the resident on 7/6/25 with diagnoses that included Chronic Obstructive Pulmonary Disease. A record review of Resident #37's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/29/25 revealed, under section C, a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Section O revealed that the Resident receives Oxygen therapy. Resident #93 An observation on 1/11/26 at 4:00 PM revealed that Resident #93 was receiving oxygen via an oxygen concentrator. The oxygen tubing and oxygen humidifier water bottle were not dated. An observation on 1/12/26 at 10:20 AM revealed the oxygen tubing and the water bottle remained undated. A record review of Resident #93's admission Record revealed the facility admitted the resident on 11/1/25 with diagnoses that included Chronic Obstructive Pulmonary Disease. A record review of Resident #93's MDS with an ARD of 11/7/25 revealed, under section C, a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Section O revealed that the Resident receives Oxygen therapy. During an interview and observation on 1/12/26 at 3:05 PM, Licensed Practical Nurse (LPN) #4 revealed that the oxygen tubing and water bottles are always to be dated when they are changed, because otherwise we don't know how long the resident has been using the same tubing. She confirmed that the oxygen tubing and water bottle for Residents #37 and #93 were not dated. LPN #4 stated, By not keeping track of when the oxygen tubing and water bottle are changed out, it could set the residents up for a respiratory infection. During an interview on 1/12/26 4:28 PM, the Director of Nurses (DON) revealed the facility previously documented when oxygen tubing and humidifier water bottles were changed; however, we were notified that our policy had changed, and we removed the documentation from our electronic system. The DON stated, oxygen tubing is changed only when visibly soiled and humidifier water bottles are changed only when empty. She confirmed that the facility does not date oxygen tubing or water bottles and acknowledged that there is no method to determine when the equipment was last changed. During an interview on 1/12/2026 at 4:44 PM, the Director of Clinical Care Coordination revealed, I think we should be changing them out weekly, but they have changed the policy now to where the facility only changes the tubing when they notice it is dirty and the bottles when they are empty. She confirmed there was no way to determine when the oxygen tubing or the humidifier water bottle was last changed due to the absence of dating and acknowledged that this practice could place residents at risk of infection. Resident #70 During an observation of Resident #70's catheter care with Certified Nurse Aide (CNA) #4 on 1/12/26 at 3:40 PM, she performed catheter care without applying a gown as required for EBP. During an interview with CNA #4 on 1/12/26 at 3:54 PM, she stated she had the gown ready for use during catheter care but forgot to apply it. She stated the purpose of wearing the gown was to protect the resident from infections. During an interview with the Director of Nursing on 1/12/26 at 4:02 PM, she stated her expectation was for staff to follow Enhanced Barrier Precautions to reduce infection risk. Record review of the admission Record revealed the facility admitted Resident #70 on 11/3/25 with medical diagnoses including Obstructive and Reflux Uropathy and Urinary Tract Infection. Record review of the MDS with an ARD of 11/10/25 revealed under section C, a BIMS summary score of 10, which indicated Resident #70 was moderately cognitively impaired. Section H indicated an indwelling catheter was marked.

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure that staff followed the resident's Kardex requiring two-person assistance for bed mobility and toileting. This failure resulted in Resident #1 falling from the bed and sustaining actual harm in the form of a skin tear, facial swelling, bruising, and maxillary hematoma, with increased pain requiring a new order for tramadol, an opioid analgesic, for one (1) of three (3) residents reviewed for accidents. ( Resident # 1)Findings include: Review of the facility policy titled, “Resident Rights & Quality of Life Policy,” with an effective date of March 13,2020, revealed Procedure: A patient or resident has the right: … To receive services in a center environment that is safe. … Record review of the “Post Fall Review” for Resident #1 dated 7/25/25 revealed an investigation of the residents fall with an injury that indicated in an Interdisciplinary Team (IDT) Review: IDT met: “CNA (Certified Nurse Assistant) was in the room changing resident. Resident rolled over to be cleaned, reached for his over bed table and rolled off. Staff informed that resident requires (2) two persons assist with incontinent care.” A phone interview with the Director of Nursing (DON) on 8/11/25 at 11:08 AM confirmed that Resident #1 required a two person assistance for bed mobility and incontinent care and CNA #1 failed to provide care according to the Kardex resulting in the resident falling off of the bed obtaining a skin tear to the buttocks and bruising and swelling to the right side of the face. She also confirmed that Resident #1s Kardex read two persons assist for bed mobility and toileting on 7/25/25 the day of the incident. She admitted that the injuries from the fall resulted in increased pain for Resident #1 and the need for a new order for tramadol for pain. Record review of a computed tomography (CT ) scan of the facial bones for Resident #1 dated 7/29/25, revealed Impression “ Small right maxillary subcutaneous hematoma.” … Record review of the Kardex Reports for Resident #1 from 7/22/25-7/25/25 revealed ADL (activity of daily living) Assistance: Extensive assist with bed mobility x 2 (two). …Extensive assist x 2 (two) with toilet use. … Record review of the July 2025 Medication Administration Record (MAR) for Resident #1 revealed Tramadol 50 mg (milligrams) give one tablet by mouth every six hours as needed for pain ordered 7/25/25 and he received six doses of tramadol from 7/25/25-7/28/25. Further review revealed Resident #1 had only received one dose of Tylenol 325 mg, two tablets for pain in the month of July prior to the fall on 7/25/25. An interview with CNA #1 on 8/11/25 at 12:00 PM confirmed that she was turning Resident #1 over to provide incontinent care on 7/25/25, stating the resident turns with one to two staff “depending on his mood.” She stated that as she was turning the resident, he reached over toward his bedside table and fell off the bed. She confirmed she was required to review each resident’s Kardex to know the required care and that she believed the Kardex read one-to-two-person assist with bed mobility. An interview with CNA #2 on 8/11/25 at 12:10 PM revealed she had been working at the facility for about a month and had cared for Resident #1. She confirmed she was trained to follow the Kardex and stated Resident #1 required two-person assistance since she had been working with him. An interview with CNA #3 on 8/11/25 at 12:15 PM revealed they are to follow the Kardex to provide appropriate care. She stated she has been assigned to Resident #1 and confirmed he required two-person assistance for bed mobility and incontinent care because he is contracted. An interview with the Administrator (ADM) on 8/11/25 at 2:00 PM confirmed that after review of the Kardex for Resident #1 from 7/22/25-7/25/25 the date of the incident that the Kardex for Resident #1 read extensive assistance of (2) two for bed mobility and toileting and staff failing to do so resulted in the accident. Record review of the “admission Record” revealed Resident #1 was admitted by the facility on 11/10/2015 with a diagnosis of Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the right dominate side. Record review of Resident #1s Section G (Activities of Daily Living) of the Minimum Data Set (MDS) with an ARD (Assessment Reference Date) of 7/15/25 revealed “Support” Bed mobility: was coded two-person physical assist. …Toileting: was coded two-person physical assist. …

Based on resident representative interviews, staff interviews, record review, and facility policy review, the facility failed to provide pharmacy services for obtaining medications timely for two (2) of four (4) residents sampled. Resident #1 and Resident #2 Findings include: Record review of facility's letterhead titled, Standards of Practice, undated, revealed, The expectation set forth by (facility's name) management is that nurses comply with current standards of practice in terms of following physician's orders. Record review of facility policy titled, Resident Rights and Quality of Life Policy, dated 3/13/20, revealed, It is the policy of (facility's name) that all patients and residents have the right to a dignified existence, self-determination, and communication with access to people and services inside and outside the center. Resident #1 During a phone interview on 6/17/25 at 12:10 PM, Resident #1's Representative (RR) revealed the resident was admitted to the facility on the evening on 5/13/25 and was sent to the hospital on 5/14/25 around 10:00 PM. He was admitted with a foot infection and Chronic Obstructive Pulmonary Disease (COPD) and was on medications for these conditions. RR stated he was uncertain if the resident received the medications and treatments needed for his infection and his lung illness prior to him returning to the hospital on [DATE]. During a phone interview on 6/17/25 at 3:26 PM, Licensed Practical Nurse (LPN) #1 revealed she had worked with Resident #1, and he had shortness of breath and she administered his as needed respiratory treatments around 3:00 AM and 9:00 PM which were effective. After his 9:00 PM treatment, he complained of chest pain, provider was notified, nitroglycerin was ordered and administered, and resident was sent to the hospital by ambulance. She revealed she was uncertain of any other medications received by the resident on admission. She revealed some medications were in the medication system in the facility, but others came from the pharmacy and if pharmacy had already brought meds to the facility, they would bring the ordered meds the next day. Record review of Resident #1's hospital Discharge Summary dated 5/13/25 revealed diagnoses of postoperative wound infection and osteomyelitis of left foot. Review revealed resident was discharged to facility on Vancomycin. Record review of Resident #1's discharge Medication List from hospitalization dated 5/13/25 at 2:53 PM, revealed Vancomycin every 12 hours. Record review of Progress Note dated 5/13/25 at 5:26 PM, revealed, Resident received to facility via (by) wheelchair van from (local hospital) in wheelchair accompanied via relative. Wound vac to left foot, resident non-weight bearing, morbidly obese. Able to make needs known with clear speech. Record review of Order Summary Report revealed an order for Vancomycin one gram intravenously (IV) two times a day related to acute osteomyelitis of left ankle and foot. Record review of Electronic Medication Administration Record (EMAR) revealed the resident did not receive the 5/13/25 evening dose or the 5/14/25 morning dose of Vancomycin as ordered. Record review of Discharge Summary for hospitalization dates of 5/14/25 through 5/15/25 revealed Reason for Hospitalization was COPD exacerbation. Record review of Resident #1's admission Record revealed he was admitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Infection of the skin and subcutaneous tissue, disruption of external operation surgical wound. Record review of Resident #1's Minimum Data Set (MDS) dated [DATE] did not reveal a Brief Interview for Mental Status (BIMS) score with reason being resident is rarely/never understood. Resident #2 During a phone interview on 06/17/25 at 1:15 PM, Resident #2's Representative revealed the resident was admitted to the facility from the hospital on 5/27/25 and she stated he was in the hospital for seizures and pneumonia and was on medications for both conditions and these medications were to be continued during the facility stay. She was uncertain if he received his antibiotics for pneumonia and his other medications that the hospital ordered. On 5/31/25, Resident #2 was difficult to arouse and was sent to the hospital. Record review of Resident #2's Discharge Summary dated 5/27/25 revealed discharge diagnoses of status epilepticus and acute respiratory failure. Record review also revealed he was discharged with five more days of antibiotics for aspiration pneumonia. The discharge summary revealed Medication List at Discharge which included Amoxicillin and Clavulanate Potassium two times daily. Record review of Resident #2's Discharge Summary with admission date of 5/31/25 revealed resident was admitted to the hospital due to aspiration into airway and sepsis with acute hypoxic respiratory failure. Record review of Resident #2's Order Summary Report revealed an order dated 5/27/25 for Amoxicillin and Clavulanate Potassium (Augmentin) two times daily. Record review of Resident #2's Electronic Medication Administration Record (EMAR) revealed resident did not receive the evening dose of Augmentin on 5/27/25. During an interview with the Director of Nursing (DON) on 6/18/25 at 3:00 PM, she revealed if a resident is admitted in the late afternoon, the medications might not arrive from the pharmacy until the next day. A medication dispensing system is available in the facility with some medications, but other medications have to come from the pharmacy which was not local. The orders from the hospital are received prior to the arrival of the resident and are entered into the facility's system by the unit manager. If these medications are entered after a certain time, the system puts the start time for the next day, but the medication start time could be entered manually to prompt the nurse to administer the medication. The DON acknowledged that Resident #1 had orders for respiratory medication and antibiotics and he did not receive these as ordered. The DON acknowledged that Resident #2 had orders for antibiotics for pneumonia that he did not receive as ordered. She stated it was the nurses' responsibility to obtain information as to when the dose was last given at the hospital, administer medications as ordered, monitor the residents for any change in condition, and to notify the provider for concerns. An interview with the Administrator on 6/18/25 at 3:30 PM, revealed the facility admitted residents from the hospital without the needed medications and pharmacy services to provide physician ordered medications to the residents timely. Resident #1 did not receive the ordered Vancomycin and Resident #2 did not receive the ordered Augmentin. These medications were not available in the facility's medication dispensing system and had to be delivered to the facility from the pharmacy which was not local. She acknowledged that not receiving medications timely and missing doses of medications could lead to complications for the residents. She confirmed that residents were admitted to the facility with specific medication orders and the facility failed to provide pharmacy services to obtain and administer these medications timely for Resident #1 and Resident #2.

Based on staff and resident interviews, record review, and facility policy review, the facility failed to honor residents' right to vote in the 2024 election for three (3) of six (6) residents sampled for resident's rights. Residents #4, #5, and #6 Findings Include: Record review of facility policy titled, Resident's Rights and Quality of Life, dated 5/1/12, revealed, It is the policy of (proper name removed) that all residents have the right to a dignified existence, self-determination, and communication with an access to people and services inside and outside the facility. A resident has the right to exercise his/her rights as a resident of the facility and a citizen or resident of the U.S. and be free of interference, coercion, discrimination, or reprisal by (proper name removed) or its employees for the exercise of such rights. During an interview on 1/16/25 at 11:10 AM, Resident #6 revealed she had told the staff several weeks before the 2024 presidential election that she wanted to vote with a mail-in ballot, but she was unable to. She stated, I wanted to vote, but I can't walk, and they didn't bring the ballot to me. An interview with Resident #7 on 1/16/25 at 11:15 AM revealed she had informed the facility staff that she wanted to vote in the 2024 presidential election and the staff told her they would get her a ballot, but she did not receive one. She stated, I wanted to vote, but I couldn't get there. During an interview on 1/16/25 at 11:45 AM, Resident #8 revealed he was registered and wanted to vote in the presidential election, but he was not taken to the poll. He stated that he was the son of a World War 2 veteran and his right to vote was taken away from him. He also stated, I'm an American and I have the right to vote. He stated he was very upset that he missed this opportunity because no one would take him. When asked if the staff asked him about identification, he said the facility had copies of his information and if there were other requirements, the staff should have assisted him. During an interview on 1/16/25 at 11:50 AM, Social Services #1 confirmed that not all of the residents that had expressed the desire to vote were given the opportunity on election day. She stated she worked with the residents that wanted to vote and completed their registration forms. She revealed she thought that with the registration forms, the residents would automatically receive their absentee ballots by mail. Towards the end of October, the residents that had previously requested the disabled status for absentee ballots received their ballots, but the ones she had registered had not received theirs. She called the Circuit Court and was told that if a resident was disabled, the resident must call and request the ballot to be mailed. She stated that there was only about a week left until the election and we didn't have time to help everybody call the Circuit Court. She acknowledged it was her responsibility to ensure that each resident's right to vote was honored and because she failed to research the proper steps in this process, many residents were unable to vote. She confirmed the facility failed to ensure that each resident that desired to vote was given the opportunity. An interview with the Administrator on 1/16/25 at 11:55 AM confirmed that each resident had the right to vote, and the facility failed to ensure they were assisted properly. Record review of the list of residents that were currently registered and newly registered for voting revealed 47 residents who desired to vote. Record review of the list titled, Voting 11/5/24 revealed nine (9) residents voted with absentee ballots, four (4) residents voted at the poll, one (1) listed as not having identification (Resident #8), one listed as being at dialysis, and six (6) declined to go to the poll. Record review of Resident #6's Admission Record revealed the facility admitted the resident to the facility on [DATE]. Diagnoses included Heart Failure, Hypertension, and Hypertensive Heart and Chronic Kidney Disease. Record review of Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Record review of Resident #7's Admission Record revealed the facility admitted the resident on 11/24/23. Diagnoses included Type 2 Diabetes Mellitus, Abnormalities of Gait and Mobility, and Peripheral Vascular Disease. Record review of Resident #7's MDS with an ARD of 12/1/24, revealed a BIMS score of 15 which indicated the resident was cognitively intact. Record review of Resident #8's Admission Record revealed the facility admitted the resident on 5/2/23 originally with the most recent admission of 4/2/24. Diagnoses included Alzheimer's Disease, Hypertensive Heart Disease, and Hypertension. Record review of Resident #8's MDS with an ARD of 1/8/25, revealed a BIMS score of 9 which indicated the resident had a moderate cognitive impairment.

Based on observation, resident and staff interviews, and record review, the facility failed to be administered in a manner that allowed it to use its resources effectively to ensure the well-being of its residents for four (4) of the four (4) days of the survey. Findings Include This tag is cross referenced to F 565, F 677, F 689, F 761, and F 880 A review of the typed statement on facility letterhead revealed that the facility did not have an Administration Policy and was signed by the Administrator. F 565 On 9/17/24 at 3:05 PM, during the resident council meeting held Resident #25 revealed that the food is terrible. She has complained about it in the resident council before, but nothing has improved. Resident #3 confirmed that they have complained about the food in resident council meetings every month and nothing is done. Resident #25 and Resident #50 stated that they never know when the resident council meeting is going to be each month because it is not put on the monthly activity calendar During an interview on 9/17/24 at 3:40 PM, with the Administrator confirmed that all residents should be made aware of the time and date of the resident council meetings are being held, because this is their home and that is their right to participate. She stated that complaints during the resident council meetings do not necessarily get put on a grievance form. She revealed that if for example it was a complaint about the food then the dietary department would meet with the resident or residents that complained. Record review of the resident council meeting minutes confirmed that food was discussed in the resident council meeting minutes for 9/24, 8/24, 7/24, 6/24, 5/24, 3/24 and 2/24 food and menu concerns were mentioned. During an interview with the Administrator on 09/18/24 at 8:25 AM, confirmed that food had been a concern for a while. During an interview on 9/18/24 at 11:00 AM, the Administrator confirmed that food complaints have been ongoing and should have been resolved by now. F 677 Resident #7 During an observation on 9/17/24 at 8:15 AM, revealed Resident #7 was lying in bed with eyes open, alert but confused. It was noted when entering the room that there was a very strong odor of urine in the room. During an observation and interview with Certified Nurse Aide (CNA) #7 on 9/17/24 at 8:18 AM, confirmed the strong odor of urine in the room. She revealed the resident was incontinent and explained that she had not made a round on the resident since her shift started at 7 AM. CNA #7 revealed the last round would have been done on the 11-7 shift. CNA #7 pulled back the top cover and checked to see if the resident was wet. An observation revealed the resident had on 2 blue briefs. The top brief was heavily saturated in urine. CNA #7 confirmed the resident was not supposed to have on 2 briefs and agreed it gives the impression that staff were not rounding and providing incontinent care, as they should be. She revealed she normally made rounds with the 11-7 shift, but she did not do it this morning and confirmed she should have. During an interview with the Director of Nursing (DON) on 9/17/24 at 11:00 AM, revealed not providing incontinent care timely and wearing 2 briefs could cause an increased risk for skin breakdown. She explained that using 2 briefs on a resident made it look like they were not wanting to make rounds on the residents. During an interview with the Administrator on 9/17/24 at 11:10 AM, revealed the aides were responsible for making rounds on the resident every 2 hours, and if the resident was a heavy wetter, they were to increase their rounds to hourly or every 30 minutes. F 689 Resident #22 During an observation of Resident #22 on 9/16/24 at 10:00 AM, revealed he was lying in bed. with a cigarette box lying at the foot of the bed in a white and blue pack. Resident #22 revealed he was a smoker and stated, They don't let us keep cigarettes in our rooms. There's not anything in the pack. The box contained 1 cigarette and one-half (1/2) of a used cigarette butt. During an interview with the Director of Nursing (DON) on 9/17/24 at 11:00 AM revealed, the Administrator keeps the cigarettes locked up in her office and distributes 2 cigarettes in a zip lock baggies to each resident that was going to smoke at each break. She revealed, we tell the families that the residents can't have them and if they buy them, they must leave them with the Administrator. She revealed Resident #22 did go out with a friend and could be getting them that way. The DON explained that the aides and nurses know that when they see cigarettes' or a lighter on a resident, they cannot have it. She stated, We cannot search the resident's room or the resident for the items. During an interview with the Administrator (ADM) on 9/17/24 at 11:10 AM revealed, the facility did not allow the residents to keep smoking paraphernalia and Resident #22 knew that. She revealed the resident had one friend that he went out of the facility with, but he knew the resident could not have them. She stated, I use the honor system. I can't go into his room and search or shake him down. She confirmed the resident could set something on fire in the building by keeping smoking materials. Resident #34 During an observation of Resident #34's bedside dresser on 9/16/24 at 10:15 AM revealed a bottle of Rolaids Antacid Ultra Strength #72 count, Magnesium 200 mg (milligrams) #60 count, and a bottle of Multivitamin tablets #200 count. An interview with the resident revealed, he brought them from home and stated, I just take them when I think about it. An interview with the ADM on 9/17/24 at 12:10 PM, revealed that they (the staff) were not aware that Resident #34 had the medication in his room and was taking it. She revealed that the resident did not have an order to self-administer meds and confirmed that he could potentially get overmedicated if he was receiving the same medications from the nurses. F 761 During an observation on 9/16/24 at 9:04 AM, revealed an unattended medication cart sitting outside the dining room near the beginning of the B Hall. The top of the cart contained a medicine cup full of a red liquid, a bottle of magnesium, Colace and calcium sitting on the top of the medication cart. During an observation and interview on 9/16/24 at 9:06 AM, with the Assistant Director of Nurses (ADON) confirmed there was a medicine cup full of a red liquid, and three bottles of over-the-counter medication that included magnesium, Colace and a bottle of calcium. She stated that medication should never be left out on the medication cart while there is no nurse at the cart. She stated this is to prevent other residents from ingesting the medication that could lead to an accident or harm. She revealed that this medication cart belonged to Licensed Practical Nurse (LPN) #2 and she was not sure where she was. During an observation and interview on 09/17/24 at 12:40 PM, revealed Registered Nurse (RN) #1 standing at the B wing medication cart. RN #1 had medication cards in her hand. She opened the red narcotic binder and placed the medication cards inside the binder. RN #1 then closed the top of the binder, left the cart, and went down the hall. The medication card edges were visible and accessible to anyone passing the medication cart. RN #1 returned to the unattended medication cart at 12:43 PM. She confirmed four (4) medication cards, including Baclofen, Buspar, Augmentin, and Cyproheptadine, were left on the medication cart unattended and unsecured. She revealed she should not have left the medication on the cart unattended and confirmed it could have been a hazard for other residents who could have gotten into the medications. During an interview with the Director of Nurses (DON) on 9/18/24 at 9:10 AM confirmed that medication should never be left on top of a medication cart unattended. She stated that any resident could have come by and drank or took that medication. F 880 An observation outside Resident #20's room on 9/16/24 at 9:18 AM, revealed, the door was open. Upon entering the room, the privacy curtain was pulled in the middle of the room, and a blue and white soiled disposable bed pad could be seen lying on the floor with a dark brown substance on it. Certified Nurse Aide (CNA) #8 was assisting the resident and revealed she was helping the resident with her colostomy bag. She confirmed the bed pad was soiled and revealed it should not be placed on the floor and should be bagged and disposed of. She revealed this action could spread germs throughout the facility. An interview with the Administrator (ADM) on 9/17/24 at 12:10 PM, revealed, soiled trash should never be placed on the floor and should be placed in a bag and transported out of the room. She confirmed placing soiled trash on the resident's floor was an infection control concern. During an observation of the facility on 09/16/24 from 10:00 AM until 11:30 AM revealed there was one (1) EBP sign on room A4 on the A-Hall. The tour of the B-Hall revealed there were (2) signs on (2) different rooms, and no signs were observed on the C- Hall or D- Hall. During an interview on 09/16/24 3:13 PM, with Certified Nurse Assistant (CNA) #3 revealed she is not familiar with EBP. She stated she has never been told anything about it and has no idea what it means. During an interview on 09/16/24 3:24 PM, with Licensed Practical Nurse (LPN) #3 confirmed she has never heard of EBP and could only guess what it was. During an interview on 09/16/24 at 3:35 PM, with Registered Nurse (RN)/Infection Preventionist revealed she thinks enhance barrier precautions means that she would like for staff to wear gloves if there is a suspicion on an infection and if it is air born then she would want them to wear a mask. During an interview on 09/16/24 at 3:56 PM, with CNA #4 on A Hall revealed she was aware of what EBP, because she works in another facility, but has not been told anything about it at this facility. During an interview on 09/16/24 at 3:58 PM, with CNA #5 on the B Hall revealed she may have attended an in-service about EBP, but she is not certain. She stated she thinks it means that they use extra precautions for residents with a EBP sign on their door. She confirmed that if there were two residents in a room with a EBP sign then she would not know which resident was on EBP. She revealed since she would not know which resident needed EBP then she would use precautions with both. She confirmed she does not know the purpose of EBP. During an interview on 9/17/24 at 11:40 AM, with the Administrator revealed she is not sure why after in servicing two months ago that EBP that it was not known by staff and implemented or why the signs were not on the doors like they should have been. She confirmed that someone should have audited staff after the in-service and implementation of EBP to make sure it was going correctly. She revealed the purpose of EBP is to prevent the staff from giving the resident an infection and from the staff bringing an infection out and giving it to someone else. An observation of medication pass on 9/18/24 at 8:15 AM, with Licensed Practical Nurse (LPN) #6, revealed she prepared Resident #2's PEG (Percutaneous Endoscopic Gastrostomy) medication and stopped at the resident's door to read the sign posted that read, Enhanced Barrier Precautions. LPN #6 entered the room and administered Resident #2's medications via PEG tube without donning (putting on) a gown. An interview with LPN #6 on 9/18/24 at 8:35 AM, confirmed she did not put on a gown to practice EBP while administering Resident #2's medications. She revealed that she did stop and read the sign on the door, but the sign did not specify that she needed to practice precautions while giving peg (Percutaneous Endoscopic Gastrostomy) meds. LPN #6 revealed she had been in-serviced on the measures, but she must have missed the part about the need to dress out with PEG meds. She confirmed that a peg tube was considered an indwelling medical device and stated, It makes sense.

Based on observations, staff and resident interviews, record review, and facility policy review, the facility Quality Assurance and Assessment (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee put into place following the recertification survey of 6/22/23. This was for deficiencies recited during a recertification survey on 9/16/24. The recited deficiencies included F 550, F565, F584, F656, F677, F689, F761, and F880. The continued failure of the facility during two state surveys indicates a pattern of the facility to sustain an effective QAA program. This was for eight (8) of 18 deficient practice citations. Findings Included: This citation is cross-referenced to: F 550, F 565, F 584, F 656, F 677, F 689, F 761, and F 880 Review of the facility policy titled Quality Assurance and Performance Improvement dated February 2017 revealed, Purpose: QAPI is a data driven, proactive approach to improving the quality of life, care and services in our centers. The activities of QAPI involve team members at all levels of the organization to identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor the effectiveness of our interventions. QAPI is consistent with our Service Standard: We continually strive to improve personal and company performance . During the recertification and complaint survey on 6/19/23 the facility was cited for F 550, F 558, F 565, F 584, F 623, F 625, F 656, F 677, F 689, F 690, F 725, F 761, and F 880. During the recertification and complaint survey on 9/16/24 the facility was cited for F 550, F 561, F 565, F 578, F 583, F 584, F 606, F 656, F 657, F 658, F 677, F 689, F 700, F 761, F 804, F 835, F 867, and F 880. During an interview on 9/18/24 at 11:30 AM, the Administrator (ADM) revealed our EMBRACE rounds, which are checklist sheets assigned to all department heads except maintenance. Our role with that program is to go out and catch the issues found and ensure they are immediately corrected. She revealed that she and the Director of Nurses (DON) have the whole building to round on and catch deficient practices. She revealed when the staff made their rounds, and they should have found the issues that the State Agents (SA) found again during this annual survey. She revealed I don't think we haven't gotten to the root cause of the issues. She confirmed she feels like the staff finds deficient practices when they do the Embrace rounds, then stated, but the follow-up is where we are missing it. An interview on 9/19/24 at 10:55 AM, the ADM revealed, regarding the re-cited deficient practices observed again with this survey, regarding Activities of Daily Living (ADL) care is something we have to work on continually and revealed what we are doing is still not working. She revealed we are all responsible for following-up and making sure that ADL care it is being done. Everybody that sees it has a responsibility even if they are not clinical and they see issues they are to report it to the clinical team. She revealed that the facility gets so focused on filling the shifts and staffing and just the day to day running of the center that we are missing those details, we are doing big picture stuff. She revealed, We are here every day, and we get kind of numb to it. I don't think it would be fair to say that it is only the floor staff that gets numb to it, all of us including myself and the DON have been in and out of rooms and should be catching these issues. The Administrator confirmed, there is a disconnect somewhere and revealed, while we are monitoring for a period of time we see improvement, but when we stop monitoring and following-up we start seeing complacency.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide dignity to residents, as evidenced by leaving urinary catheter bags uncovered for two (2) of four (4) residents with a catheter. Resident #52 and Resident #190. Findings include: A review of the facility policy, Resident's Rights and Quality of Life dated 05/01/2012, revealed . all residents have the right to a dignified existence, self-determination, and communication with an access to people and services inside and outside the facility. Resident #52 An observation on 09/16/24 at 9:25 AM and again at 10:25 AM, revealed Resident #52 lying in bed, with the bed against the right wall. Resident #52's urinary catheter bag and tubing were exposed with approximately 100 cc (cubic centimeters) of urine in the catheter bag with no privacy covering over the urinary drainage bag. An observation and interview on 09/16/24 at 3:15 PM with the Assistant Director of Nurses (ADON) revealed all urinary catheter bags are to always be in a covered privacy bag. She confirmed that the urinary catheter bag without a privacy bag is a dignity issue, and the resident should have had a privacy bag over it when it was observed uncovered this morning. A record review of Resident #52's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Seizures, Urinary Tract Infection, and cognitive communication deficit. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/20/24, revealed under Section H- Bladder and Bowel That Resident #52 had an indwelling catheter. 45598 Resident #190 On 09/16/24 at 9:45 AM, an observation in Resident #190's room, revealed a catheter bag hanging on the left side of the bed with no privacy bag covering and it was observed with 350 milliliters (mls) of yellow urine in the drainage bag and it was facing the door. On 09/16/24 at 10:30 AM an observation and interview with Resident #190 revealed a urinary catheter bag hanging on the left side of the bed facing the doorway with no privacy bag in place. There was yellow urine draining into the catheter bag. Resident #190 revealed that therapy staff wheeled her down the hall to physical therapy with the uncovered catheter bag attached to her wheelchair nearly every day. Resident #190 revealed that she worried that other people would stare at her catheter and she stated, It makes me feel nasty. On 09/16/24 at 11:08 AM, an interview with Registered Nurse (RN) Unit Manager revealed that she walked through the facility this morning, saw that Resident #190's catheter bag was not in a privacy bag. RN Unit Manager revealed that having a urinary catheter bag uncovered was a privacy issue and that all catheter bags should be covered. On 09/17/24 at 10:15 AM, an interview with Director of Nursing (DON), revealed that all urinary catheter drainage bags should be covered due to privacy and dignity issues that it may cause the resident. She agreed that not having a privacy bag over Resident #190's urinary catheter bag was a dignity issue. On 09/16/24 at 10:20 AM, an interview with Physical Therapy Assistant (PTA), revealed that she had Resident #190 on her caseload and she received therapy services five days a week. PTA revealed that she transported Resident #190 to therapy in her wheelchair and that she hadn't paid much attention to her catheter bag. She revealed that she normally took the catheter bag from the bed, hooked it on the wheelchair and just went with it during transport to therapy. PTA agreed that transporting a resident with a catheter bag without a privacy bag was a dignity issue and the bag should be covered. She revealed that she would make sure from now on that all catheter bags were covered before transport to therapy. Record review of Resident #190's Admission Record revealed an admitted [DATE] and that she had diagnoses that included Obstructive and Reflux of Uropathy, Rhabdomyolysis, and Paraplegia. Record review of Resident #190's MDS with ARD of 09/13/24 under Section C revealed a BIMS Score of 14 which indicated that she was cognitively intact. Section H revealed that she had an indwelling catheter.

Based on resident and staff interview, record review and facility policy review the facility failed to ensure that all residents were made aware of the resident council meetings each month in order to make the choice to attend (Resident #27 and Resident #50) for two (2) of 16 residents reviewed. The facility also failed to resolve grievances for seven (7) of eight (8) resident council meetings. CROSS REFERENCE F804??????? Findings Include: Review of the facility policy titled Resident Council with an effective date of 5/1/12 revealed under Procedure .#4. Activity Director/SS Designee will provide written answers to questions, requests and grievances to the Resident Council. #5. The Activity Director/SS Designee shall communicate to all residents when and where resident council meetings are held . Record review of the Resident Council Meeting minutes confirmed that food concerns were discussed in the minutes for 9/24, 8/24, 7/24, 6/24, 5/24, 3/24 and 2/24. Food and menu concerns were mentioned and no resolution to the grievances. An interview and record review on 9/16/24 at 10:00 AM, with Residents #27 and Resident #50, Resident #27 stated that the food is terrible and that she has received hashbrowns before that were still frozen inside. She stated that when she ask for an alternate meal then she gets the same meal. Resident #50 confirmed that the same thing had happened to her and that she has complained to the aides, but that's all she knows to tell because that's who brings the meals in to her. Resident #27 stated the chicken is too hard to chew. They both agreed that they never know when the Resident Council Meetings are and Resident #50 stated that she has been here three (3) years, and she has been to one meeting. Resident #27 stated that she has never heard of a Resident Council Meeting. A review of the activities calendar in the resident's room revealed there was no Resident Council Meeting scheduled for September 2024 . An interview and record review on 9/16/24 at 10:10 AM with the Activities Director revealed that she had a Resident Council Meeting on 9/11/24, but confirmed it was not on the September Activities Calendar. She stated that sometimes she is not able to put it on the calendar because she has to coordinate with the dietary manager because they have complaints about food a lot. She revealed when she is not able to put the Resident Council Meetings on the Activities Calendar, then she puts it on a flyer and hangs it in the hall by the large activities calendar. She admitted that if residents did not see the flyer, then the only way they would know when the meeting was scheduled would be by word of mouth from other residents and staff. An interview on 9/16/24 at 10:03 AM, with Resident #43 confirmed that the chicken taste like it's been cooked for weeks and is too hard to chew. He stated he has gone to the cook's multiple times and complained, but nothing has improved. An interview on 9/16/24 at 12:30 PM, with Social Services confirmed that they have had a lot of complaints about the food, wanting a different menu or extra seasoning. She stated she handles grievances but food complaints from the Resident Council Meetings usually do not get put on a grievance form. She stated that she thinks dietary handles the complaints about the food but stated that she wasn't sure. An interview on 9/17/24 at 10:50 AM, with Resident #79 revealed the food is terrible and he has complained about it to the aides and the business office person and the dietician. He stated that the dietician has come and talked with him more than once, but nothing has improved. He stated that he usually does not get food that he likes. An observation of the lunch meal on 9/17/24 at 12:44 PM, revealed that Resident #27 received a hamburger steak with gravy, fried potatoes and a roll. The hamburger patty was approximately an 1/8 inch thick, and the brown gravy was watery and poured over the top of the hamburger patty. An interview on 9/17/24 at 3:00 PM, with the Activities Director revealed that she had not informed all residents of the meeting with the state surveyor for today. She stated that she had just let whoever was at the activities at 2:30 PM stay if they wanted. She stated that she started to put a flyer out but didn't. During the resident council meeting held on 9/17/24 at 3:05 PM Resident #25 revealed the food is terrible and she has complained about it in Resident Council before, but nothing has improved. Resident #3 confirmed they have complained about the food in Resident Council Meetings as well but have not gotten any resolution to their grievances. An interview on 9/17/24 at 3:40 PM, with the Administrator confirmed that all residents should be made aware of the time and date that the Resident Council Meetings are being held, because this is their home and that is their right to participate. She stated that complaints during the Resident Council Meetings do not necessarily get put on a grievance form. She revealed that if for example it was a complaint about the food then the dietary department would meet with the resident or residents that complained. An interview on 09/18/24 at 8:25 AM, with the Administrator confirmed that food has been a concern for a while. We met once a month for a while, but when the dietary manager went out on maternity leave in 3/2024 that committee dwindled away. She stated that residents were allowed to come to the meetings when they had them. An interview on 9/18/24 at 9:30 AM, with the Dietary Manager and the District Dietary Manager they confirmed they have had complaints about food for a while. The Dietary Manager stated that some of the complaints they have received have been wanting the menu changed, too many potatoes, not liking the chicken. The District Dietary Manager revealed most of the complaints have just been personal preferences by the residents. She stated that she was off on maternity leave from 3/24 through 5/24 and confirmed that the food committee meetings that were being held once a month stopped after she left on maternity leave. She admitted that she has gotten complaints from the resident council meetings and if she does not attend then the Activities Director just verbally tells her who complained and what it was about. She revealed that she then goes and talks to that resident. She revealed that she still gets repetitive complaints about food. An interview on 9/18/24 at 11:00 AM, with the Administrator confirmed that food complaints have been ongoing and should have been resolved by now and confirmed that this issue was an unresolved grievance. Record review of the Grievance Log for the last six (6) months revealed there was one grievance regarding disliking the food for Resident #25 on 5/20/24 and that the resident had requested a peanut butter and jelly sandwich with each meal. An interview on 09/19/24 at 8:51 AM, with Resident #25 confirmed she has complained about the food for a long time and recalls filing a grievance in 5/2024. When asked if she was getting her peanut butter and jelly sandwiches with every meal, she stated, I don't know what you are talking about, I don't want all those sandwiches. She stated that she had not received sandwiches of any kind with meals and doesn't want sandwiches. She stated her grievance was about the food and it has not been resolved as of yet. She confirmed that she just picks around on the food and stated, Have you tried it?, If so, then you know what we are going through. Record review of Resident #3's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Palsy. Record review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/3/24 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident is cognitively intact. Record review of Resident #25's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Hypertensive Heart Disease without Heart Failure. Record review of Resident #25 MDS with an ARD of 8/6/24 revealed under Section C a BIMS score of 08, which indicated the resident is moderately cognitively impaired. Record review of Resident #27's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus. Record review of Resident #27's MDS with an ARD of 7/25/24 revealed under Section C a BIMS score of 15, which indicated the resident is cognitively intact. Record review of Resident #43's Admission Record revealed he was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's Disease. Record review of Resident #43's MDS with an ARD of 7/23/24 revealed no score for his BIMS score in Section C. Record review of Resident #50's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease. Record review of Resident #50's MDS with an ARD of 9/13/24 revealed under Section C a BIMS score of 15, which indicated the resident is cognitively intact. Record review of Resident #79's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Chronic Kidney Disease, stage 3. Record review of Resident #79's MDS with an ARD of 7/15/24 revealed under Section C a BIMS score of 14, which indicated the resident is cognitively intact.

Based on observation, resident and staff interviews, statement on facility letterhead and facility policy review, the facility failed to maintain a clean and safe environment, as evidenced by a dirty wheelchair, (Resident #71) and electrical wires exposed on a bed control (Resident #12) for two (2) of the 22 residents sampled residents. Findings Include: A review of the statement on facility on letterhead signed by the Administrator and dated September 18, 2024, revealed, (Proper Name) utilizes the Embrace Program for our wheelchair cleaning and inspection of bed controls and electrical connections. A review of the facility policy titled Resident's Right and Quality of Life, dated May 1, 2012, revealed, A resident has the right: to receive services in a facility environment that is safe, clean, and comfortable . Resident #12 On 09/16/24 at 10:10 AM, an observation revealed Resident #12's electric bed control in disrepair and laying beside her in bed on her right side. The cord was frayed, and it had an area that measured approximately one-half inch with red, yellow, brown, blue, and black wires exposed. On 09/17/24 at 3:07 PM, an interview with Certified Nursing Assistant (CNA) #5, confirmed that Resident #12's bed control cord was torn with wires exposed and she revealed that she hadn't noticed it before. She revealed that this was an electrical fire hazard and needed to be fixed. CNA #5 revealed that anytime they noticed an issue like that, they reported it to maintenance, and they got right on it. On 09/17/24 at 3:10 PM, an interview with Registered Nurse (RN) Unit Manager, confirmed that Resident #12's bed control cord was frayed and had wires exposed. She revealed that this was a safety hazard, and she would put a work order in for maintenance to fix it. On 09/17/24 at 3:55 PM, an interview with Resident #12 revealed that the bed control cord had been torn since she had been at the facility and stated, That's been over a year. She also revealed that she was concerned that the exposed wires might burn her or cause a fire. On 09/17/24 at 4:00 PM, an observation and interview with Maintenance Supervisor, confirmed the exposed wires on the cord of Resident #12's bed control. He revealed that the wires were coated, and they were low voltage but if the covering came off and the wires touched, the resident could get a little tinge from it. Record review of Resident #12's Admission Record revealed an admitted [DATE] and that she had diagnoses that included Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Need for Assistance with Personal Care. Record review of Resident #12's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/05/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that she was cognitively intact. Resident # 71 On 9/16/24 at 9:25 AM, an observation revealed Resident #71's wheelchair base and wheel spokes with a thick, grayish-dried substance and food crumbs on the wheelchair base. An observation on 9/17/24 at 9:05 AM, revealed Resident #71 sitting in the smoking area in a wheelchair with a thick, grayish-dried substance and food crumbs on the wheelchair base. In an interview on 9/17/24 at 10:50 AM, Resident #71 revealed that his wheelchair is filthy and needs to be cleaned. During an interview on 9/17/24 at 11:05 AM, Certified Nurse Aide (CNA) #1 revealed he normally works the night shift, and they are responsible for cleaning the wheelchairs; there's a list we follow to ensure all the wheelchairs get cleaned. An interview and observation on 9/17/24 at 11:15 AM, the Assistant Director of Nurses (ADON) revealed that the night shift is responsible for cleaning the wheelchairs. She confirmed that Resident #71's wheelchair was dirty and appeared covered in dirt and food particles. She revealed the wheelchair should have been cleaned. A record review of Resident #71's Admission Record revealed he was admitted to the facility on [DATE] with diagnoses that include Cerebral infarction and Need for Assistance with Personal Care. A record review of Resident #71's MDS with an ARD of 07/23/24, revealed a BIMS score of 14, which indicated the resident is cognitively intact. 46013

Based on observation, resident and staff interview, record review, facility policy review, the facility failed to implement a comprehensive care plan related to Activity of Daily Living (ADL) for Resident #58, Resident #59 and for Resident #22 for smoking . For three (3) of 22 care plans reviewed. Findings Include: Facility policy titled, Care Plans, with no date, revealed, Care plans will be developed for all patients and residents based upon the Resident Assessment Instrument (RAI) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. Resident #22 Record review of Resident #22's Care Plans with a date initiated of 5/29/21 revealed , Focus: At risk for smoking related injury related to: Smokes independently .Interventions .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management. Patient is not to have cigarettes or smoking material on person During an observation of Resident #22 on 9/16/24 at 10:00 AM, revealed he was lying in bed. with a cigarette box lying at the foot of the bed in a white and blue pack. Resident #22 revealed he was a smoker and stated, They don't let us keep cigarettes in our rooms. There's not anything in the pack. The box contained 1 cigarette and one-half (1/2) of a used cigarette butt. During an interview with the Administrator on 9/18/24 at 2:40 PM, revealed, the purpose of the care plan was to provide the necessary care and to allow staff to know how to care for the resident. An interview with the Assistant Director of Nursing (ADON) on 9/19/24 at 8:49 AM, confirmed Resident #22's care plan was not followed. Record review of the Admission Record revealed the facility admitted Resident #22 on 2/24/24 with a medical diagnosis that included Personal history of nicotine dependence. Resident #58 Record review of Resident #58's Care Plan revealed that he had an ADL self-care performance deficit r/t (related to) contractures, decreased mobility with interventions initiated on 04/01/24 that included, BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. An observation and interview on 09/16/24 at 10:50 AM with Resident #58 revealed long jagged fingernails approximately one-half to three-fourths inch long on his bilateral hands. Resident #58 stated, They're slow on checking fingernails. He revealed that his shower days were Tuesday, Thursday, and Saturday and he confirmed that they did not take care of his nails like they were supposed to. An observation and interview on 09/17/24 at 11:27 AM, with Certified Nursing Assistant (CNA) #2 in Resident #58's room confirmed that he had long jagged fingernails on both hands and that his fingernails should be cut. On 09/18/24 at 9:10 AM, an interview with Minimum Data Set (MDS) Coordinator, revealed that they developed care plans to drive the care needed for the residents. She revealed that the care plans were patient specific. On 09/18/24 at 9:35 AM, an interview with Licensed Practical Nurse (LPN) #2, revealed that the Certified Nursing Assistants were supposed to check fingernails with every bath and as needed. She agreed that nail care was included in the care plan and if they left their fingernails long and dirty, they did not follow the care plan. An interview with Administrator (ADM) on 09/18/24 at 11:15 AM, confirmed that nail care was included in Resident #58's care plan and agreed that the staff did not follow the care plan for nail care. Record review of Resident #58's Admission Record revealed an admitted [DATE] and that he had diagnoses that included Cervical Disc Disorder with Myelopathy, Need for Assistance with Personal Care, and Muscle Weakness. Record review of Resident #58's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/01/24 under Section C revealed a Brief Interview for Mental Status Score (BIMS) of 15 which indicated that he was cognitively intact. Under Section GG revealed that he required partial to moderate assistance with showering and bathing himself and required substantial/maximal assistance with personal hygiene. Record review of Resident #58's Task Care Record revealed that a staff member signed that he received his shower on Saturday evening, 09/14/24. Resident #59 Record review of Resident #59's Care Plan initiated on 06/13/24 revealed that he had self care deficit related to history of CVA (Cerebrovascular Accident), decreased functional abilities, hemiplegia to left nondominant side, weakness. Interventions included, Nail, hair, and oral care daily and as needed and Provide cueing, supervision, and assistance with ADLs as needed. An observation and interview on 09/16/24 at 10:40 AM, with Resident #59 revealed long jagged fingernails on both hands and he had three fingernails on his right hand with brown substance underneath. He revealed that the aides helped with his baths every other day but they had not checked his fingernails in a while. Resident #59 revealed that he couldn't see that well and he needed help to keep them cleaned and trimmed. On 09/18/24 at 11:20 AM an interview with Administrator (ADM) revealed that nail care was included in Resident #59's care plan and she agreed that they did not follow their care plan for nail care. Record review of Resident #59's Admission Record revealed an admitted [DATE] and that he had diagnoses that included Hemiplegia, Cerebral Infarction, and Generalized Muscle Weakness. Record review of Resident #59's MDS with ARD of 09/09/24 under Section C revealed a BIMS Score of 15 which indicated that he was cognitively intact. Section GG revealed that he required setup or clean up assistance with personal hygiene needs. Section B revealed that his vision was highly impaired. Record review of Resident #59's Task Care Record revealed that a staff member signed that he received his shower on Monday evening, 09/16/24. 45598

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide the necessary assistance with Activities of Daily Living (ADL) care for a resident requiring nail care (Resident #58, #59) and incontinent care (Resident #7) for three (3) of 22 sampled residents. Findings Include: Review of the facility policy ADL's (Activities of Daily Living) dated August, 2021, revealed, Policy: Ensure ADL's are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences. An observation on 9/17/24 at 8:15 AM, revealed Resident #7 was lying in bed with eyes open, alert but confused and it was noted a very strong odor of urine in the room. An observation and interview with Certified Nurse Aide (CNA) #7 on 9/17/24 at 8:18 AM, confirmed the strong odor of urine in the room and confirmed the resident was incontinent and explained that she had not made a round on the resident since her shift started at 7 AM. The CNA revealed the last round would have been done on the 11-7 shift. The CNA pulled back the top cover and checked to see if the resident was wet. An observation revealed the resident had on two (2) blue incontinent briefs. The top brief was heavily saturated in urine. CNA #7 confirmed the resident was not supposed to have on 2 briefs and agreed it gives the impression that staff were not rounding and providing incontinent care, as they should be. She revealed she normally made rounds with the 11-7 shift, but she did not do it this morning and confirmed she should have. An interview with CNA #8 on 9/17/24 at 8:22 AM, revealed they were supposed to round on the residents every 2 hours or more if needed. She revealed they were required to make rounds with the off going shift to ensure the residents were clean and dry. An interview with the Director of Nursing (DON) on 9/17/24 at 11:00 AM, revealed not providing incontinent care timely and wearing 2 briefs could cause an increased risk for skin breakdown. She explained that using 2 briefs on a resident made it look like they were not wanting to make rounds on the residents. An interview with the Administrator on 9/17/24 at 11:10 AM, revealed the aides were responsible for making rounds on the resident every 2 hours, and if the resident was a heavy wetter, they were to increase their rounds to hourly or every 30 minutes. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/13/24 revealed under, bladder and bowel in section H, Resident #7 was always incontinent of bladder. Also revealed under section GG, the resident was dependent on staff for toileting hygiene. Record review of the Admission Record revealed the facility admitted Resident #7 on 2/19/23 with a medical diagnosis of Unspecified Dementia. Resident #58 On 09/16/24 at 10:50 AM, an observation and interview with Resident #58 revealed long jagged fingernails approximately one-half to three-fourths inch long on his bilateral hands. Resident #58 stated, They're slow on checking fingernails. He revealed that his shower days were Tuesday, Thursday, and Saturday and he confirmed that they did not take care of his fingernails like they were supposed to. On 09/17/24 at 9:07 AM, an observation in Resident #58's room revealed long jagged fingernails on both of his hands. He revealed that he had his shower on Saturday night and revealed that they had not provided nail care. On 09/17/24 at 11:27 AM, an observation and interview with CNA#2 in Resident #58's room confirmed that he had long jagged fingernails on both of his hands. She revealed that long jagged fingernails could scratch him on his skin and cause a possible infection. On 09/18/24 at 9:35 AM, an interview with Licensed Practical Nurse (LPN) #4, revealed that the CNAs were supposed to check fingernails with every bath and as needed. On 09/17/24 at 11:45 AM, the Assistant Director of Nursing (ADON) confirmed that Resident #58's fingernails were long and jagged and needed to be cut. On 09/18/24 at 11:15 AM an interview with Administrator (ADM) revealed that nail care was supposed to be done during resident baths and showers. She revealed that the CNAs were also supposed to be checking nails every day and cleaning them as needed. She revealed that ADL concerns had been on-going and they were working on trying to fix issues. ADM confirmed that they should have identified these ADL concerns regarding the nails and fixed the problem. Record review of Resident #58's Admission Record revealed an admitted [DATE] and that he had diagnoses that included Cervical Disc Disorder with Myelopathy, Need for Assistance with Personal Care, and Muscle Weakness. Record review of Resident #58's MDS with ARD of 07/01/24 under Section C revealed a BIMS Score of 15 which indicated that he was cognitively intact. Record review of Resident #58's Task Care Record revealed that a staff member signed that he received his shower on Saturday evening, 09/14/24. Record review of Resident #58's MDS with ARD of 7/01/24 under Section GG revealed that he required partial to moderate assistance with showering and bathing himself and required substantial/maximal assistance with personal hygiene. Resident #59 On 09/16/24 at 10:40 AM, an observation and interview with Resident #59 revealed long jagged fingernails on both hands and he had three fingernails on his right hand with brown substance underneath. He revealed that the aides helped with his baths every other day but they had not checked his fingernails in a while. Resident #59 revealed that he couldn't see that well and he needed help to keep them cleaned and trimmed. On 09/17/24 at 11:25 AM, an interview with CNA #2 revealed that they had scheduled times for resident baths or showers and that they were supposed to check, clean and clip fingernails during that time. She revealed that personal hygiene included mouth care, nail care, peri-care and shaving. She confirmed that Resident #59's fingernails were long and jagged and should have already been taken care of. An observation and interview on 09/17/24 at 11:33 AM, with Registered Nurse (RN) #1 confirmed that Resident #59 had long jagged fingernails and brown substance underneath three fingernails on his right hand. She revealed that fingernails carried germs and could cause infection if Resident #59 scratched himself. Record review of Resident #59's Admission Record revealed an admitted [DATE] and that he had diagnoses that included Hemiplegia, Cerebral Infarction, and Generalized Muscle Weakness. Record review of Resident #59's MDS with ARD of 09/09/24 under Section C revealed a BIMS score of 15 which indicated that he was cognitively intact. Section B revealed that his vision was highly impaired. Section GG revealed that he required setup or clean up assistance with personal hygiene needs. Record review of Resident #59's Task Care Record revealed that a staff member signed that he received his shower on Monday evening, 09/16/24. 45598

Based on staff interviews, record review, and facility policy review, the facility failed to report to the State Agency (SA) an incident of elopement for one (1) of of four (4) residents who was an elopement risk. Resident #1. Resident #1 was admitted to the facility on [DATE] at approximately 4:20 PM. Resident was observed by Licensed Practical Nurse (LPN) #1 to be pacing in the hallway and stating she was leaving and going home and required redirecting several times. LPN #1 reported she last saw Resident #1 a few minutes before 7:00 PM. CNA #1 reported she last saw Resident #1 approximately 7:00 PM when dinner trays were picked up. At the end of LPN #1's shift, at approximately 7:20 PM, LPN #1 went to check on Resident #1 and the resident could not be located. Resident #1 was away from the facility unsupervised on 7/14/2021 from approximately 7:00 PM until the Resident's son was able to locate the Resident at her residence at approximately 9:00 PM. The facility's failure to report an elopement placed Resident #1 and other residents with wandering behaviors and at risk of elopement in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality (SQC) that began on 07/14/2021, when Resident #1 eloped from the facility. The facility Administrator was notified of the IJ on 07/20/2021 at 7:00 PM. The facility provided an acceptable Removal Plan on 7/22/2021, in which the facility alleged all corrective actions were completed to remove the IJ on 7/21/2021, and the IJ removed on 7/22/2021. The SA determined the IJ was removed on 7/22/2021, prior to exit, and the scope and severity for 42 CFR: 483.12(c)(1), F 609, Reporting of Alleged Violations, was lowered to a D, while the facility develops and implements a plan or correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019, revealed, Purpose: To prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws .Immediately reporting all alleged violations to the Administrator, designee, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. During an interview with the Director of Nursing (DON) and the Administrator on 7/19/2021 at 3:20 PM, the DON stated the facility has not had an elopement, but some residents did leave Against Medical Advice (AMA). The Administrator stated the facility has not had an elopement, and if they had, she would have reported it. Interview with the Administrator on 7/19/2021 at 5:40 PM, revealed she received a phone call from the Interim Administrator on 7/14/2021 between 9:30 PM - 10:00 PM. She was told that a resident had left the facility and they had investigated the incident. She was told by the Interim Administrator that the resident did not want to be in the facility and somebody had picked her up and that Resident #1's son said a friend picked her up and took her home. She was informed by the Interim Administrator that this incident was Against Medical Advice (AMA) and not elopement. The Administrator confirmed she did not report this incident based on this information. Interview and record review with the Director of Nursing (DON) on 7/19/2021 at 6:00 PM, revealed she reached Resident #1's son by phone and she was told by her son that Resident #1 was in (Proper Name of Town) and thought a friend had picked her up. The DON stated she documented the event but was unable to locate what was documented. She stated the Corporate Nurse had taken notes on 7/14/2021 and they read as: Patient admitted , alcoholic with dementia, left AMA with a friend and Left after about four hours. Called friend to pick her up. She stated she did not report the AMA incident. Phone interview with the Interim Administrator on 7/20/2021 at 11:27 AM, revealed that when considering whether this situation was an elopement or an AMA, she called the Corporate Nurse and was told it sounded like an AMA since a family member picked her up. The Interim Administrator stated since they considered this an AMA discharge, the facility did not report it. Interview with the DON on 7/20/2021 at 5:23 PM, revealed the DON stated an elopement is when a resident gets out of the building and the staff does not know where they are and Resident #1 was out of the facility and the staff did not know where she was, so that would be an elopement. She stated the Corporate Nurse listed this incident as AMA based on the son telling the DON and Interim Administrator that a family member picked the resident up, so the incident was not reported. The DON stated, I wanted to call this in, but corporate was pushing us not to report. Interview with Interim Administrator on 7/21/2021 at 4:50 PM, revealed that during the phone call with Resident #1's son, he said a family member picked the resident up. The Interim Administrator asked the Corporate Nurse/Director of Clinical Operations if this incident was AMA or elopement. The Interim Administrator stated the Corporate Nurse said, It sounds like AMA to me. She stated this incident was not reported. Interview with Administrator on 7/22/2021 at 9:45 AM, revealed the incident with Resident #1 leaving the facility should have been investigated as an elopement and called in to the proper agencies. She confirmed the facility failed to report this elopement. Interview with DON on 7/22/2021 at 10:20 AM, she confirmed the resident leaving the facility and away from the staff's supervision should have been considered an elopement and should have been reported to the proper entities, including the SA. She confirmed the facility failed to report this elopement to the proper authorities. Phone interview with Resident #1's Son on 7/22/2021 at 10:57 AM, revealed the facility did call him to tell him that his mom was missing. SA asked the son if he told them on that first phone call that he knew where his mother was or who had picked her up and he stated, No Ma'am, I did not tell them that. I did not know where she was or who had picked her up. I had to leave work to look for her. Resident #1's Son stated he called the facility back when he found his mother. Interview with Corporate Nurse on 7/22/2021 at 2:00 PM, revealed when the incident of Resident #1 leaving the facility occurred, she spoke with the Interim Administrator and was given the information that the resident had left with a family member and was at home with the son and was fine. She decided this was an AMA situation rather than an elopement. She stated once the situation was looked into more, it was apparent the situation was an elopement rather than AMA and confirmed the elopement incident should have been reported and the facility failed to report. The facility provided an acceptable Removal Plan on 7/22/2021. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan On 7/20/21, at 7 PM the State Agency (SA) surveyors notified the facility's Administrator of an Immediate Jeopardy (IJ) which began on 7/14/21 related to the facility's failure to supervise, provide adequate staffing, failed to report, and failed to implement a care plan when Resident # 1 left the facility unsupervised without staff knowledge and unnoticed on 7/14/21, resulting in an elopement. IJ templates were provided to the Administrator. Resident #1 (R1) was admitted to facility on 7/14/21 at 4:20 PM. The resident was walking up and down the hall and License Practical Nurse #1 (LPN 1) redirected her several times. LPN #1 stated she saw the resident at 7:10 PM and redirected the resident to her room. At 7:30 PM the LPN was getting ready to leave her shift and went to R1's room to check on her and resident was not in her room. LPN 1 notified Charge Nurse # 1 and an elopement exercise was initiated. The resident was not found in the center so the search was extended to the outside of the center and a team member got in her car and drove around the surrounding streets. Administrator and Director of Nursing (DNS) was notified of missing resident. Unit Manager made several attempts to contact the Responsible Party (RP) without success. Director of Nursing attempted to contact the RP upon arrival to the center without success. The RP returned call to center at 8:27 PM. RP left work and went home. RP called DNS back @ 8:59PM and stated that he was with his mother at she was fine. Windows and doors were checked. The facility never determined how the resident got out. Facility completed an elopement evaluation and determined the resident to be at risk for elopement. The facility did not initiate a care plan immediately, therefore staff were not aware the resident was an elopement risk. The facility failed to provide interventions to prevent elopement, nor provide adequate staffing to monitor the resident, therefore the resident left the facility without notifying any staff she was leaving. The resident did not return to the center for further assessment after elopement. The family was given a verbal discharge over the phone. The facility failed to do proper discharge planning. The facility failed to report the elopement to the appropriate entities. Measures immediately taken to achieve compliance with prevention of elopement, adequate discharge, and staffing expectation, and to aide in preventing future elopements and possible harm were: * Quality Assurance meeting was completed on 7/20/21 @ 9 PM. Discussion and an immediate plan including initiation of 100% head count. There were 89 residents on census that day. After a head count was completed there was only 88 residents accounted. All doors were checked. The egress doors did not open. The Quality Assurance meeting was held via telephone conference and included: Medical Director; Administrator, Director of Nursing Services, Assistant Director of Nursing Services, and Regional Director of Clinical Operations. * An initial investigation was started the evening of 7/14/21 by the Interim - Administrator and Director of Nursing, including interviews of team member's that were in the center at that time. * Doors were checked by the Interim-Administrator on 7/14/21. Doors were checked on 7/19/21 by the Administrator. Doors and windows were checked on 7/20/21 by the Maintenance Assistant. Door codes were change on 7/20/21 by the Maintenance Director. * Facility had census of 90 residents, elopement evaluations were completed on 7/20/21 & 7/21/21 for all 90 residents by the Director of Nursing and MDS nurse. Five residents were identified at risk for elopement and reviewed. Three residents were previously at risk for elopement and already had wander guards in place. Two additional residents were identified that voiced desire to leave the center that had not previously made those comments. Wander guards were placed on them at that time. * Care plans for those five residents identified at risk for elopement were reviewed and updated as appropriate by the Minimum Data Set Nurse #1 (MDS1) and Director of Clinical Operations #1 (DCO1). All 5 were identified to have appropriate interventions in place to prevent elopement. * On 7/20/21, one resident was admitted Res # and he was assessed and was not at risk for elopement. * Beginning on 7/20/21, Director of Nursing/Assistant Director of Nursing/Unit managers to review the Baseline Care plan for 100% of new admissions on the day of admission to ensure that all high risk areas have an appropriate care plan in place. * The Director of Care Coordination reviewed discharge planning with Resident # on admission on 7/20/21, and will update as needed throughout residents stay in the facility. Discharge planning will include the resident, their representative and the administrative team. Education has been provided to the Social Services Director and Director of Care Coordination by the Director of Clinical Operations regarding daily monitoring expectations regarding Discharge notification education provided on 7/21/21 @ 9:00am. * Administrator was educated on expectations of Reporting of any violation of Centers for Medicare and Medicaid (CMS) regulations per CMS guidance on 7/21/21 by the Director of Clinical Operations. * An Elopement drill was completed on 7/21/21 @ 6:20 PM by the Administrator. Staff were observed to appropriately respond to the elopement drill. * Elopement books on each unit were updated on 7/21/21 with photos of all identified at risk residents by the Social Service Director. * All staff education began on 7/20/21 @ 9:30 PM by the Director of Clinical Operations regarding the following areas: Elopement process and monitoring to prevent elopement, adequate staffing to prevent elopement, expectations of reporting to State and Federal regulations, discharge process with timely notification of discharge guidelines, and process and implementation of baseline care plan for all high risk areas identified. Education to be completed by 7/21/21. Any staff who have not received the education will be removed from the schedule after 7/21/21 and will not be allowed to work until education is completed. * Beginning on 7/21/21, all new admissions/readmissions will be reviewed in Daily Clinical Start up by the DNS/ADNS to assess elopement risk and to ensure appropriate interventions in place. * On 7/21/21 @ 5:22 PM, the Administrator called the elopement in to the Mississippi State Department of Health. * Facility will ensure adequate staffing to ensure proper monitoring of residents through scheduling of additional staff and use of extra shift bonus program as needed for any additional shift worked. Daily work force management meeting was held on 7/20/21 and staffing was reviewed. Staffing will be held daily Monday through Friday by Administrator, Director of Nursing, and Human Resources Coordinator to review and ensure staffing is adequate and address as needed. DNS receives all call outs and will adjust staffing as needed with use of shift bonus offerings and utilization of PRN staff when needed. * The facility's corrective actions were initiated on 07/20/2021. All actions to remove the Immediate Jeopardy were completed on 7/21/21. The facility alleged immediate jeopardy removal as of 7/21/21. (Proper Name) Administrator On 7/23/21, the SA validated the facility's Removal Plan by staff interviews, record reviews, and review of in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ: * The SA validated through interview with the Administrator and DON and record review of the sign-in sheet and agenda that a Quality Assurance meeting was completed on 7/20/21 @ 9PM. Discussion and an immediate plan including initiation of 100% head count. There were 89 residents on census that day. After a head count was completed there was only 88 residents accounted. All doors were checked. The egress doors did not open. The Quality Assurance meeting was held via telephone conference and included: Medical Director; Administrator, Director of Nursing Services, Assistant Director of Nursing Services, and Regional Director of Clinical Operations. * The SA validated through a record review that the initial investigation was started the evening of 7/14/21 by the Interim - Administrator and Director of Nursing, including interviews of team member's that were in the center at that time. * The SA validated through interview with the Administrator and Maintenance Director that doors were checked by the Interim-Administrator on 7/14/21. Doors were checked on 7/19/21 by the Administrator. Doors and windows were checked on 7/20/21 by the Maintenance Assistant. Door codes were change on 7/20/21 by the Maintenance Director. * The SA validated through interview with the DON and record review that elopement evaluations were completed on 7/20/21 & 7/21/21 for all 90 residents by the Director of Nursing and MDS nurse. Five residents were identified at risk for elopement and reviewed. Three residents were previously at risk for elopement and already had wander guards in place. Two additional residents were identified that voiced desire to leave the center that had not previously made those comments. Wander guards were placed on them at that time. * The SA validated through interview with the Minimum Data Set Nurse (MDS) and record review that care plans for those five residents identified at risk for elopement were reviewed and updated as appropriate by the Minimum Data Set Nurse #1 (MDS1) and Director of Clinical Operations #1 (DCO1). All 5 were identified to have appropriate interventions in place to prevent elopement. * The SA validated through record review that on 7/20/21, one resident was admitted Res # and he was assessed and was not at risk for elopement. * The SA validated through record review and interview with the MDS nurse that beginning on 7/20/21, Director of Nursing/Assistant Director of Nursing/Unit managers to review the Baseline Care plan for 100% of new admissions on the day of admission to ensure that all high risk areas have an appropriate care plan in place. * The SA validated through record review and interview with the Administrator that the Director of Care Coordination reviewed discharge planning with Resident # on admission on 7/20/21, and will update as needed throughout residents stay in the facility. Discharge planning will include the resident, their representative and the administrative team. Education has been provided to the Social Services Director and Director of Care Coordination by the Director of Clinical Operations regarding daily monitoring expectations regarding Discharge notification education provided on 7/21/21 @ 9:00am. * The SA validated through record review and interview that the Administrator was educated on expectations of Reporting of any violation of Centers for Medicare and Medicaid (CMS) regulations per CMS guidance on 7/21/21 by the Director of Clinical Operations. * The SA validated through record review of the sign-in sheet and interview with selected staff who participated in the drill that an Elopement drill was completed on 7/21/21 @ 6:20PM by the Administrator. Staff were observed to appropriately respond to the elopement drill. * The SA validated through record review that Elopement books on each unit were updated on 7/21/21 with photos of all identified at risk residents by the Social Service Director. * The SA validated through record review of in-service sign-in sheets and interview with selected staff that all staff education began on 7/20/21 @ 9:30PM by the Director of Clinical Operations regarding the following areas: Elopement process and monitoring to prevent elopement, adequate staffing to prevent elopement, expectations of reporting to State and Federal regulations, discharge process with timely notification of discharge guidelines, and process and implementation of baseline care plan for all high risk areas identified. Education to be completed by 7/21/21. Any staff who have not received the education will be removed from the schedule after 7/21/21 and will not be allowed to work until education is completed. * The SA validated through interview with the Administrator that beginning on 7/21/21, all new admissions/readmissions will be reviewed in Daily Clinical Start up by the DNS/ADNS to assess elopement risk and to ensure appropriate interventions in place. * The SA validated through record review of the phone record that on 7/21/21 @ 5:22PM, the Administrator called the elopement in to the Mississippi State Department of Health. * The SA validated through interview with the Administrator that the facility will ensure adequate staffing to ensure proper monitoring of residents through scheduling of additional staff and use of extra shift bonus program as needed for any additional shift worked. Daily work force management meeting was held on 7/20/21 and staffing was reviewed. Staffing will be held daily Monday through Friday by Administrator, Director of Nursing, and Human Resources Coordinator to review and ensure staffing is adequate and address as needed. DNS receives all call outs and will adjust staffing as needed with use of shift bonus offerings and utilization of PRN staff when needed. * The SA validated that all corrective actions to remove the IJ had been completed as of 7/21/21 and the IJ removed on 7/22/21.

Based on Resident Representative interview, staff interviews, record review, and facility policy review, the facility failed to honor a residents right to return to the facility after an elopement for one (1) of (1) resident reviewed for discharge. Resident #1. Resident #1 was admitted to the facility on [DATE] at approximately 4:20 PM. Resident was observed by Licensed Practical Nurse (LPN) #1 to be pacing in the hallway and stating she was leaving and going home and required redirecting several times. LPN #1 reported she last saw Resident #1 a few minutes before 7:00 PM. Certified Nursing Assistant (CNA) #1 reported she last saw Resident #1 approximately 7:00 PM when dinner trays were picked up. At the end of LPN #1's shift, at approximately 7:20 PM, LPN #1 went to check on Resident #1 and the resident could not be located. Resident #1 was away from the facility unsupervised on 7/14/2021 from approximately 7:00 PM until the Resident's son was able to locate the Resident at her residence at approximately 9:00 PM. The Resident Representative requested to return the Resident to the facility and was told that the resident could not return. The facility's failure to allow Resident #1 to return to the facility placed Resident #1 and other residents with wandering behaviors and at risk of elopement in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality (SQC) that began on 07/14/2021, when Resident #1 eloped from the facility. The facility Administrator was notified of the IJ on 07/20/2021 at 7:00 PM. The facility provided an acceptable Removal Plan on 7/22/2021, in which the facility alleged all corrective actions were completed to remove the IJ on 7/21/2021, and the IJ removed on 7/21/2021. The SA determined the IJ was removed on 7/21/2021, prior to exit, and the scope and severity for 42 CFR: 483.12(c)(1), F 609, Reporting of Alleged Violations, was lowered to a D, while the facility develops and implements a plan or correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of facility policy titled, Transfer and Discharge, dated November 1, 2016, revealed, (Proper Facility Name) shall permit each Resident to remain at the center, and not transfer or discharge the Resident from the Center except in accordance with Federal and State laws, and as described in this policy .Notice Requirements: 4. Before (Proper Facility Name) transfers or discharges the Resident, it shall notify the Resident and the Resident's Representative of the basis for the transfer or discharge in a language and manner they understand . Phone interviews with Resident #1's son on 7/19/2021 at 5:11 PM and 6:14 PM, revealed Resident #1 was discharged from the hospital and admitted to the facility on [DATE]. He stated on that same day, Resident #1 left the facility. The son stated he spoke with an employee of the facility around 7:00 PM - 8:00 PM, but he uncertain of the time. He stated he was informed his mom left the facility and asked if he could help locate her. The son stated he left work and started searching for her and found her alone at home. He stated he questioned her on how she got out of facility and got home and stated she told him, I walked out the front door and I walked to the highway and someone picked me up and brought me home. The son does not know who picked her up and brought her home and his mother did not know the person who picked her up, but he believes that person may have known his mother. He called facility to report he had found Resident #1 and asked about bringing her back, but the employee he spoke with said no. He stated the next day, his Mom had to go back to the emergency room due to arm pain. When she left the hospital the day after that, she was admitted to another nursing home facility. He stated his mother does not have a cell phone. He stated Resident #1's memory is decent, but she can not remember addresses or phone numbers. Phone interview with the Interim Administrator on 7/20/2021 at 11:27 AM, revealed she was notified of Resident #1 missing at approximately 7:45 PM on 7/14/2021 and she and the Director of Nursing (DON) arrived at the facility approximately 7:55 PM. She and the DON were able to reach Resident #1's son by phone. The son informed the DON that a family member had picked her up and took her home and he was on his way to get her. The Interim Administrator stated the Resident's son asked about bringing her back to the facility and she told him that was not a good idea since the resident did not want to be at the facility, and they would try to find a different placement the next day. Interview with the DON on 7/20/2021 at 5:23 PM, revealed during a phone call on 7/14/2021, with Resident #1's son and the Interim Administrator, the son asked about bringing his mother back to the facility and the Interim Administrator told him no, she could not return. The DON confirmed the facility failed to properly discharge Resident #1 and that Resident #1 should have been allowed to return to facility. Interview with Administrator on 7/22/2021 at 9:45 AM, revealed Resident #1's son inquired on bringing his Mom back to the facility, but she was not allowed to return. The Administrator confirmed Resident #1's discharge was not a proper discharge. She stated the resident should have been allowed to return to the facility. She stated on return to the facility the resident should have been assessed for injury as well as a complete assessment. She stated upon return to facility a wander guard could have been applied since the resident was an elopement risk. The Administrator confirmed Resident #1 was inappropriately discharged . The facility provided an acceptable Removal Plan on 7/22/2021. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan On 7/20/21, at 7 PM the State Agency (SA) surveyors notified the facility's Administrator of an Immediate Jeopardy (IJ) which began on 7/14/21 related to the facility's failure to supervise, provide adequate staffing, failed to report, and failed to implement a care plan when Resident # 1 left the facility unsupervised without staff knowledge and unnoticed on 7/14/21, resulting in an elopement. IJ templates were provided to the Administrator. Resident #1 (R1) was admitted to facility on 7/14/21 at 4:20PM. The resident was walking up and down the hall and License Practical Nurse #1 (LPN 1) redirected her several times. LPN #1stated she saw the resident at 7:10PM and redirected the resident to her room. At 7:30PM the LPN was getting ready to leave her shift and went to R1's room to check on her and resident was not in her room. LPN 1 notified Charge Nurse # 1 and an elopement exercise was initiated. The resident was not found in the center so the search was extended to the outside of the center and a team member got in her car and drove around the surrounding streets. Administrator and Director of Nursing (DNS) was notified of missing resident. Unit Manager made several attempts to contact the Responsible Party (RP) without success. Director of Nursing attempted to contact the RP upon arrival to the center without success. The RP returned call to center at 8:27PM. RP left work and went home. RP called DNS back @ 8:59PM and stated that he was with his mother at she was fine. Windows and doors were checked. The facility never determined how the resident got out. Facility completed an elopement evaluation and determined the resident to be at risk for elopement. The facility did not initiate a care plan immediately, therefore staff were not aware the resident was an elopement risk. The facility failed to provide interventions to prevent elopement, nor provide adequate staffing to monitor the resident, therefore the resident left the facility without notifying any staff she was leaving. The resident did not return to the center for further assessment after elopement. The family was given a verbal discharge over the phone. The facility failed to do proper discharge planning. The facility failed to report the elopement to the appropriate entities. Measures immediately taken to achieve compliance with prevention of elopement, adequate discharge, and staffing expectation, and to aide in preventing future elopements and possible harm were: * Quality Assurance meeting was completed on 7/20/21 @ 9PM. Discussion and an immediate plan including initiation of 100% head count. There were 89 residents on census that day. After a head count was completed there was only 88 residents accounted. All doors were checked. The egress doors did not open. The Quality Assurance meeting was held via telephone conference and included: Medical Director; Administrator, Director of Nursing Services, Assistant Director of Nursing Services, and Regional Director of Clinical Operations. * An initial investigation was started the evening of 7/14/21 by the Interim - Administrator and Director of Nursing, including interviews of team member's that were in the center at that time. * Doors were checked by the Interim-Administrator on 7/14/21. Doors were checked on 7/19/21 by the Administrator. Doors and windows were checked on 7/20/21 by the Maintenance Assistant. Door codes were change on 7/20/21 by the Maintenance Director. * Facility had census of 90 residents, elopement evaluations were completed on 7/20/21 & 7/21/21 for all 90 residents by the Director of Nursing and MDS nurse. Five residents were identified at risk for elopement and reviewed. Three residents were previously at risk for elopement and already had wander guards in place. Two additional residents were identified that voiced desire to leave the center that had not previously made those comments. Wander guards were placed on them at that time. * Care plans for those five residents identified at risk for elopement were reviewed and updated as appropriate by the Minimum Data Set Nurse #1 (MDS1) and Director of Clinical Operations #1 (DCO1). All 5 were identified to have appropriate interventions in place to prevent elopement. * On 7/20/21, one resident was admitted Res # and he was assessed and was not at risk for elopement. * Beginning on 7/20/21, Director of Nursing/Assistant Director of Nursing/Unit managers to review the Baseline Care plan for 100% of new admissions on the day of admission to ensure that all high risk areas have an appropriate care plan in place. * The Director of Care Coordination reviewed discharge planning with Resident # on admission on 7/20/21, and will update as needed throughout residents stay in the facility. Discharge planning will include the resident, their representative and the administrative team. Education has been provided to the Social Services Director and Director of Care Coordination by the Director of Clinical Operations regarding daily monitoring expectations regarding Discharge notification education provided on 7/21/21 @ 9:00am. * Administrator was educated on expectations of Reporting of any violation of Centers for Medicare and Medicaid (CMS) regulations per CMS guidance on 7/21/21 by the Director of Clinical Operations. * An Elopement drill was completed on 7/21/21 @ 6:20PM by the Administrator. Staff were observed to appropriately respond to the elopement drill. * Elopement books on each unit were updated on 7/21/21 with photos of all identified at risk residents by the Social Service Director. * All staff education began on 7/20/21 @ 9:30PM by the Director of Clinical Operations regarding the following areas: Elopement process and monitoring to prevent elopement, adequate staffing to prevent elopement, expectations of reporting to State and Federal regulations, discharge process with timely notification of discharge guidelines, and process and implementation of baseline care plan for all high risk areas identified. Education to be completed by 7/21/21. Any staff who have not received the education will be removed from the schedule after 7/21/21 and will not be allowed to work until education is completed. * Beginning on 7/21/21, all new admissions/readmissions will be reviewed in Daily Clinical Start up by the DNS/ADNS to assess elopement risk and to ensure appropriate interventions in place. * On 7/21/21 @ 5:22PM, the Administrator called the elopement in to the Mississippi State Department of Health. * Facility will ensure adequate staffing to ensure proper monitoring of residents through scheduling of additional staff and use of extra shift bonus program as needed for any additional shift worked. Daily work force management meeting was held on 7/20/21 and staffing was reviewed. Staffing will be held daily Monday through Friday by Administrator, Director of Nursing, and Human Resources Coordinator to review and ensure staffing is adequate and address as needed. DNS receives all call outs and will adjust staffing as needed with use of shift bonus offerings and utilization of PRN staff when needed. * The facility's corrective actions were initiated on 07/20/2021. All actions to remove the Immediate Jeopardy were completed on 7/21/21. The facility alleged immediate jeopardy removal as of 7/21/21. (Proper Name) Administrator On 7/23/21, the SA validated the facility's Removal Plan by staff interviews, record reviews, and review of in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ: * The SA validated through interview with the Administrator and DON and record review of the sign-in sheet and agenda that a Quality Assurance meeting was completed on 7/20/21 @ 9PM. Discussion and an immediate plan including initiation of 100% head count. There were 89 residents on census that day. After a head count was completed there was only 88 residents accounted. All doors were checked. The egress doors did not open. The Quality Assurance meeting was held via telephone conference and included: Medical Director; Administrator, Director of Nursing Services, Assistant Director of Nursing Services, and Regional Director of Clinical Operations. * The SA validated through a record review that the initial investigation was started the evening of 7/14/21 by the Interim - Administrator and Director of Nursing, including interviews of team member's that were in the center at that time. * The SA validated through interview with the Administrator and Maintenance Director that doors were checked by the Interim-Administrator on 7/14/21. Doors were checked on 7/19/21 by the Administrator. Doors and windows were checked on 7/20/21 by the Maintenance Assistant. Door codes were change on 7/20/21 by the Maintenance Director. * The SA validated through interview with the DON and record review that elopement evaluations were completed on 7/20/21 & 7/21/21 for all 90 residents by the Director of Nursing and MDS nurse. Five residents were identified at risk for elopement and reviewed. Three residents were previously at risk for elopement and already had wander guards in place. Two additional residents were identified that voiced desire to leave the center that had not previously made those comments. Wander guards were placed on them at that time. * The SA validated through interview with the Minimum Data Set Nurse (MDS) and record review that care plans for those five residents identified at risk for elopement were reviewed and updated as appropriate by the Minimum Data Set Nurse #1 (MDS1) and Director of Clinical Operations #1 (DCO1). All 5 were identified to have appropriate interventions in place to prevent elopement. * The SA validated through record review that on 7/20/21, one resident was admitted Res # and he was assessed and was not at risk for elopement. * The SA validated through record review and interview with the MDS nurse that beginning on 7/20/21, Director of Nursing/Assistant Director of Nursing/Unit managers to review the Baseline Care plan for 100% of new admissions on the day of admission to ensure that all high risk areas have an appropriate care plan in place. * The SA validated through record review and interview with the Administrator that the Director of Care Coordination reviewed discharge planning with Resident # on admission on 7/20/21, and will update as needed throughout residents stay in the facility. Discharge planning will include the resident, their representative and the administrative team. Education has been provided to the Social Services Director and Director of Care Coordination by the Director of Clinical Operations regarding daily monitoring expectations regarding Discharge notification education provided on 7/21/21 @ 9:00am. * The SA validated through record review and interview that the Administrator was educated on expectations of Reporting of any violation of Centers for Medicare and Medicaid (CMS) regulations per CMS guidance on 7/21/21 by the Director of Clinical Operations. * The SA validated through record review of the sign-in sheet and interview with selected staff who participated in the drill that an Elopement drill was completed on 7/21/21 @ 6:20PM by the Administrator. Staff were observed to appropriately respond to the elopement drill. * The SA validated through record review that Elopement books on each unit were updated on 7/21/21 with photos of all identified at risk residents by the Social Service Director. * The SA validated through record review of in-service sign-in sheets and interview with selected staff that all staff education began on 7/20/21 @ 9:30PM by the Director of Clinical Operations regarding the following areas: Elopement process and monitoring to prevent elopement, adequate staffing to prevent elopement, expectations of reporting to State and Federal regulations, discharge process with timely notification of discharge guidelines, and process and implementation of baseline care plan for all high risk areas identified. Education to be completed by 7/21/21. Any staff who have not received the education will be removed from the schedule after 7/21/21 and will not be allowed to work until education is completed. * The SA validated through interview with the Administrator that beginning on 7/21/21, all new admissions/readmissions will be reviewed in Daily Clinical Start up by the DNS/ADNS to assess elopement risk and to ensure appropriate interventions in place. * The SA validated through record review of the phone record that on 7/21/21 @ 5:22PM, the Administrator called the elopement in to the Mississippi State Department of Health. * The SA validated through interview with the Administrator that the facility will ensure adequate staffing to ensure proper monitoring of residents through scheduling of additional staff and use of extra shift bonus program as needed for any additional shift worked. Daily work force management meeting was held on 7/20/21 and staffing was reviewed. Staffing will be held daily Monday through Friday by Administrator, Director of Nursing, and Human Resources Coordinator to review and ensure staffing is adequate and address as needed. DNS receives all call outs and will adjust staffing as needed with use of shift bonus offerings and utilization of PRN staff when needed. * The SA validated that all corrective actions to remove the IJ had been completed as of 7/21/21 and the IJ removed on 7/22/21.

Based on staff interview, Resident and Resident Representative interview, record review, and facility policy review, the facility failed to immediately develop and implement a baseline care plan for a newly admitted resident who was exit seeking and identified as an elopement risk upon admission for one (1) or four (4) residents reviewed for elopement risk. Resident #1. Resident #1 was admitted to the facility on [DATE] at approximately 4:20 PM. Resident was observed by Licensed Practical Nurse (LPN) #1 to be pacing in the hallway and stating she was leaving and going home and required redirecting several times. Dietary #1 reported Resident #1 had approached her in the dining room and requested for her to take her home. LPN #1 reported she last saw Resident #1 a few minutes before 7:00 PM. Certified Nursing Assistant (CNA) #1 reported she last saw Resident #1 approximately 7:00 PM when dinner trays were picked up. At the end of LPN #1's shift, at approximately 7:20 PM, LPN #1 went to check on Resident #1 and the resident could not be located. Resident #1 was away from the facility unsupervised on 7/14/2021 from approximately 7:00 PM until the Resident's son was able to locate the Resident at her residence at approximately 9:00 PM. The facility's failure to develop a baseline careplan to implement measures to safeguard a resident identified as at risk of elopement and to prevent an elopement placed Resident #1 and other residents with wandering behaviors and at risk of elopement in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 07/14/2021, when Resident #1 eloped from the facility. The facility Administrator was notified of the IJ on 07/20/2021 at 7:00 PM. The facility provided an acceptable Removal Plan on 7/22/2021, in which the facility alleged all corrective actions were completed to remove the IJ on 7/21/2021, and the IJ removed on 7/21/2021. The SA determined the IJ was removed on 7/21/2021, prior to exit, and the scope and severity for 42 CFR: 483.21(a)(1), F 655, Baseline Care Plan, was lowered to a D, while the facility develops and implements a plan or correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy, Clinical Admission Process, dated April 2017, revealed, Purpose: To provide a comprehensive baseline physical evaluation, identify risks and establish individualized interventions for residents upon admission. Process: The admission nurse is responsible for initiating the Clinical Health Status and establishing interim care plan interventions determined by individual risk indicators .As risk is identified, by areas such as falls, pain, smoking, etc. an individualized intervention is implemented on both the interim care plan and the Care Giver Guide. The identified interventions are initiated when recognized. Record review of the Baseline Care Plan V6 dated 7/14/21, revealed Section 6, Safety, Elopements, was blank. Interview with the DON on 7/20/2021 at 5:23 PM, revealed measures should have been put into place when Resident #1 was listed as an elopement risk based on the elopement assessment. She stated interventions such as a wander guard, frequent monitoring, and staff to maintain close visual contact with the resident should have been initiated. She confirmed the facility failed to initiate a baseline care plan when the elopement assessment was completed and the elopement risk was identified. Interview with the Minimum Data Set (MDS) Nurse on 7/22/2021 at 10:00 AM, revealed the baseline care plan covers until we can initiate what needs to be initiated, and a care plan is always initiated as soon as the Resident enters the building so it can be tailored to the resident. Interview with Administrator on 7/22/2021 at 9:45 AM, revealed if a problem or concern is identified in the assessment of a resident, a care plans should be initiated immediately so interventions can be done for the resident's care. She stated the care plan for Resident #1 was not initiated as required for the risk of elopement, therefore, interventions were not initiated. Removal Plan On 7/20/21, at 7 PM the State Agency (SA) surveyors notified the facility's Administrator of an Immediate Jeopardy (IJ) which began on 7/14/21 related to the facility's failure to supervise, provide adequate staffing, failed to report, and failed to implement a care plan when Resident # 1 left the facility unsupervised without staff knowledge and unnoticed on 7/14/21, resulting in an elopement. IJ templates were provided to the Administrator. Resident #1 (R1) was admitted to facility on 7/14/21 at 4:20PM. The resident was walking up and down the hall and License Practical Nurse #1 (LPN 1) redirected her several times. LPN #1stated she saw the resident at 7:10PM and redirected the resident to her room. At 7:30PM the LPN was getting ready to leave her shift and went to R1's room to check on her and resident was not in her room. LPN 1 notified Charge Nurse # 1 and an elopement exercise was initiated. The resident was not found in the center so the search was extended to the outside of the center and a team member got in her car and drove around the surrounding streets. Administrator and Director of Nursing (DNS) was notified of missing resident. Unit Manager made several attempts to contact the Responsible Party (RP) without success. Director of Nursing attempted to contact the RP upon arrival to the center without success. The RP returned call to center at 8:27 PM. RP left work and went home. RP called DNS back @ 8:59 PM and stated that he was with his mother at she was fine. Windows and doors were checked. The facility never determined how the resident got out. Facility completed an elopement evaluation and determined the resident to be at risk for elopement. The facility did not initiate a care plan immediately, therefore staff were not aware the resident was an elopement risk. The facility failed to provide interventions to prevent elopement, nor provide adequate staffing to monitor the resident, therefore the resident left the facility without notifying any staff she was leaving. The resident did not return to the center for further assessment after elopement. The family was given a verbal discharge over the phone. The facility failed to do proper discharge planning. The facility failed to report the elopement to the appropriate entities. Measures immediately taken to achieve compliance with prevention of elopement, adequate discharge, and staffing expectation, and to aide in preventing future elopements and possible harm were: * Quality Assurance meeting was completed on 7/20/21 @ 9 PM. Discussion and an immediate plan including initiation of 100% head count. There were 89 residents on census that day. After a head count was completed there was only 88 residents accounted. All doors were checked. The egress doors did not open. The Quality Assurance meeting was held via telephone conference and included: Medical Director; Administrator, Director of Nursing Services, Assistant Director of Nursing Services, and Regional Director of Clinical Operations. * An initial investigation was started the evening of 7/14/21 by the Interim - Administrator and Director of Nursing, including interviews of team member's that were in the center at that time. * Doors were checked by the Interim-Administrator on 7/14/21. Doors were checked on 7/19/21 by the Administrator. Doors and windows were checked on 7/20/21 by the Maintenance Assistant. Door codes were change on 7/20/21 by the Maintenance Director. * Facility had census of 90 residents, elopement evaluations were completed on 7/20/21 & 7/21/21 for all 90 residents by the Director of Nursing and MDS nurse. Five residents were identified at risk for elopement and reviewed. Three residents were previously at risk for elopement and already had wander guards in place. Two additional residents were identified that voiced desire to leave the center that had not previously made those comments. Wander guards were placed on them at that time. * Care plans for those five residents identified at risk for elopement were reviewed and updated as appropriate by the Minimum Data Set Nurse #1 (MDS1) and Director of Clinical Operations #1 (DCO1). All 5 were identified to have appropriate interventions in place to prevent elopement. * On 7/20/21, one resident was admitted Res # and he was assessed and was not at risk for elopement. * Beginning on 7/20/21, Director of Nursing/Assistant Director of Nursing/Unit managers to review the Baseline Care plan for 100% of new admissions on the day of admission to ensure that all high risk areas have an appropriate care plan in place. * The Director of Care Coordination reviewed discharge planning with Resident # on admission on 7/20/21, and will update as needed throughout residents stay in the facility. Discharge planning will include the resident, their representative and the administrative team. Education has been provided to the Social Services Director and Director of Care Coordination by the Director of Clinical Operations regarding daily monitoring expectations regarding Discharge notification education provided on 7/21/21 @ 9:00 am. * Administrator was educated on expectations of Reporting of any violation of Centers for Medicare and Medicaid (CMS) regulations per CMS guidance on 7/21/21 by the Director of Clinical Operations. * An Elopement drill was completed on 7/21/21 @ 6:20PM by the Administrator. Staff were observed to appropriately respond to the elopement drill. * Elopement books on each unit were updated on 7/21/21 with photos of all identified at risk residents by the Social Service Director. * All staff education began on 7/20/21 @ 9:30 PM by the Director of Clinical Operations regarding the following areas: Elopement process and monitoring to prevent elopement, adequate staffing to prevent elopement, expectations of reporting to State and Federal regulations, discharge process with timely notification of discharge guidelines, and process and implementation of baseline care plan for all high risk areas identified. Education to be completed by 7/21/21. Any staff who have not received the education will be removed from the schedule after 7/21/21 and will not be allowed to work until education is completed. * Beginning on 7/21/21, all new admissions/readmissions will be reviewed in Daily Clinical Start up by the DNS/ADNS to assess elopement risk and to ensure appropriate interventions in place. * On 7/21/21 @ 5:22 PM, the Administrator called the elopement in to the Mississippi State Department of Health. * Facility will ensure adequate staffing to ensure proper monitoring of residents through scheduling of additional staff and use of extra shift bonus program as needed for any additional shift worked. Daily work force management meeting was held on 7/20/21 and staffing was reviewed. Staffing will be held daily Monday through Friday by Administrator, Director of Nursing, and Human Resources Coordinator to review and ensure staffing is adequate and address as needed. DNS receives all call outs and will adjust staffing as needed with use of shift bonus offerings and utilization of PRN staff when needed. * The facility's corrective actions were initiated on 07/20/2021. All actions to remove the Immediate Jeopardy were completed on 7/21/21. The facility alleged immediate jeopardy removal as of 7/21/21. (Proper Name) Administrator On 7/23/21, the SA validated the facility's Removal Plan by staff interviews, record reviews, and review of in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ: * The SA validated through interview with the Administrator and DON and record review of the sign-in sheet and agenda that a Quality Assurance meeting was completed on 7/20/21 @ 9 PM. Discussion and an immediate plan including initiation of 100% head count. There were 89 residents on census that day. After a head count was completed there was only 88 residents accounted. All doors were checked. The egress doors did not open. The Quality Assurance meeting was held via telephone conference and included: Medical Director; Administrator, Director of Nursing Services, Assistant Director of Nursing Services, and Regional Director of Clinical Operations. * The SA validated through a record review that the initial investigation was started the evening of 7/14/21 by the Interim - Administrator and Director of Nursing, including interviews of team member's that were in the center at that time. * The SA validated through interview with the Administrator and Maintenance Director that doors were checked by the Interim-Administrator on 7/14/21. Doors were checked on 7/19/21 by the Administrator. Doors and windows were checked on 7/20/21 by the Maintenance Assistant. Door codes were change on 7/20/21 by the Maintenance Director. * The SA validated through interview with the DON and record review that elopement evaluations were completed on 7/20/21 & 7/21/21 for all 90 residents by the Director of Nursing and MDS nurse. Five residents were identified at risk for elopement and reviewed. Three residents were previously at risk for elopement and already had wander guards in place. Two additional residents were identified that voiced desire to leave the center that had not previously made those comments. Wander guards were placed on them at that time. * The SA validated through interview with the Minimum Data Set Nurse (MDS) and record review that care plans for those five residents identified at risk for elopement were reviewed and updated as appropriate by the Minimum Data Set Nurse #1 (MDS1) and Director of Clinical Operations #1 (DCO1). All 5 were identified to have appropriate interventions in place to prevent elopement. * The SA validated through record review that on 7/20/21, one resident was admitted Res # and he was assessed and was not at risk for elopement. * The SA validated through record review and interview with the MDS nurse that beginning on 7/20/21, Director of Nursing/Assistant Director of Nursing/Unit managers to review the Baseline Care plan for 100% of new admissions on the day of admission to ensure that all high risk areas have an appropriate care plan in place. * The SA validated through record review and interview with the Administrator that the Director of Care Coordination reviewed discharge planning with Resident # on admission on 7/20/21, and will update as needed throughout residents stay in the facility. Discharge planning will include the resident, their representative and the administrative team. Education has been provided to the Social Services Director and Director of Care Coordination by the Director of Clinical Operations regarding daily monitoring expectations regarding Discharge notification education provided on 7/21/21 @ 9:00 am. * The SA validated through record review and interview that the Administrator was educated on expectations of Reporting of any violation of Centers for Medicare and Medicaid (CMS) regulations per CMS guidance on 7/21/21 by the Director of Clinical Operations. * The SA validated through record review of the sign-in sheet and interview with selected staff who participated in the drill that an Elopement drill was completed on 7/21/21 @ 6:20 PM by the Administrator. Staff were observed to appropriately respond to the elopement drill. * The SA validated through record review that Elopement books on each unit were updated on 7/21/21 with photos of all identified at risk residents by the Social Service Director. * The SA validated through record review of in-service sign-in sheets and interview with selected staff that all staff education began on 7/20/21 @ 9:30PM by the Director of Clinical Operations regarding the following areas: Elopement process and monitoring to prevent elopement, adequate staffing to prevent elopement, expectations of reporting to State and Federal regulations, discharge process with timely notification of discharge guidelines, and process and implementation of baseline care plan for all high risk areas identified. Education to be completed by 7/21/21. Any staff who have not received the education will be removed from the schedule after 7/21/21 and will not be allowed to work until education is completed. * The SA validated through interview with the Administrator that beginning on 7/21/21, all new admissions/readmissions will be reviewed in Daily Clinical Start up by the DNS/ADNS to assess elopement risk and to ensure appropriate interventions in place. * The SA validated through record review of the phone record that on 7/21/21 @ 5:22 PM, the Administrator called the elopement in to the Mississippi State Department of Health. * The SA validated through interview with the Administrator that the facility will ensure adequate staffing to ensure proper monitoring of residents through scheduling of additional staff and use of extra shift bonus program as needed for any additional shift worked. Daily work force management meeting was held on 7/20/21 and staffing was reviewed. Staffing will be held daily Monday through Friday by Administrator, Director of Nursing, and Human Resources Coordinator to review and ensure staffing is adequate and address as needed. DNS receives all call outs and will adjust staffing as needed with use of shift bonus offerings and utilization of PRN staff when needed. * The SA validated that all corrective actions to remove the IJ had been completed as of 7/21/21 and the IJ removed on 7/22/21.

Based on observation, staff interview, Resident interview, Resident Representative interview, record review, and facility policy review, the facility failed to provide adequate supervision to prevent Resident #1's elopement from the facility for one (1) or four (4) residents reviewed for elopement risk. Resident #1. Resident #1 was admitted to the facility on [DATE] at approximately 4:20 PM. Resident was observed by Licensed Practical Nurse (LPN) #1 to be pacing in the hallway and stating she was leaving and going home and required redirecting several times. LPN #1 reported she last saw Resident #1 a few minutes before 7:00 PM. Certified Nursing Assistant (CNA) #1 reported she last saw Resident #1 approximately 7:00 PM when dinner trays were picked up. At the end of LPN #1's shift, at approximately 7:20 PM, LPN #1 went to check on Resident #1 and the resident could not be located. Resident #1 was away from the facility unsupervised on 7/14/2021 from approximately 7:00 PM until the Resident's son was able to locate the Resident at her residence at approximately 9:00 PM. The facility's failure to provide adequate supervision to prevent an elopement placed Resident #1 and other residents with wandering behaviors and at risk of elopement in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality (SQC) that began on 07/14/2021, when Resident #1 eloped from the facility. The facility Administrator was notified of the IJ on 07/20/2021 at 7:00 PM. The facility provided an acceptable Removal Plan on 7/22/2021, in which the facility alleged all corrective actions were completed to remove the IJ on 7/21/2021, and the IJ removed on 7/22/20. The scope and severity for CFR(s): 42 CFR: 483.25(d)(1)(2), F 689, Free of Accidents/Hazards/Supervision/Devices, was lowered to a D, while the facility develops and implements a plan or correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's policy, Elopement, dated April 2017, revealed, .Process: On admission, newly admitted or readmitted residents are assessed for elopement risk. If an elopement risk is determined an individualized plan is established and intervention is initiated to mitigate that risk . Record review of the written statement from the Director of Nursing (DON) revealed, On July 14, 2021, I was called to (Proper Name of Facility) by Registered Nurse (RN) #1 stating that the nurse on B hall (LPN #1) was unable to locate her new resident, Resident #1. I informed her I would come immediately to center. After arriving to facility with the Interim Administrator, we spoke with several of the staff concerning how said resident could have left center undetected. Those staff members included: (Insert proper names for six (6) employees). All staff members stated they had not witnessed anyone leaving the center. Visitor log reviewed and no visitors were logged in during that time. The doors were tested to see if they would open when handle held down for 15 seconds. (sign on front door states it will). Front door did not open after 15 seconds. This was signed by the DON. Interview with the Director of Nursing (DON) on 7/19/2021 at 3:20 PM, the DON stated the facility has not had an elopement, but some residents did leave Against Medical Advice (AMA). Interview with the Administrator on 7/19/2021 at 3:20 PM, Administrator stated the facility has not had an elopement, and if they had, she would have reported it. Phone interviews with Resident #1's son on 7/19/2021 at 5:11 PM and 6:14 PM, revealed Resident #1 was discharged from the hospital and admitted to the facility on [DATE]. He stated on that same day, Resident #1 left the facility. The son stated he spoke with an employee of the facility around 7:00 PM - 8:00 PM, but he is uncertain of the time. He stated he was informed his mom left the facility and asked if he could help locate her. The son stated he left work and started searching for her and found her alone at her home. He stated he questioned her on how she got out of facility and got home and stated she told him, I walked out the front door and I walked to the highway and someone picked me up and brought me home. The son does not know who picked her up and brought her home and his mother did not know the person who picked her up, but he believes that person may have known his mother. He called the facility to report he had found Resident #1 and asked about bringing her back, but the employee he spoke with said no. He stated the next day, his Mom had to go back to the emergency room due to arm pain. When she left the hospital the day after that, she was admitted to another nursing home facility. He stated Resident #1's memory is decent, but she can not remember addresses or phone numbers. Interview with Administrator on 7/19/2021 at 5:40 PM, revealed she received a phone call from the Interim Administrator on 7/14/2021 between 9:30 PM - 10:00 PM. She was told that a resident had left the facility and they had investigated the incident. She was told by the Interim Administrator that the resident did not want to be in the facility and somebody had picked her up and that Resident #1's son said a friend picked her up and took her home. She was informed by the Interim Administrator that this incident was Against Medical Advice (AMA) and not elopement. Interview and record review with the Director of Nursing (DON) on 7/19/2021 at 6:00 PM, revealed she was notified of Resident #1 missing around 7:40 PM. The DON stated she could not find her documentation regarding the investigation of the elopement, but she knows she documented it. She stated the Corporate Nurse was present during the conversations of the incident, and she was documenting the information. The DON spoke with the Corporate Nurse concerning her notes and stated the Corporate Nurse documented, Patient admitted , alcoholic with dementia, left AMA with a friend and Resident #1 left after about 4 hours. Called friend to pick her up. The DON stated Resident #1's son told her and the Interim Administrator that his mother was in (Insert Proper Name of Local Town) and that a friend picked her up and she is unsure how the resident got out of the facility. She stated I was not here. Staff member had to let them in and out. Residents know the codes, also. They sit up front and learn the code. Sometimes staff hollers the code down the hall. The DON stated that no Against Medical Advice papers were signed and no staff members witnessed the resident leave the building. Interview with LPN #2 on 7/19/2021 at 7:15 PM, revealed on 7/14/2021, she was working on D-Hall when Resident #1 left the building. LPN #2 stated she was passing medications around 7:20 PM when she received a text message from LPN #1 informing her that a resident could not be located. LPN #2 stated she notified RN #1 Nursing Supervisor, who notified the DON and the Interim Administrator. LPN #2 stated the building and outside was searched, and a head count was done and all other residents were located. Interview with Licensed Practical Nurse (LPN) #1 on 7/20/2021 at 9:18 AM, revealed on 7/14/2021 at approximately 4:20 PM, she admitted Resident #1 to B-Hall from the hospital. LPN #1 stated the resident kept pacing back and forth in the hallway, saying she wanted to leave and go home and required redirecting several times. LPN #1 stated upon admission, Resident #1 was dressed in a hospital type gown, but the last time she saw her, a little before 7:00 PM, Resident #1 had changed into a t-shirt and pajama pants. LPN #1 stated at the end of her shift, around 7:15 PM - 7:20 PM, she counted medications with the oncoming nurse at the nurse's station and after counting the medications, she went to check on Resident #1 to see if she was calmer than she had been previously. LPN #1 stated Resident #1 was not in her room, so she looked around the hallway. She asked CNA #1 if she knew where Resident #1 was, and she also did not know. LPN #1 stated as she was searching the hall and rooms, she notified LPN #2 of the situation so other staff, the DON, Supervisor, and Interim Administrator could be contacted and a Code for elopement was called. LPN #1 stated each room inside the facility and outside the building was searched and Resident #1 could not be located. Concerning staffing on 7/14/2021, LPN #1 stated B-Hall had around 15 - 20 residents with two of those being new admissions, and it was only her and CNA #1 on that hall. LPN #1 stated, when you have residents like (formal name of Resident #1), I would not say there was adequate staffing. LPN #1 stated she did not fill out an inventory list, but she looked through Resident #1's belongings to ensure there were no unsafe items and Resident #1 did not have a cell phone in her possessions. LPN #1 stated she did not make a phone call for the Resident #1, and she is unaware of anyone else making a phone call for the resident. LPN #1 revealed when she left the facility after work, it was not raining and had not rained that day. Observation, interview, and tour with the Administrator on 7/20/2021 at 10:30 AM, of the doors on the end of B-Hall and front door revealed when the door latch was pressed, the alarm sounded and in 15 seconds the doors unlocked and were able to be opened. The alarm continued to sound until the keypad code was pressed. The Administrator stated, In reality a resident could push the door and exit building. Interview with the Maintenance Director #1 on 7/20/2021 at 10:35 AM, revealed he is changing the keypad codes on all the exterior doors. He stated the door alarms will sound if the lever is pushed or door is opened unless the code is entered. Phone interview with the Interim Administrator on 7/20/2021 at 11:27 AM, revealed on 7/14/2021 at approximately 7:45 PM, she and the DON received a call from the facility informing them that Resident #1 could not be located. She stated they immediately went to the facility and RN #1 had attempted to contact Resident #1's son, but calls had not been returned. The Interim Administrator stated she and the DON spoke with Resident #1's son and he informed them that a family member had picked Resident #1 up and brought her home and he was going to pick her up. She stated the son asked about bringing Resident #1 back to the facility but stated she told him not to bring her back and they would try to get another placement the next day. The Interim Administrator said she spoke with the Corporate Nurse and told her what Resident #1's son had said and asked if she thought it was an elopement or AMA, and the Corporate Nurse said it sounds like AMA since a family member picked her up. As for how the resident left the facility, the Interim Administrator stated the resident could have leaned on the doors for 15-20 seconds and they would have unlock due to the fire code and an alarm would sound or she could have followed someone out. The Interim Administrator stated Resident #1 did leave the building and staff were unaware of her location. Interview with Resident #1 on 7/20/2021 at 2:30 PM, revealed the resident stated she walked out of the facility. She walked halfway home and somebody stopped and picked her up. She stated she does not know who it was, but it was a man. Resident #1 stated, everybody in (Proper Name of Local Town) knows me. Resident #1 stated the weather was fine when she left the building and it was not raining. Interview with Certified Nurse Assistant (CNA) #1 on 7/20/2021 at 3:12 PM, revealed she was working on B-Hall when Resident #1 was admitted to the facility and stated that Resident #1 came into the facility saying, it's time to go home. CNA #1 stated she was able to calm Resident #1, and the resident was able to eat dinner, and when the dinner tray was picked up around 7:00 PM, the resident was in her room. CNA #1 stated she was outside B-Hall's exterior door around 7:00 PM with a resident that smokes for the smoke break, so she would have seen Resident #1 if she exited the building or attempted to exit the building through that door and the alarm would have sounded. CNA #1 stated when she was coming back into the building, LPN #1 told her Resident #1 was missing and a Code was called. CNA #1 stated there were about 15 residents in the isolation area of B-Hall on 7/14/2021. CNA #1 stated she checked Resident #1's inventory and she did not have a phone and she did not assist the resident to make a phone call. Interview with RN #2 on 7/20/2021 at 4:19 PM, revealed she is the Infection Control Nurse and the Director of Clinical Education. RN #2 stated if a resident is determined to be at high risk for elopement, the assessment should be done immediately and interventions should include wander guard use, one on one with the resident, monitor and frequent visual checks, and baseline care plan. Interview with Registered Nurse (RN) #1 on 7/20/2021 at 4:59 PM, revealed RN #1 stated she worked as A/B Hall Manager on 7/14/2021 when Resident #1 left the facility. RN #1 stated she was informed that Resident #1 could not be found so a Code 10 was called and this included searching inside the building, outside the building, driving on the road to search, and check of local stores. RN #1 stated she notified the Director of Nursing (DON) and the Interim Administrator at 7:59 PM of the elopement and that a Code 10 had been called. RN #1 stated the DON and the Interim Administrator came to the facility and the staff continued to search for Resident #1. RN #1 stated the DON was able to speak to Resident #1's son and he said Resident #1 was at home. RN #1 stated she did not know Resident #1 was wandering until the last minute when she left facility. Since Resident #1 was wandering, an elopement assessment should have been done, a wander guard bracelet should have been placed on the resident, the family and doctor should have been notified, and the resident's information should have been placed in the elopement book. Interview with the DON on 7/20/2021 at 5:23 PM, revealed LPN #1 did the assessment on Resident #1 and she signed off on LPN #1's assessment. Stated due to Resident #1 making repetitive statements about going home and her ability to leave the building on her own, a care plan and interventions to prevent elopement should have been done immediately. Interventions should have included a wander guard, frequent monitoring, and staff to maintain close visual contact with the resident. She thought a care plan was automatically generated when the assessment was completed. The DON stated elopement is when a resident gets out of the facility and staff does not know where they are, and Resident #1 was out of the facility and the staff did not know where she was so this would be elopement. The Interim Administrator informed Resident #1's son not to bring her back to the facility. The DON confirmed the facility failed to accurately assess and investigate this incident and that it was elopement and not AMA. Interview with the Interim Administrator on 7/21/2021 at 4:50 PM revealed the decision to call this incident an AMA rather than an elopement was made by the Corporate Nurse based on inaccurate information that a family member picked up Resident #1. Interview with Dietary #1 on 7/21/2021 at 5:30 PM revealed she has known the resident all of her life. Dietary #1 stated she went to see Resident #1 when she arrived at the facility to encourage her to eat her dinner. Stated while she was cleaning kitchen before leaving for the evening, Resident #1 came into the dining room area and asked for Dietary #1 to take her home. Dietary #1 stated she informed Resident #1 she could not take her home and the resident left the dietary area and headed back to her room. Stated she left work around 7:00 PM - 7:15 PM and soon after arriving home, she received a call from facility staff asking if she knew anything about Resident #1's location and she informed them she did not know. Review of information from MapQuest revealed the distance from the Facility to the Resident's home is 15.2 miles. Review of weather conditions on 7/14/2021 at 7:00 PM revealed: Temperature 79 degrees, Humidity 79%, Wind 13 MPH, No precipitation. Information obtained on TimeAndDate.com. Observation on 7/21/2021 at 7:00 PM revealed the facility is located on a two-lane road. East of the facility on the next lot is an auto repair business that is completely fenced in. West of the facility is a small business. Across the street from the facility is a small community college. The Resident and the Resident ' s son stated the resident walked to a local highway (Insert Highway name), which is a two-lane highway located 0.5 miles from the facility. For the resident to walk to this highway, she left the facility and turned to the right and was walking east. The facility is on a two-lane road that runs east and west. Traffic at 7:00 PM on a weekday consists of traffic going west to east were 46 vehicles in a 10 minute period. Traffic traveling east to west consisted of 32 vehicles in a 10-minute time frame. None of these were 18 wheelers, only personal vehicles and two (2) small trucks. Once the resident walked east for 0.5 miles, there is an intersection with a traffic light which crosses the facility road and a local 2-lane highway. At that intersection there are four businesses, one on each corner. There are two convenience stores, one on the northwest corner and one on the northeast corner. On the southeast corner there is a veterinarian clinic. On the southwest corner, there is an outpatient physical therapy clinic. To head to the Resident ' s home, she would have turned right at this intersection. No one is certain on how far the resident walked prior to being picked up and taken home. Traffic flow on this highway at 7:10 PM on a weekday consisted of traffic flow traveling north and south. In a ten-minute time frame, the traffic traveling from north to south consisted of 58 vehicles, and traffic traveling from south to north consisted of 53 vehicles. None of these vehicles during this time were 18 wheelers, only personal vehicles and 3 small trucks. The terrain on the road the facility is on is flat with no curves or hills from the facility to the intersection. The shoulder of the road heading east has a 10 - 12-foot-wide paved shoulder that runs approximately 0.4 miles of the distance between the facility and the intersection. After that section, there is a shoulder that is approximately 5-6 feet wide with a gradual decline to a small drainage ditch approximately 2-3 feet at the lowest point. The terrain of the highway south of the intersection is flat with no immediate curves and good visibility for approximately 4 miles. Approximately 200 yards past the intersection going south on highway is a small residential neighborhood road and approximately 0.5 miles past that is a small church on the west side of the highway. There are scattered and wide spaced houses on east and west side of road as well as open fields. The shoulder of the road for the first 4 miles of the road from intersection heading towards resident ' s home, consist of a grassy shoulder approximately 7 feet wide. Past the shoulder is a steady decline into a drainage ditch that is approximately 7-8 feet below road height. Interview with the Administrator on 7/22/2021 at 9:45 AM, revealed an assessment should have been done as well as implementing interventions such as wander guard use and frequent monitoring of resident by staff. Confirmed Resident #1 leaving the facility was an elopement and a reportable event, and the facility failed to report this to the proper agencies. Confirmed the facility failed to initiate a baseline care immediately when a problem/concern was identified for the risk of elopement and interventions to prevent an elopement were not initiated. Interview with DON on 7/22/2021 at 10:20 AM, confirmed the resident leaving the facility and away from the staff's supervision should have been considered elopement and should have been reported to the proper entities, including the SA. DON confirmed that due to the needs of the residents and a resident at risk for elopement had been identified, the staffing was insufficient on the hall Resident #1 was on. DON confirmed the discharge was inappropriate and the resident should have been allowed to return to the facility. DON confirmed an elopement care plan and interventions should have been initiated as soon as the elopement risk was identified. Telephone interview on 7/22/21 at 10:57 AM with Resident #1's son revealed the facility did call him when his mom was missing. When asked on the first phone call with the facility if he told the staff he knew where his mother was and that a family member picked her up, he responded, No ma'am, I did not tell them that. I did not know where she was or who picked her up. I had to leave work to look for her. The Son stated when he found his mother, he called back to the facility to tell them he had located her. Interview with Corporate Nurse on 7/22/2021 at 2:00 PM revealed the information she received initially led her to consider this incident an AMA. She stated once the situation was looked into more, it was apparent the situation was an elopement rather than AMA and confirmed the facility failed to report the elopement of Resident #1 and failure to use appropriate measures to prevent elopement put Resident #1 and other residents with wandering behaviors at risk. Record review of the Admission Record revealed Resident #1 was admitted to the facility on [DATE]. Record review of the Minimum Data Set (MDS), Section C had not been done due to the short period of time the resident was in the facility. Resident was admitted to facility at 4:20 PM on 7/14/2021 and left the facility around 7 PM on 7/14/2021. The facility provided an acceptable Removal Plan on 7/22/2021. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan On 7/20/21, at 7 PM the State Agency (SA) surveyors notified the facility's Administrator of an Immediate Jeopardy (IJ) which began on 7/14/21 related to the facility's failure to supervise, provide adequate staffing, failed to report, and failed to implement a care plan when Resident # 1 left the facility unsupervised without staff knowledge and unnoticed on 7/14/21, resulting in an elopement. IJ templates were provided to the Administrator. Resident #1 (R1) was admitted to facility on 7/14/21 at 4:20PM. The resident was walking up and down the hall and License Practical Nurse #1 (LPN 1) redirected her several times. LPN #1 stated she saw the resident at 7:10 PM and redirected the resident to her room. At 7:30 PM the LPN was getting ready to leave her shift and went to R1's room to check on her and resident was not in her room. LPN 1 notified Charge Nurse # 1 and an elopement exercise was initiated. The resident was not found in the center so the search was extended to the outside of the center and a team member got in her car and drove around the surrounding streets. Administrator and Director of Nursing (DNS) was notified of missing resident. Unit Manager made several attempts to contact the Responsible Party (RP) without success. Director of Nursing attempted to contact the RP upon arrival to the center without success. The RP returned call to center at 8:27PM. RP left work and went home. RP called DNS back @ 8:59 PM and stated that he was with his mother at she was fine. Windows and doors were checked. The facility never determined how the resident got out. Facility completed an elopement evaluation and determined the resident to be at risk for elopement. The facility did not initiate a care plan immediately, therefore staff were not aware the resident was an elopement risk. The facility failed to provide interventions to prevent elopement, nor provide adequate staffing to monitor the resident, therefore the resident left the facility without notifying any staff she was leaving. The resident did not return to the center for further assessment after elopement. The family was given a verbal discharge over the phone. The facility failed to do proper discharge planning. The facility failed to report the elopement to the appropriate entities. Measures immediately taken to achieve compliance with prevention of elopement, adequate discharge, and staffing expectation, and to aide in preventing future elopements and possible harm were: * Quality Assurance meeting was completed on 7/20/21 @ 9 PM. Discussion and an immediate plan including initiation of 100% head count. There were 89 residents on census that day. After a head count was completed there was only 88 residents accounted. All doors were checked. The egress doors did not open. The Quality Assurance meeting was held via telephone conference and included: Medical Director; Administrator, Director of Nursing Services, Assistant Director of Nursing Services, and Regional Director of Clinical Operations. * An initial investigation was started the evening of 7/14/21 by the Interim - Administrator and Director of Nursing, including interviews of team member's that were in the center at that time. * Doors were checked by the Interim-Administrator on 7/14/21. Doors were checked on 7/19/21 by the Administrator. Doors and windows were checked on 7/20/21 by the Maintenance Assistant. Door codes were change on 7/20/21 by the Maintenance Director. * Facility had census of 90 residents, elopement evaluations were completed on 7/20/21 & 7/21/21 for all 90 residents by the Director of Nursing and MDS nurse. Five residents were identified at risk for elopement and reviewed. Three residents were previously at risk for elopement and already had wander guards in place. Two additional residents were identified that voiced desire to leave the center that had not previously made those comments. Wander guards were placed on them at that time. * Care plans for those five residents identified at risk for elopement were reviewed and updated as appropriate by the Minimum Data Set Nurse #1 (MDS1) and Director of Clinical Operations #1 (DCO1). All 5 were identified to have appropriate interventions in place to prevent elopement. * On 7/20/21, one resident was admitted Res # and he was assessed and was not at risk for elopement. * Beginning on 7/20/21, Director of Nursing/Assistant Director of Nursing/Unit managers to review the Baseline Care plan for 100% of new admissions on the day of admission to ensure that all high risk areas have an appropriate care plan in place. * The Director of Care Coordination reviewed discharge planning with Resident # on admission on 7/20/21, and will update as needed throughout residents stay in the facility. Discharge planning will include the resident, their representative and the administrative team. Education has been provided to the Social Services Director and Director of Care Coordination by the Director of Clinical Operations regarding daily monitoring expectations regarding Discharge notification education provided on 7/21/21 @ 9:00 am. * Administrator was educated on expectations of Reporting of any violation of Centers for Medicare and Medicaid (CMS) regulations per CMS guidance on 7/21/21 by the Director of Clinical Operations. * An Elopement drill was completed on 7/21/21 @ 6:20PM by the Administrator. Staff were observed to appropriately respond to the elopement drill. * Elopement books on each unit were updated on 7/21/21 with photos of all identified at risk residents by the Social Service Director. * All staff education began on 7/20/21 @ 9:30 PM by the Director of Clinical Operations regarding the following areas: Elopement process and monitoring to prevent elopement, adequate staffing to prevent elopement, expectations of reporting to State and Federal regulations, discharge process with timely notification of discharge guidelines, and process and implementation of baseline care plan for all high risk areas identified. Education to be completed by 7/21/21. Any staff who have not received the education will be removed from the schedule after 7/21/21 and will not be allowed to work until education is completed. * Beginning on 7/21/21, all new admissions/readmissions will be reviewed in Daily Clinical Start up by the DNS/ADNS to assess elopement risk and to ensure appropriate interventions in place. * On 7/21/21 @ 5:22 PM, the Administrator called the elopement in to the Mississippi State Department of Health. * Facility will ensure adequate staffing to ensure proper monitoring of residents through scheduling of additional staff and use of extra shift bonus program as needed for any additional shift worked. Daily work force management meeting was held on 7/20/21 and staffing was reviewed. Staffing will be held daily Monday through Friday by Administrator, Director of Nursing, and Human Resources Coordinator to review and ensure staffing is adequate and address as needed. DNS receives all call outs and will adjust staffing as needed with use of shift bonus offerings and utilization of PRN staff when needed. * The facility's corrective actions were initiated on 07/20/2021. All actions to remove the Immediate Jeopardy were completed on 7/21/21. The facility alleged immediate jeopardy removal as of 7/21/21. (Proper Name)Administrator On 7/23/21, the SA validated the facility's Removal Plan by staff interviews, record reviews, and review of in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ: * The SA validated through interview with the Administrator and DON and record review of the sign-in sheet and agenda that a Quality Assurance meeting was completed on 7/20/21 @ 9PM. Discussion and an immediate plan including initiation of 100% head count. There were 89 residents on census that day. After a head count was completed there was only 88 residents accounted. All doors were checked. The egress doors did not open. The Quality Assurance meeting was held via telephone conference and included: Medical Director; Administrator, Director of Nursing Services, Assistant Director of Nursing Services, and Regional Director of Clinical Operations. * The SA validated through a record review that the initial investigation was started the evening of 7/14/21 by the Interim - Administrator and Director of Nursing, including interviews of team member's that were in the center at that time. * The SA validated through interview with the Administrator and Maintenance Director that doors were checked by the Interim-Administrator on 7/14/21. Doors were checked on 7/19/21 by the Administrator. Doors and windows were checked on 7/20/21 by the Maintenance Assistant. Door codes were change on 7/20/21 by the Maintenance Director. * The SA validated through interview with the DON and record review that elopement evaluations were completed on 7/20/21 & 7/21/21 for all 90 residents by the Director of Nursing and MDS nurse. Five residents were identified at risk for elopement and reviewed. Three residents were previously at risk for elopement and already had wander guards in place. Two additional residents were identified that voiced desire to leave the center that had not previously made those comments. Wander guards were placed on them at that time. * The SA validated through interview with the Minimum Data Set Nurse (MDS) and record review that care plans for those five residents identified at risk for elopement were reviewed and updated as appropriate by the Minimum Data Set Nurse #1 (MDS1) and Director of Clinical Operations #1 (DCO1). All 5 were identified to have appropriate interventions in place to prevent elopement. * The SA validated through record review that on 7/20/21, one resident was admitted Res # and he was assessed and was not at risk for elopemen [TRUNCATED]

Based on resident interview, staff interview, record review and facility policy review, the facility failed to ensure a resident was free from verbal and mental abuse for one (1) of nine (9) residents reviewed for abuse, Resident #1. On 11/21/19, at or around 11:30 AM, Resident #1 reported an allegation of verbal and mental abuse against the Assistant Director of Nursing Services/Registered Nurse (RN) #1, to her daughter (Responsible Party (RP) #2 by phone, during the incident. The allegation consisted of Resident #1 was made to get up out of the bed and sit in the wheelchair, while she was in pain, and had no desire to sit up that day in the wheelchair. RN #1 would not allow Certified Nursing Assistant (CNA) #1 and CNA #2 to put Resident #1 back to bed, when she was crying and yelling out in pain. This incident occurred in Resident #1's room, and was witnessed by other staff. Resident #1 stated she felt like she was fighting for her life, and that nobody had ever made her feel that way before, in her whole life. Resident #1 stated she felt so helpless. The Administrator was notified by Resident #1's daughter (RP #2) via phone, shortly after the incident on 11/21/19. The Administrator was told by Resident #1's daughter (RP #2), she did not like the way that RN #1 had spoken to her mother (Resident #1) and stated, You better do something with (RN #1) before I come up there and whip his ass. Don't nobody talk to my momma the way he did. The Administrator did not investigate the allegation of verbal and mental abuse, suspend the employee, or protect Resident #1 and all other residents. The facility's failure to protect Resident #1 from verbal and mental abuse, and allow a staff member to work in the facility, following an incident of witnessed verbal and mental abuse, placed Resident #1 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 11/21/19, when the verbal and mental abuse occurred. The facility's Administrator was notified of the IJ and SQC on 12/30/19 at 4:30 PM and provided with the IJ template. An acceptable credible Removal Plan was provided by the facility on 12/31/19, in which the facility alleged all corrective actions were completed as of 12/31/19, and the IJ was removed on 01/01/20. The State Agency (SA) validated the Removal Plan and determined that the IJ was removed on 01/02/20, prior to exit. Therefore, the scope and severity for the IJ and SQC at 42 CFR(s): 483.12(a)(1) F600, Freedom from Abuse, Neglect, and Exploitation, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Abuse, Neglect, Misappropriation, Exploitation Policy, dated 01/19, revealed: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain or mental anguish. Mental Abuse: is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Investigation: The Administrator will oversee in conducting an internal investigation against any violation/alleged violation of abuse and report the results of the investigation to the enforcement agency, the state survey and the certification agency within five days of the incident. Investigations will be prompt, comprehensive and responsive to the situation and founded conclusions. The investigation will include, but not limited to: Identification and removal of the alleged person. Interviews of all persons involved, witnesses, alleged victim, and follow up resolution and measures to prevent repeat incidents. Review of an anonymous complaint allegation, submitted to the SA on 12/23/19, documented on 11/20/19, the Assistant Director of Nursing Services made Resident #1 cry. Review of the facility Customer Concern/Grievance Communication Form, dated 11/21/19 and signed by the Administrator, revealed: Resident #1 concerned with approach of Assistant Director of Nursing (ADON)/RN #1 motivating her to do therapy. Administrator, Director of Rehab (DOR) and ADON/RN #1 met with resident to talk about concerns with therapy goals and motivation of ADON/RN #1. Talked with ADON/RN #1 and therapy about approach and different forms of encouragement. Customer (Resident #1) contacted for follow up on 11/21/19. On 12/30/19 at 10:00 AM, during an interview with Resident #1, she stated, the incident happened about a month or two ago and she was not sure of the date. Resident #1 stated, They (facility) are trying to sweep it under the rug. Resident #1 began to cry and was emotionally upset recalling the event. Resident #1 stated on that day (11/21/19), she really didn't want to get up at all, because she had been awake all night with spasms in her legs. Resident #1 revealed RN #1 told her she needed to get up, so she allowed Certified Nursing Assistant (CNA) #1 and CNA #2 to get her up with the lift and they placed her in her wheelchair in her room. Resident #1 stated she was in a lot of pain in her right leg, and felt like she was sliding out of the wheelchair. Resident #1 revealed she asked to be placed back in the bed. Resident #1 stated Certified Nursing Assistant (CNA) #1 and CNA #2 went into the hallway to get the lift and was stopped by RN #1. Resident #1 stated, RN #1 took the lift back out of the room, and wouldn't let the CNAs put her back to bed. Resident #1 stated she called her daughter (Responsible Party (RP) #2), and while she was telling her daugher what was going on, RN #1 took her cell phone and wouldn't give it back to her. Resident #1 stated RN #1 went out of the room to talk to her daughter. Resident #1 revealed RN #1 came back in the room, and gave her phone back, but her daughter had hung up. Resident #1 stated she had called her daughter, because she knew her daughter would stop RN #1 from treating her this way. Resident #1 stated RN #1 always had smart comments, but had never acted like he did that day, and was out of control. Resident #1 stated, Nobody had ever made me feel that way before in my whole life. I felt like I was fighting for my life. I felt so helpless, and he knew I couldn't do anything to stop him because I'm paralyzed. Resident #1 stated RN #1 told the staff not to listen to her or her family, and to listen to him because he was the boss. Resident #1 stated CNA #1 wanted to put her back to bed, and was about to cry, because RN #1 wouldn't let her. Resident #1 stated the Administrator came to her room, the same day this incident occurred, because her daughter had left a message for her. Resident #1 stated the Administrator told her RN #1 didn't mean anything by that, and she needed for them to be friends. During an interview, on 12/30/19 at 1:00 PM, CNA #1 revealed around lunchtime on 11/21/19, RN #1 asked them (CNAs) to get Resident #1 up. CNA #1 stated after they got Resident #1 up, she began begging to be put back to bed, after about five minutes. CNA #1 stated Resident #1 was crying, so they went and got the lift. CNA #1 stated RN #1 stopped them, and told them to go on and pass out the trays. CNA #1 stated RN #1 told them that he was their boss, and they do what he said to do. CNA #1 stated RN #1 stayed in Resident #1's room and that they (RN #1 and Resident #1) could be heard yelling at each other, all the way to the nurse's desk. CNA #1 stated Resident #1 was crying, screaming and cussing at Resident #1. CNA #1 was emotional and crying while recalling the incident. CNA #1 stated, I felt so helpless and I was upset that she (Resident #1) was crying and begging to go back to bed, and he (RN #1) wouldn't allow us to put her to bed. I was fearful of him and I asked him how is that right that you get to treat her that way. CNA stated RN #1 replied, Because I'm the boss. CNA #1 stated Resident #1 had never been out of the bed, other than to go to the shower and the resident was scared. CNA #1 stated, since RN #1 had come on board, he wanted Resident #1 to get up and sit up. CNA #1 stated Resident #1 was almost falling out of her chair before RN #1 would let them (CNAs) put her back to bed, which was about 30-45 minutes later. CNA #1 stated she didn't know what else to do, so she went and got the phone numbers for the Ombudsman and the SA, and put them in Resident #1's phone. On 12/30/19 at 1:10 PM, an interview with the Administrator, confirmed she did not have an investigation report regarding the allegation of abuse for Resident #1, which occurred on 11/21/19. The Administrator stated, it wasn't an allegation of abuse. The Administrator stated she talked to Resident #1 , but she didn't write anything down. The Administrator stated Resident #1 wasn't upset. The Administrator revealed she didn't get a statement from RN #1. The Administrator stated she didn't investigate the incident as abuse, because it wasn't. The Administrator stated RN #1 was just motivating Resident #1. The Administrator confirmed she had received a call from the resident's daughter. The Administrator stated the resident's daughter was concerned, and didn't like the way RN #1 had talked to her mother. The Administrator stated Resident 1's daughter ( RP #2) said if she didn't do something about it, then she was coming to the facility. The Administrator stated, I didn't think there was anything to it, because she never showed up. During an interview, on 12/30/19 at 1:10 PM, the Director of Nursing (DON) confirmed she was on vacation the week of 11/19/19 through 11/26/19, and RN #1 was serving as the interim DON while she was away. The DON stated she had never heard any complaints or concerns about RN #1. On 12/30/19 at 12:50 PM, during an interview with the Physical Therapist (PT), she stated Resident #1 began therapy on 10/22/19 with a desire to sit up in her wheelchair for about an hour by Thanksgiving. The PT stated they (Therapy) had her up several times a week for about an hour. The PT stated there were some days Resident #1 didn't feel like getting up, so they would try again the next day. The PT confirmed she had heard about the incident that occurred between Resident #1 and the RN #1. The PT confirmed restorative recommendations for Resident #1 were written on 11/13/19, for the resident to sit up at least one hour daily, with precautions due to occasional muscle spasms in right leg and to perform passive range of motion to right leg. Review of the Therapy to Restorative Nursing Recommendations, for Resident #1, dated 11/13/19, revealed: Able to sit up in manual chair at least one hour daily, increase out of bed time as able past one hour. Precautions: Occasional muscle spasms in right leg greater than left leg. Review of the Physical Therapy PT Evaluation and Plan of Treatment, for Resident #1, dated 10/22/19, documented, the reason for referral to therapy was due to increased desire for out of bed activity and clearance by (MD) Medical Director to get up in the chair. Resident #1 was being evaluated for functional mobility and had been bedridden greater than a year, with multiple pressure breakdown to bilateral breasts, back area, right lateral leg, sacral area. Review of Resident #1's Physical Therapy PT Discharge Summary, dated 11/20/19, documented, Discharge 11/20/19: Patient unable to sit unsupported and is a total assist time two (persons). Discharge Recommendations: restorative program progress out of bed, up in chair tolerance. On 12/30/19 at 2:15 PM, during an interview, the Therapy Director (TD) stated she had received a text from the Administrator, on the day of the incident, around 4:00 PM, requesting her to get RN #1 and come to the Administrator's office. The TD stated the Administrator told them she had received a call from Resident #1's daughter, and that she was upset with RN #1. The TD revealed the Administrator wanted to know she would go with her and RN #1, to Resident 1's room, to address what was wrong. The Therapy Director confirmed, Resident #1 was crying and upset, and told the Administrator she wouldn't wish on anybody, to be in that much pain and to be treated the way she had been treated by RN #1. The TD stated she remained in the room the whole time the Administrator talked to the resident, and that Resident #1 continued crying and was emotional. The TD stated she had never seen Resident #1 that emotional and upset before, and tried to calm her down. On 12/30/19 at 2:30 PM, during a phone interview, CNA #2 confirmed RN #1 would not allow her and CNA #1 to put Resident #1 back to bed. CNA #2 stated RN #1 was telling Resident #1, she was not going back to bed. CNA #2 confirmed Resident #1 was crying and upset. CNA #2 stated RN #1 could have handled the incident a lot better than he did. CNA #2 revealed she didn't reported the incident to anyone. CNA #2 stated, It wouldn't do any good to report it to the DON or the Administrator, they protect each other. CNA #2 stated RN #1 was over the CNAs. On 12/30/19 at 3:55 PM, during an interview, RN #1 revealed he was the Assistant Director of Nursing Services (ADNS) at the facility, and the overseer of the Restorative Program. RN #1 stated, on 11/13/19, he had met with Resident #1 and her son (RP #1), and told them the goal was for Resident #1 to sit up two (2) hours, three (3) times a week. RN #1 stated he told Resident #1 they were going to attack this thing, and he was going to be tough on her. RN #1 stated Resident #1 began refusing to get up, so he called her son (RP #2) to let him know. RN #1 stated on 11/21/19, he went into Resident #1's room, and she had her daughter (RP #2) on the phone. RN #1 stated he told Resident #1 he was going to call her son (RP #1). RN #1 did not indicate he had taken the phone away from Resident #1. RN #1 stated after about five to ten minutes, the CNAs were trying to put Resident #1 back to bed. RN #1 stated he told the CNAs to go on and pass the trays out, and he would handle the resident. RN #1 confirmed the resident was crying and yelling . RN #1 stated Resident #1 was complaining of her right hip hurting. RN #1 stated he padded the resident in her wheelchair, and she continued to sit up, until he told the CNAs to put her back to bed after about 45 minutes or so. RN #1 stated Resident #1 wanted to go back to bed, but they had made a plan for her to get up 3 times a week and told her he was going to be tough on her. RN #1 stated, Hindsight, I could have handled it differently. I probably did cause her mental anguish, but I don't think I abused her. Review of the Order Summary Report for Resident #1, revealed an order dated 05/31/19, for [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 10-325 milligrams give one (1) tablet via Percutaneous Endoscopic Gastrostomy (PEG) tube every four (4) hours as needed for pain Review of Resident #1's Medication Administration Record [REDACTED]. On 12/31/19 at 9:58 AM, during an interview with the Regional Nurse Consultant (RNC), she stated she received a call from the Minimum Data Set (MDS) Nurse, at approximately 9:30 PM on 12/02/19. The RNC stated, the MDS Nurse asked if anyone had said anything to her about RN #1 making a resident cry. The RNC stated I said no. The RNC revealed she called the Administrator, within five minutes, and asked her if she knew anything about this incident. The RNC stated the Administrator said she had done a grievance. The RNC stated the Administrator told her Resident #1's daughter had called and said the resident was upset. The RNC stated she then told the Administrator to go to Resident #1's room the next day, and talk to her. The RNC revealed, the Administrator called her back the following day, and informed her Resident #1 was crying and upset, because she didn't like how RN #1 was motivating her. On 12/31/19 at 10:30 AM, during an interview with Resident #1's son (RP #1) at the facility (Resident 1's room), and with the resident's daughter (RP#2) by phone, RP #1 stated he was not aware of the full story of what had occurred on 11/21/19. RP #1 stated he got a phone call from his sister (RP #2), and she told him she had left a message for the Administrator, and that he needed to go to the facility to see what was going on. RP #1 stated his sister told him their mother (Resident #1) had called her and was upset about how RN #1 talked to her. RP #1 stated he came to the facility, but RN #1 told him he and Resident #1 just had a conversation, and RN #1 made it sound like it wasn't a big deal. Resident #1 stated to RP #1, during the interview, she called RP #2 because she didn't want to upset him, and she knew RP #2 would take care of RN #1. RP #2 confirmed by phone interview, she was upset about how RN #1 had talked to her mother. RP #2 stated she had left a message for the Administrator to call her, but the Administrator never called her back. During an interview, on 12/31/19 at 11:15 AM, Resident #1's Nurse Practitioner (NP) confirmed that she was not aware of the incident that occurred on 11/21/19. The NP stated, This is the first that I've heard about it, and I've been her NP for years. On 12/31/19 at 3:45 PM, an interview with Resident #1's primary Physician (Physician #1), revealed he was not aware of the incident and no one had called or informed him of the situation. On 01/02/20 at 2:40 PM, during an interview with the MDS Nurse, she stated the staff knew the incident had been reported to the Administrator, and the CNAs were upset Resident #1 had been made to cry by RN #1. The MDS Nurse stated it was extremely out of Resident #1's character to be that upset. The MDS nurse stated, they (staff) didn't see anything being done about the incident, so she called the MDS corporate person, and she then called the Regional Nurse Consultant. During an interview, on 01/02/20 at 2:00 PM, the Receptionist confirmed she had taken the phone call on 11/21/19, from Resident #1's daughter. The Receptionist stated RP #1 wanted to speak with the Administrator right away, and that RP #2 was upset, because she didn't like how RN #1 talked to her mother and wanted somebody to take care of it. The Receptionist stated she went and told the Administrator right away that RP #2 had called, and was upset. The Receptionist stated she didn't know if the Administrator had handled the situation or not. Review of a document titled, Position Description, dated 05/28/19 and signed by the Administrator, revealed: Serve as the center abuse coordinator. Strive to ensure the safety of all residents within the center; ensures education and understanding of all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect, or misappropriation by protecting, investigating and making any required reporting. Review of the facility's personnel file for RN #1, revealed he was hired on 09/23/19, and had no prior disciplines or any corrective actions in his employee file. Review of an In-service Attendance Record, dated 11/07/19, with a topic on Abuse, Neglect, Misappropriation and Exploitation, revealed RN #1 was in attendance. This in-service was held two (2) weeks prior to the incident with Resident #1. Review of the Admission Record, revealed the facility admitted Resident #1 on 10/01/18. [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS Assessment, with an Assessment Reference Date (ARD) of 11/25/19, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognitive skills for daily decision making. The facility submitted an acceptable Removal Plan on 12/31/19, for the I[NAME] Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. 1. The facility failed to protect a resident from abuse and neglect on 11/21/19, when the Assistant Director of Nursing (Registered Nurse (RN) #1) would not place Resident #1 back to bed when she was crying and yelling in pain. RN #1 refused to allow the Certified Nurse Assistant (CNA) staff to assist the resident. RN #1 continued to practice in his role, after the resident suffered from mental anguish, which caused psychosocial harm to Resident #1. The Administrator knew of the incident on 11/21/19 but failed to protect the resident by suspending RN #1, thoroughly investigate the incident, or report the incident to the Mississippi State Department of Health within two hours of the allegation of abuse. 2. Quality Assurance Performance Improvement (QAPI) meeting was held on (MONTH) 30, 2019 at 5:30 PM. Systemic changes and monitoring were developed, presented and approved by Administrator (Adm), Director of Nursing Services (DNS), Nurse Consultant and Clinical Education Nurse, and Medical Director. Systemic changes include monthly education and orientation by the Administrator or Director of Clinical Education to all staff regarding Abuse and Neglect, Reporting and Investigation allegations of abuse, customer service and residents' rights. Grievances and/or allegations will be reviewed and investigated at Daily Stand up by the Adm/DNS/Designee with follow up as needed. 3. The Administrator (ADM) called the MS State Department of Health regarding an allegation of abuse and initiated an investigation on (MONTH) 30, 2019. 4. The Assistant Director of Nursing (ADNS)/RN#1 was suspended pending an investigation on (MONTH) 30, 2019 by the DNS. 5. The Mississippi State Board of Nursing was notified on (MONTH) 31, 2019 related to the ADNS's abuse and neglect. 6. Medical Director was notified by the Director of Clinical Education on (MONTH) 30, 2019 at 4:30 PM. 7. Psychological Services consult was ordered by the Medical Director for Resident #1 to be evaluated and provide care for any mental anguish. The Social Worker called the Psychological Services on (MONTH) 30, 2019 at 4:45 PM. 8. Resident #1's responsible party was notified by the Administrator on (MONTH) 30, 2019 at 6:00 PM of the abuse allegation and the request for psychological services to evaluate Resident #1. 9. Alert and oriented residents were interviewed on (MONTH) 30, 2019 between 4:00-6:00 PM for any feelings of mental anguish or concerns with care by the Social Worker (SW) and Director of Clinical Operations (DCO), the Health Information Coordinator and the Director of Care Coordination with no other allegations of abuse. 10. The Administrator reported the allegation of abuse to the Attorney General's office on (MONTH) 30, 2019 at 4:24 PM. 11. The Administrator was suspended by the Vice President of Operations pending an investigation on (MONTH) 31, 2019 at 1:30 PM. 12. The local Police Department was notified 2:45 PM on (MONTH) 31, 2019. 13. Six (6) Registered Nurses (RN), Five (5) Licensed Practical Nurses (LPNs), 13 Certified Nursing Assistants (CNAs), 1 Workforce Manager, and 1 Social Service Coordinator (SSC), 1 Human Resources (HR), 1 Business Office Manager (BOM), 8 Therapy staff, 1 Maintenance staff, were educated by the Director of Clinical Education (DCE) beginning (MONTH) 30, 2019 at 3:30 PM on Abuse and Neglect, Reporting and Investigations, Residents Rights and Preferences, and Customer Service. 14. No employee will work until education is completed. 15. The Administrator was educated on (MONTH) 30, 2019 at 5:30 PM by the Senior Director of Clinical Operations on Abuse and Neglect, Reporting and Investigations, Residents' Rights and Preferences and Customer Service. The facility alleges the Immediate Jeopardy was removed as of (MONTH) 1, 2020. The SA validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ: 1. The State Agency validated that Resident #1 was free from abuse and neglect that occurred on 11/21/19 when the Assistant Director of Nursing/Registered Nurse (RN) #1 would not place Resident #1 back to bed when she was crying and yelling in pain and the ADNS refused to allow the Certified Nurse Assistants (C.N.A) staff to assist the resident. The ADNS continued to practice in his role after the resident suffered from mental anguish, which caused psychosocial harm to Resident #1. The Administrator knew of the incident on 11/21/19 and failed to protect the resident by suspending the ADNS, thoroughly investigate the incident, or report the incident to the Mississippi State Department of Health within two hours of the allegation of abuse. 2. The SA validated through record review and interviews the Quality Assurance Performance Improvement (QAPI) meeting was held on (MONTH) 30, 2019 at 5:30 PM. Systemic changes and monitoring were developed, presented and approved by Administrator (Adm), Director of Nursing Services (DNS), Nurse Consultant and Clinical Education Nurse, and Medical Director. Systemic changes include monthly education and orientation by the Administrator or Director of Clinical Education to all staff regarding Abuse and Neglect, Reporting and Investigation allegations of abuse, customer service and residents' rights. Grievances and/or allegations will be reviewed and investigated at Daily Stand up by the Adm/DNS/Designee with follow up as needed. The systemic changes were discussed at the QAPI meeting at 5:30 PM. 3. The SA validated through interview the Administrator (ADM) called the MS State Department of Health regarding an allegation of abuse and initiated an investigation on (MONTH) 30, 2019. 4. The SA validated through documentation the Assistant Director of Nursing (ADNS) was suspended pending an investigation on (MONTH) 30, 2019 by the DNS. 5. The SA validated through documentation the Mississippi State Board of Nursing was notified on (MONTH) 31, 2019 related to the ADNS's abuse and neglect. 6. The SA validated through interview the Medical Director was notified by the Director of Clinical Education on (MONTH) 30, 2019 at 4:30 PM. 7. The SA validated though documentation the Psychological Services consult was ordered by the Medical Director for Resident #1 to be evaluated and provided care for any mental anguish. The Social Worker called the Psychological Services on (MONTH) 30, 2019 at 4:45 PM. 8. The SA validated through interview Resident #1's responsible party was notified by the Administrator on (MONTH) 30, 2019 at 6:00 PM of the abuse allegation and the request for psychological services to evaluate Resident #1. 9. The SA validated through documentation and interviews alert and oriented residents were interviewed on (MONTH) 30, 2019 between 4:00-6:00 PM for any feelings of mental anguish or concerns with care by the Social Worker (SW) and Director of Clinical Operations (DCO), the Health Information Coordinator and the Director of Care Coordination with no other allegations of abuse. 10. The SA validated through documentation the Administrator reported the allegation of abuse to the Attorney General's office on (MONTH) 30, 2019 at 4:24 PM. 11. The SA validated through documentation the Administrator was suspended by the Vice President of Operations pending an investigation on (MONTH) 31, 2019 at 1:30 PM. 12. The SA validated through documentation the local Police Department was notified at 2:45 PM on (MONTH) 31, 2019. 13. The SA validated through interviews with the Nursing, Dietary, Housekeeping, Social Services, Therapy, Business Office and Maintenance and through documentation beginning (MONTH) 30, 2019 at 3:30 PM there were in-services regarding Abuse and Neglect, Reporting and Investigations, Residents Rights and Preferences, and Customer Service being held. 14. The SA validated the Administrator was educated on (MONTH) 30, 2019 at 5:30 PM by the Senior Director of Clinical Operations on Abuse and Neglect, Reporting and Investigations, Residents' Rights and Preferences and Customer Service. The SA validated that all corrective actions were completed as of 12/31/19 and the IJ was removed as of 01/01/20.

Based on resident interview, staff interview, record review, and facility policy review, the facility failed to report an allegation of staff to resident abuse within the two (2) hour required timeframe, for one (1) of nine (9) residents reviewed, Resident #1. On 11/21/19, at or around 11:30 AM, Resident #1 reported an allegation of verbal and mental abuse against the Assistant Director of Nursing Services (ADNS)/Registered Nurse (RN #1), to her daughter by phone, during the incident. The allegation consisted of Resident #1 was made to get up out of the bed, sit in the wheelchair, while she was in pain and had no desire to sit up in the wheelchair; and RN #1 would not allow Certified Nursing Assistant (CNA) #1 and CNA #2 to put Resident #1 back to bed when she was crying and yelling out in pain. Resident #1 stated she felt like she was fighting for her life and that nobody had ever made her feel that way before in her whole life; and she felt so helpless. The Administrator was notified by Resident #1's daughter (Responsible Party (RP) #1) by phone, shortly after the incident occurred. The Administrator did not investigate the allegation, suspend the employee (RN #1), or protect Resident #1 and all other residents. The failure of the facility to notify the appropriate state agencies in a timely manner of an allegation of verbal and mental abuse and ensure that proper measures had been addressed, and allowing the staff member to work in the facility, following an incident of witnessed verbal and mental abuse, placed Resident #1 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 11/21/19, when the verbal and mental abuse occurred. The facility's Administrator was notified of the IJ and SQC on 12/30/19 at 4:30 PM and provided with the IJ template. An acceptable credible Removal Plan was provided by the facility on 12/31/19, in which the facility alleged all corrective actions were completed as of 12/31/19, and the IJ was removed on 01/01/20. The State Agency (SA) validated the Removal Plan and determined that the IJ was removed on 01/02/20, prior to exit. Therefore, the scope and severity for the IJ and SQC at 42 CFR(s): 483.12(c)(1)(4), Reporting of Alleged Violations, (F609), was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Abuse, Neglect, Misappropriation, Exploitation Policy, dated 01/19, revealed, Investigation: The Administrator will oversee in conducting an internal investigation against any violation/alleged violation of abuse and report the results of the investigation to the enforcement agency, the state survey and the certification agency within five days of the incident. Investigations will be prompt, comprehensive and responsive to the situation and founded conclusions. The investigation will include, but not limited to: Identification and removal of the alleged person. Interviews of all persons involved, witnesses, alleged victim, and follow up resolution and measures to prevent repeat incidents. Reporting: Immediately reporting all alleged violations to the Administrator, designee, state agency, and all other required agencies within specified timeframes. Review of an anonymous complaint allegation, MS # , submitted to the SA on 12/23/19, documented on 11/20/19 RN #1 made Resident #1 cry. Review of the facility's Customer Concern/Grievance Communication Form, dated 11/21/19 and completed by the Administrator, revealed: Resident #1 was concerned with approach of Assistant Director of Nursing (ADON)/RN #1 motivating her to do therapy. Administrator, Director of Rehab (DOR) and ADON met with resident to talk about concerns with therapy goals and motivation of ADON. The Administrator talked with ADON and therapy about approach and different forms of encouragement. Customer (Resident #1) contacted for follow up on 11/21/19. On 12/30/19 at 10:00 AM, during an interview with Resident #1, she stated, This happened about a month or two ago, I'm not sure of the date, but they (facility) are trying to sweep it under the rug. Resident #1 began to cry and was emotionally upset recalling the event of that day. Resident #1 stated on that day she really didn't want to get up at all, because she had been awake all night with spasms in her legs, but RN #1 told her she needed to get up, so she allowed Certified Nursing Assistant (CNA) #1 and CNA #2 to get her up with the lift, and they placed her in a wheelchair, in her room. After about five minutes, Resident #1 stated she was in a lot of pain in her right leg and felt like she was sliding out of the wheelchair. Resident #1 stated she asked to be placed back in the bed, and CNA #1 and CNA #2 went into the hallway to get the lift, but was stopped by RN #1. Resident #1 stated, He (RN #1) took the lift back out of the room and wouldn't let them put me to bed. I picked up my cell phone and called my daughter and while I was telling her what was going on, he took my cell phone from me, and he wouldn't give it back to me. He went out of the room to talk to my daughter and came back in the room and gave me my phone back, but she had hung up. Resident #1 stated she had called her daughter (Responsible Party (RP) #2) because she knew that her daughter would stop him from treating her this way. Resident #1 stated RN #1 always had smart comments, but he had never acted like he did that day; and he was out of control. Resident #1 stated, Nobody had ever made me feel that way before, I felt like I was fighting for my life. I felt so helpless and he knew I couldn't do anything to stop him because I'm paralyzed. Resident #1 stated, RN #1 told the staff not to listen to me or my family and to listen to him because he was the boss. Resident #1 stated CNA #1 wanted to put her back to bed, and she was about to cry because RN #1 wouldn't let her. Resident #1 stated the Administrator came to her room, the same day this incident occurred, because her daughter had left a message for her. Resident #1 stated the Administrator told her RN #1 didn't mean anything by that, and she needed for them to be friends. During an interview, on 12/30/19 at 1:00 PM, CNA #1 stated around lunch time (11:30 AM), RN #1 asked her and CNA #2 to get Resident #1 up. After they got Resident #1 up, Resident #1 began begging to be put back to bed, after about five minutes. CNA #1 stated, Resident #1 was crying, so they went and got the lift. CNA #1 stated RN #1 stopped them and told them to go on and pass the trays out, and that he was their boss and they better do what he said. CNA #1 stated RN #1 stayed in the room with Resident #1 the whole time. CNA #1 stated she could hear them (Resident #1 and RN #1) yelling at each other all the way to the nurse's desk. CNA #1 stated Resident #1 was crying, screaming and cussing at RN #1. CNA #1 became emotional and was crying, while recalling the incident. CNA #1 stated, she felt so helpless and was upset that Resident #1 was crying and begging to go back to bed, and RN #1 wouldn't allow them to put her to bed. CNA #1 stated she was fearful of him (RN #1) and had asked him how is that right that he got to treat Resident #1 that way and he said, Because I'm the boss. CNA #1 stated Resident #1 had never been out of the bed other than to go to the shower and she was scared, but since RN #1 had come on board, he wanted Resident #1 to get up and sit up. CNA #1 stated Resident #1 was almost falling out of her wheelchair before RN #1 would let them (CNAs) put the resident back to bed. CNA #1 revealed it was about 30-45 minutes later. CNA #1 stated she didn't know what else to do, so after they got Resident #1 in the bed, she went and got the Ombudsman and the SA phone numbers and put them in Resident #1's phone. CNA #1 confirmed she did not report this incident to anyone because she was fearful of losing her job. CNA #1 stated, He (RN #1) kept saying, I'm the boss and you better do what I say. On 12/30/19 at 1:10 PM, during an interview with the Administrator, she confirmed she did not have an investigation report regarding this allegation of abuse. The Administrator stated, It wasn't an allegation of abuse. I talked to Resident #1, but I didn't write anything down, she wasn't upset. I didn't get a statement from RN#1 because I didn't investigate it as abuse because it wasn't, he was just trying to motivate her. The Administrator confirmed she had received a call from the Resident #1's daughter (RP #2) and that the daughter was concerned and didn't like the way RN #1 had talked to her mother. The Administrator revealed, Resident #1's daughter said if the Administrator didn't do something about the incident, then she was coming to the facility. The Administrator stated, I didn't think there was anything to it because she never showed up. The Administrator stated she had never had any allegations or concerns regarding RN #1. The Administrator confirmed she never reported the incident to the State Agency. Review of a signed copy of the Administrator Position Description, dated 05/28/19 and signed by the Administrator, documented: Serve as the center abuse coordinator. Strive to ensure the safety of all residents within the center; ensures education and understanding of all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect, or misappropriation by protecting, investigating and making any required reporting. On 12/30/19 at 2:15 PM, during an interview with the Therapy Director (TD), she stated the Administrator informed her of receiving a phone call from Resident #1's daughter regarding an incident between Resident #1 and RN #1, that caused the resident to be upset. The TD revealed the Administrator asked her to accompany her to Resident #1's room to see what was wrong. The TD stated Resident #1 was crying and upset when she and the Administrator went to her room. The TD stated Resident #1 told the Administrator that she wouldn't wish this (her condition) on anybody, to be in this much pain and to be treated this way. The TD stated the entire time she was in room, while the Administrator talked with Resident #1, the resident was crying and emotional. The TD stated she had never seen Resident #1 that emotional and upset before. The TD stated she thought the Administrator was handling the situation. and stated, I didn't know it (incident) wasn't reported to the State. I thought that was what she was doing. On 12/30/19 at 2:30 PM, during a phone interview with CNA #2, she stated RN #1 would not allow her and CNA #1 to put Resident #1 back to bed. She stated he (RN #1) was telling Resident #1, You're not going back to bed. CNA #2 confirmed Resident #1 was crying and upset. CNA #2 stated, He (RN #1) could have handled it a lot better than he did. The SA asked CNA#2 if she reported this incident to anyone and she stated, It wouldn't do any good to report it to the DON or the Administrator, they protect each other. He is very rude, and he is not suitable for his position. CNA #2 stated RN #1 was over the CNAs. During an interview, on 12/30/19 at 3:55 PM, RN #1 stated he was the Assistant Director of Nursing Services (ADNS) at the facility and oversees the Restorative Program. RN #1 stated on 11/13/19, he met with Resident #1 and her son (Responsible Party) and told them the goal was for the resident to sit up two (2) hours, three (3) times a week. RN #1 stated he told Resident #1, they were going to attack this thing (therapy) and that he was going to be tough on her. RN #1 stated Resident #1 refusing to get up, so he called her son to let him know. RN #1 stated on 11/21/19, he went into Resident #1's room and she was on the phone with her daughter. RN #1 stated he told Resident #1 he was going to call her son. RN #1 stated after about five (5) to ten (10) minutes, the CNAs were trying to put her back to bed. RN #1 revealed he told the CNAs to go on and that he would put Resident #1 back to bed after the trays were passed out. RN #1 further stated he would go down to Resident #1's room and handle the resident. RN #1 stated Resident #1 was crying, yelling, and saying her right hip hurt. RN #1 revealed he padded the resident in the wheelchair, and she continued to sit up until I told the CNAs to put her back to bed. The SA asked RN #1 if the resident wanted to continue to sit up and he stated, No, but we had made a plan for her to get up three times a week and I told her I was going to be tough on her. RN #1 stated, Hindsight, I could have handled it differently. I probably did cause her mental anguish, but I don't think I abused her. On 12/31/19 at 9:58 AM, during an interview, with the Regional Nurse Consultant (RNC), revealed she had received a call from the Minimum Data Set (MDS) Nurse around 9:30 PM on 12/02/19. The RNC stated the MDS Nurse asked, Did anyone say anything to you about (RN #1) making a resident cry? The RNC stated she told her no. The RNC stated she then called the Administrator within five minutes and asked her if she knew anything about this incident, and the Administrator stated, Yes, I did a grievance. Her daughter had called and said her mom was upset. The RNC stated she told the Administrator to go to Resident #1's room the next day and talk to her. The RNC revealed the Administrator called her back the next day and told the her The resident was crying and upset because she didn't like how (RN #1) was motivating her. On 12/31/19 at 10:30 AM, an interview with Resident #1's son/Responsible Party (RP) #1, at the facility and Resident #1's daughter/RP #2 by phone, revealed RP #1 was not aware of the full story of what had occurred that day (11/21/19). RP #1 stated he got a phone call from his sister and she told him that she had left a message for the Administrator, and he needed to come up to the facility to see what was going on RP #1 further revealed RP #2 stated their momma (Resident #1) had called her upset about how (RN #1 ) had talked to her. RP #1 stated he came to the facility, but RN #1 told him they (RN #1 and Resident #1) just had a conversation and RN #1 made it (the incident) sound like it wasn't a big deal. Resident #1 stated to the son (RP #1), while he was in the room, on 12/31/19 at 10:30 AM, that she had called her daughter (RP #2) because she didn't want to upset her son, and she knew her daughter would take care of RN#1. Resident #1's daughter (RP #2), confirmed by phone, she was upset about how RN#1 had talked to her mother and that she had left a message with the receptionist for the Administrator to call her, but the Administrator never called her back. On 12/31/19 at 11:15 AM, during an interview with Resident #1's Nurse Practitioner (NP), she confirmed that she was not aware of the incident that occurred on 11/21/19. The NP stated, This is the first that I have heard about it and I have been her doctor for years. During an interview, on 12/31/19 at 3:45 PM, Resident #1's Primary Physician (Physician #1) stated he was not aware of the incident and had heard nothing about it. On 01/02/20 at 2:00 PM, during an interview with the Receptionist, she stated that she had taken the phone call 11/21/19, around 11:30 AM, from Resident #1's daughter (RP #2). The Receptionist confirmed RP #2 wanted to speak with the Administrator right away. The Receptionist stated RP #2 told her she was upset because she didn't like how RN #1 talked to her mother and that she wanted somebody to take care of it. The Receptionist stated she went and told the Administrator right away that RP #2 had called and was upset. The Receptionist confirmed she didn't know if the situation was handled or not. On 01/02/20 at 2:40 PM, an interview with the Minimum Data Set (MDS) Nurse, she stated the staff knew it (the incident) had been reported to the Administrator and the CNAs were upset that Resident #1 had been made to cry by RN #1. The MDS Nurse stated it was extremely out of Resident #1's character to be that upset. The MDS Nurse stated, We didn't see anything being done about it, so I called my corporate person and she then called (Regional Nurse Consultant Proper Name). Review of RN #1's personnel file, revealed he was hired on 09/23/19, and had no prior disciplines or any corrective actions in his employee file. A review of In-service Attendance Records, dated 11/07/19 and 12/30/19, titled Topic: Abuse, Neglect, Misappropriation, Exploitation Policy, revealed RN #1, CNA #1 and CNA #2 attended both in-services. Review of the Admission Record revealed the facility admitted Resident #1 on 10/01/18. [DIAGNOSES REDACTED]. Review of the MDS Quarterly Assessment, with an Assessment Reference Date (ARD) of 11/25/19, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognitive skills for daily decision making. The facility submitted an acceptable Removal Plan on 12/31/19, for the I[NAME] Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit: 1. The facility failed to protect a resident from abuse and neglect on 11/21/19, when the Assistant Director of Nursing, Registered Nurse (RN) #1 would not place Resident #1 back to bed when she was crying and yelling in pain. RN #1 refused to allow the Certified Nurse Assistant (CNA) staff to assist the resident. RN #1 continued to practice in his role, after the resident suffered from mental anguish, which caused psychosocial harm to Resident #1. The Administrator knew of the incident on 11/21/19 but failed to protect the resident by suspending RN #1, thoroughly investigate the incident, or report the incident to the Mississippi State Department of Health within two hours of the allegation of abuse. 2. The Administrator (ADM) called the MS State Department of Health regarding an allegation of abuse and initiated an investigation on (MONTH) 30, 2019. 3. The Assistant Director of Nursing (ADNS)/RN#1 was suspended pending an investigation on (MONTH) 30, 2019 by the DNS. 4. The Mississippi State Board of Nursing was notified on (MONTH) 31, 2019 related to the ADNS's abuse and neglect. 5. Medical Director was notified by the Director of Clinical Education on (MONTH) 30, 2019 at 4:30 PM. 6. Psychological Services consult was ordered by the Medical Director for Resident #1 to be evaluated and provide care for any mental anguish. The Social Worker called the Psychological Services on (MONTH) 30, 2019 at 4:45 PM. 7. Resident #1's responsible party was notified by the Administrator on (MONTH) 30, 2019 at 6:00 PM of the abuse allegation and the request for psychological services to evaluate Resident #1. 8. Alert and oriented residents were interviewed on (MONTH) 30, 2019 between 4:00-6:00 PM for any feelings of mental anguish or concerns with care by the Social Worker (SW) and Director of Clinical Operations (DCO), the Health Information Coordinator and the Director of Care Coordination with no other allegations of abuse. 9. The Administrator reported the allegation of abuse to the Attorney General's office on (MONTH) 30, 2019 at 4:24 PM. 10. The Administrator was suspended by the Vice President of Operations pending an investigation on (MONTH) 31, 2019 at 1:30 PM. 11. The local Police Department was notified 2:45 PM on (MONTH) 31, 2019. 12. Six (6) Registered Nurses (RN), Five (5) Licensed Practical Nurses (LPNs), 13 Certified Nursing Assistants (CNAs), 1 Workforce Manager, and 1 Social Service Coordinator (SSC), 1 Human Resources (HR), 1 Business Office Manager (BOM), 8 Therapy staff, 1 Maintenance staff, were educated by the Director of Clinical Education (DCE) beginning (MONTH) 30, 2019 at 3:30 PM on Abuse and Neglect, Reporting and Investigations, Residents Rights and Preferences, and Customer Service. 13. No employee will work until education is completed. 14. The Administrator was educated on (MONTH) 30, 2019 at 5:30 PM by the Senior Director of Clinical Operations on Abuse and Neglect, Reporting and Investigations, Residents' Rights and Preferences and Customer Service. 15. Quality Assurance Performance Improvement (QAPI) meeting was held on (MONTH) 30, 2019 at 5:30 PM. Systemic changes and monitoring were developed, presented and approved by Administrator (Adm), Director of Nursing Services (DNS), Nurse Consultant and Clinical Education Nurse, and Medical Director. Systemic changes include monthly education and orientation by the Administrator or Director of Clinical Education to all staff regarding Abuse and Neglect, Reporting and Investigation allegations of abuse, customer service and residents' rights. Grievances and/or allegations will be reviewed and investigated at Daily Stand up by the Adm/DNS/Designee with follow up as needed. The facility alleges that the Immediate Jeopardy is removed as of (MONTH) 1, 2020. The SA validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ: 1. The State Agency validated that Resident #1 was free from abuse and neglect that occurred on 11/21/19 when the Assistant Director of Nursing/Registered Nurse (RN) #1 would not place Resident #1 back to bed when she was crying and yelling in pain and the ADNS refused to allow the Certified Nurse Assistants (C.N.A) staff to assist the resident. The ADNS continued to practice in his role after the resident suffered from mental anguish, which caused psychosocial harm to Resident #1. The Administrator knew of the incident on 11/21/19 and failed to protect the resident by suspending the ADNS, thoroughly investigate the incident, or report the incident to the Mississippi State Department of Health within two hours of the allegation of abuse. 2. The SA validated through record review and interviews the Quality Assurance Performance Improvement (QAPI) meeting was held on (MONTH) 30, 2019 at 5:30 PM. Systemic changes and monitoring were developed, presented and approved by Administrator (Adm), Director of Nursing Services (DNS), Nurse Consultant and Clinical Education Nurse, and Medical Director. Systemic changes include monthly education and orientation by the Administrator or Director of Clinical Education to all staff regarding Abuse and Neglect, Reporting and Investigation allegations of abuse, customer service and residents' rights. Grievances and/or allegations will be reviewed and investigated at Daily Stand up by the Adm/DNS/Designee with follow up as needed. The systemic changes were discussed at the QAPI meeting at 5:30 PM. 3. The SA validated through interview the Administrator (ADM) called the MS State Department of Health regarding an allegation of abuse and initiated an investigation on (MONTH) 30, 2019. 4. The SA validated through documentation the Assistant Director of Nursing (ADNS) was suspended pending an investigation on (MONTH) 30, 2019 by the DNS. 5. The SA validated through documentation the Mississippi State Board of Nursing was notified on (MONTH) 31, 2019 related to the ADNS's abuse and neglect. 6. The SA validated through interview the Medical Director was notified by the Director of Clinical Education on (MONTH) 30, 2019 at 4:30 PM. 7. The SA validated though documentation the Psychological Services consult was ordered by the Medical Director for Resident #1 to be evaluated and provided care for any mental anguish. The Social Worker called the Psychological Services on (MONTH) 30, 2019 at 4:45 PM. 8. The SA validated through interview Resident #1's responsible party was notified by the Administrator on (MONTH) 30, 2019 at 6:00 PM of the abuse allegation and the request for psychological services to evaluate Resident #1. 9. The SA validated through documentation and interviews alert and oriented residents were interviewed on (MONTH) 30, 2019 between 4:00-6:00 PM for any feelings of mental anguish or concerns with care by the Social Worker (SW) and Director of Clinical Operations (DCO), the Health Information Coordinator and the Director of Care Coordination with no other allegations of abuse. 10. The SA validated through documentation the Administrator reported the allegation of abuse to the Attorney General's office on (MONTH) 30, 2019 at 4:24 PM. 11. The SA validated through documentation the Administrator was suspended by the Vice President of Operations pending an investigation on (MONTH) 31, 2019 at 1:30 PM. 12. The SA validated through documentation the local Police Department was notified at 2:45 PM on (MONTH) 31, 2019. 13. The SA validated through interviews with the Nursing, Dietary, Housekeeping, Social Services, Therapy, Business Office and Maintenance and through documentation beginning (MONTH) 30, 2019 at 3:30 PM there were in-services regarding Abuse and Neglect, Reporting and Investigations, Residents Rights and Preferences, and Customer Service being held. 14. The SA validated the Administrator was educated on (MONTH) 30, 2019 at 5:30 PM by the Senior Director of Clinical Operations on Abuse and Neglect, Reporting and Investigations, Residents' Rights and Preferences and Customer Service. The SA validated that all corrective actions were completed as of 12/31/19 and the IJ was removed as of 01/01/20.

Based on resident interview, staff interview, record review and facility policy review, the facility failed to investigate and prevent further potential abuse and mistreatment from occurring, after an allegation of staff to resident abuse had been made for one (1) of nine (9) residents reviewed, Resident #1. On 11/21/19, at or around 11:30 AM, Resident #1 reported an allegation of verbal and mental abuse against the Assistant Director of Nursing Services (Registered (RN) #1) to her daughter (Responsible Party (RP #2) by phone during the incident. The allegation consisted of Resident #1 was made to get up out of the bed and sit in the wheelchair while she was in pain and had no desire to sit up that day in the wheelchair and the RN #1 would not allow Certified Nursing Assistant (CNA) #1 and CNA #2 to put Resident #1 back to bed when she was crying and yelling out in pain. This occurred in Resident #1's room and was witnessed by other staff. Resident #1 stated that she felt like she was fighting for her life and that nobody had ever made her feel that way before in her whole life and she felt so helpless. The Administrator was notified by Resident #1's daughter by phone on or around 11:30 AM when the incident occurred. The Administrator was told by Resident #1's daughter (Responsible Party (RP) #2) that she did not like the way that RN #1 had spoken to her mother and stated, You better do something with RN #1 before I come up there and whip his ass, don't nobody talk to my momma the way he did. The Administrator did not investigate the allegation, suspend the employee, or protect Resident #1 and all other residents. The failure of the facility to notify the appropriate state agencies in a timely manner and by not protecting residents from further mental abuse by allowing a witnessed abuse to a resident occur, and the facility allowing RN #1 to continue to work in the facility, placed Resident #1 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 11/21/19, when the verbal and mental abuse occurred. The facility's Administrator was notified of the IJ and SQC on 12/30/19 at 4:30 PM and provided with the IJ template. An acceptable credible Removal Plan was provided by the facility on 12/31/19, in which the facility alleged all corrective actions were completed as of 12/31/19, and the IJ was removed on 01/01/20. The State Agency (SA) validated the Removal Plan and determined that the IJ was removed on 01/02/20, prior to exit. Therefore, the scope and severity for the IJ and SQC at 42 CFR(s): 483.12(c)(2)-(4), F610, Investigate/Prevent/Correct Alleged Violation, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Abuse, Neglect, Misappropriation, Exploitation Policy, dated 01/19, revealed, Definitions of Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain or mental anguish. Mental Abuse: is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Investigation: The Administrator will oversee in conducting an internal investigation against any violation/alleged violation of abuse and report the results of the investigation to the enforcement agency, the state survey and the certification agency within five days of the incident. Investigations will be prompt, comprehensive and responsive to the situation and founded conclusions. The investigation will include, but not limited to: Identification and removal of the alleged person. Interviews of all persons involved, witnesses, alleged victim, and follow up resolution and measures to prevent repeat incidents. Reporting: Immediately reporting all alleged violations to the Administrator, designee, state agency, and all other required agencies within specified timeframes. Review of an anonymous complaint allegation, submitted to the SA on 12/23/19, documented that on 11/20/19 the Assistant Director of Nursing Services (RN #1) made Resident #1 cry. Review of the facility's Customer Concern/Grievance Communication Form, dated 11/21/19 and completed by the Administrator, revealed: Resident concerned with approach of ADON (RN #1) motivating her to do therapy. Administrator, Director of Rehab (DOR) and ADON (RN #1) meet with resident to talk about concerns with therapy goals and motivation of ADON. Talked with ADON and therapy about approach and different forms of encouragement. Customer contacted for follow up on 11/21/19. On 12/30/19, at 10:00 AM, during an interview with Resident #1, she stated, This happened about a month or two ago, I'm not sure of the date, but they (facility) are trying to sweep it under the rug. Resident #1 began to cry and was emotionally upset recalling the event of that day (11/21/19). Resident #1 stated on that day, she really didn't want to get up at all because she had been awake all night with spasms in her legs, but RN #1 told her she needed to get up. Resident #1 stated she allowed CNA #1 and CNA #2 to get her up with the lift, and they placed her in the wheelchair in her room. After about five minutes, Resident #1 stated she was in a lot of pain in her right leg, and felt like she was sliding out of the wheelchair. Resident #1 stated she asked to be placed back in the bed. Resident #1 revealed CNA #1 and CNA #2 went into the hallway to get the lift, and was stopped by RN #1. Resident #1 stated, He (RN #1) took the lift back out of the room, and wouldn't let them put me to bed. Resident #1 stated she picked up her cell phone and called her daughter (RP #2). Resident #1 stated while she was telling RP #2 what was going on, RN #1 took her cell phone, and wouldn't give it back to her. Resident #1 stated RN #1 went out of the room to talk to her daughter (RP #2), and then came back in the room, gave her phone back, but RP #2 had hung up. Resident #1 stated she had called her daughter because she knew her daughter would stop him from treating her that way. Resident #1 stated RN #1 always had smart comments, but he had never acted like he did that day; and that he was out of control. Resident #1 stated, Nobody had ever made me feel that way before, I felt like I was fighting for my life. I felt so helpless and he knew I couldn't do anything to stop him because I'm paralyzed. He told the staff not to listen to me or my family and to listen to him because he was the boss. Resident #1 stated CNA #1 wanted to put her back to bed. Resident #1 revealed CNA #1 was about to cry because RN #1 wouldn't allow her to put her back to bed. Resident #1 stated the Administrator came to her room the same day the incident occurred, because her daughter (RP #2) had left a message for the Administrator. Resident #1 stated, the Administrator told her that RN #1 didn't mean anything by that (incident) and she needed them to be friends. During at interview, on 12/30/19 at 1:00 PM, CNA #1 stated around lunchtime (11:30 AM) on 11/21/19, RN #1 had asked us (CNAs) to get Resident #1 up. CNA #1 stated after they got Resident #1 up, the resident began begging to be put back to bed, which was after about five minutes. CNA #1 stated Resident #1 was crying, so they went and got the lift,and RN #1 stopped them. CNA #1 stated RN #1 told them to go on and pass the trays out, he was their boss and they had better do what he said. CNA #1 stated RN #1 stayed in Resident #1's room the whole time. CNA #1 stated, RN #1 and Resident #1 could be heard yelling at each other all the way to the nurse's desk. CNA #1 revealed Resident #1 was crying, screaming and cussing at RN #1. CNA #1 became emotional and was crying while recalling the incident. CNA #1 stated, she felt so helpless and was upset that Resident #1 was crying and begging to go back to bed, and RN #1 wouldn't allow them to put her to bed. CNA #1 stated she was fearful of RN#1, but asked him how was that right the way he treated Resident #1. CNA #1 stated RN #1 told her, Because I'm the boss. CNA #1 stated Resident #1 had never been out of the bed, other than to go to the shower, and she was scared. CNA #1 stated since RN #1 came on board, he wanted Resident #1 to get up and sit up. CNA #1 stated Resident #1 was almost falling out of her wheelchair before RN #1 would let them (CNAs) put the resident back to bed. CNA #1 revealed it was about 30-45 minutes later. CNA #1 stated she didn't know what else to do, so after Resident #1 was put back to bed, she went and got the phone numbers for the Ombudsman and the S[NAME] CNA #1 stated she put the phone numbers in Resident #1's phone. CNA #1 confirmed she did not report this incident to anyone, because she was fearful of losing her job. CNA #1 stated, RN #1 kept saying, he was the boss and we better do what he said. On 12/30/19 at 1:10 PM, an interview with the Administrator, confirmed she did not have an investigation report regarding the allegation of abuse (11/21/19). The Administrator stated, It wasn't an allegation of abuse. I talked to Resident #1, but I didn't write anything down, she wasn't upset. I didn't get a statement from RN#1 because I didn't investigate it as abuse because it wasn't, he was just trying to motivate her. The Administrator confirmed she had received a call from the resident's daughter (RP #2), and that RP #2 was concerned, didn't like the way RN #1 had talked to her mother, and was coming up to the facility if she didn't do something about it. The Administrator stated, I didn't think there was anything to it because she never showed up. The Administrator stated she had never had any allegations or concerns regarding RN #1. The Administrator confirmed she never reported the incident to the State Agency. On 12/30/19 at 1:10 PM, during an interview, the Director of Nursing (DON) confirmed she was on vacation the week of 11/19/19 through 11/26/19. The DON stated RN #1 was serving as the interim DON while she was away, and she had no knowledge of any complaints or concerns about RN #1, while she was on vacation. During an interview, on 12/30/19 at 2:15 PM, the Therapy Director stated she had received a text from the Administrator that day (11/21/19) around 4:00 PM, and it state for me to get RN #1 and come to her office. The Therapy Director stated she and RN #1 went to the Administrator's office and was told by the Administrator, she had received a call from Resident #1's daughter (RP #2). The Administrator revealed RP #2 she was upset about an incident that occurred between Resident #1 and RN #1, and she wanted to know if we would go with her to the resident's room to see what was wrong. The Therapy Director stated Resident #1 was crying and upset, and told the Administrator she wouldn't wish on anybody, being in that much pain and being treated that way (incident with RN #1). The Therapy Director stated she was in the room, the entire time the Administrator talked Resident #1. The Therapy Director stated Resident #1 was crying and emotional, and she had never seen the resident that emotional and upset before. The Therapy Director stated she thought the Administrator was handling the situation, and didn't know the incident wasn't reported to the State. The Therapy Director stated she thought that was what the Administrator was doing. On 12/30/19 at 2:30 PM, during a phone interview with CNA #2, she stated RN #1 would not allow her and CNA #1 to put Resident #1 back to bed. CNA #2 stated RN #1 was telling the resident, You're not going back to bed. CNA #2 confirmed Resident #1 was crying and upset. CNA #2 stated, He (RN #1) could have handled it a lot better than he did. CNA #2 revealed it wouldn't have done any good to report the incident to the DON or the Administrator. CNA #2 revealed, they (DON, Administrator) protect each other. CNA #2 stated Resident #1 was over the CNAs. On 12/30/19 at 3:55 PM, during an interview, RN #1 stated he was the Assistant Director of Nursing Services (ADNS) at the facility, and oversees the Restorative Program. RN #1 stated on 11/13/19, he had met with Resident #1 and her son (RP #1), and told them the goal was to have Resident #1 sit up two (2) hours, three (3) times a week. RN #1 stated he told the resident he was going to be tough on her. RN #1 stated Resident #1 began refusing to get up, so he called RP #1 to let him know. RN #1 stated on 11/21/19, he went to Resident #1's room, and the resident had her daughter (RP #2) on the phone. RN #1 stated he told Resident #1 he was going to call her son (RP #1). RN #1 stated, after about five to ten minutes, the CNAs were trying to put Resident #1back to bed. RN #1 stated he told the CNAs to go on and he would put Resident #1 back to bed after the trays were passed, and that he would go down to Resident #1's room and handle her. RN#1 stated Resident #1 was crying, yelling and complaining her right hip hurt. RN #1 stated he padded the resident in the wheelchair, and she continued to sit up, until he told the CNAs to put her back to bed. RN #1 revealed Resident #1 did not want to continue to sit up, but stated, We had made a plan for her to get up three times a week, and I told her I was going to be tough on her. RN #1 stated, Hindsight, I could have handled it differently. I probably did cause her mental anguish, but I don't think I abused her. On 12/31/19 at 9:58 AM, and interview with the Regional Nurse Consultant (RNC) revealed, she received a call from the Minimum Data Set (MDS) Nurse around 9:30 PM, on 12/02/19. The RNC stated the MDS Nurse asked her if anyone had said anything to her RN #1 making a resident cry. The RNC stated she told the MDS Nurse no. The RNC stated she then called the Administrator, within five minutes, and asked the Administrator if she knew anything about this incident, and the Administrator said, Yes, I did a grievance. The RNC stated the Administrator told her Resident #1's daughter had called, and reported her mom was upset. The RNC revealed she told the Administrator to go to Resident #1's room the next day, and talk to her. The RNC stated the Administrator called her back, the following day, and told her Resident #1 was crying and upset, because she didn't like how RN #1 was motivating her. On 12/31/19 at 10:30 AM, an interview with Resident #1's son (RP#1), at the facility (Resident #1's room), and with Resident 1's daughter (RP#2) by phone, revealed, RP #1 stated he was not aware of the full story of what had occurred that day (11/21/19). RP #1 stated he received a phone call from his sister, and she told me that she had left a message for the Administrator. RP #1 stated his sister said that he needed to come up to the facility, to see what was going on, because their mother was her upset about how RN #1 had talked to her. RP #1 stated that he came to the facility, but RN #1 informed him that he and Resident #1 had just had a conversation. RP #1 stated RN #1 made it sound like it wasn't a big deal. Resident #1 stated to the RP #1, while he was in the room, on 12/31/19 at 10:30 AM, she had called her daughter (RP #2) because she didn't want to upset him (RP #1). Resident #1 stated she knew RP #2 would take care of RN #1. RP #2 confirmed by phone, she was upset about how RN #1 had talked to her mother (Resident #1). RP #2 stated she left a message with the receptionist for the Administrator to call her, but that the Administrator never called her back. During an interview, on 12/31/19 at 11:15 AM, Resident #1's Nurse Practitioner (NP) confirmed she was not aware of the incident that occurred on 11/21/19. The NP stated, this was the first that she had heard about it, and she had been Resident #1's doctor for years. On 12/31/19 at 3:45 PM, an interview with Resident #1's Primary Physician (Physician #1), revealed she was not aware of the incident, and had heard nothing about it. On 01/02/20 at 2:40 PM, during an interview with the MDS Nurse, she stated the staff knew the incident had been reported to the Administrator. The MDS Nurse stated the CNAs were upset that Resident#1 had been made to cry by RN #1. The MDS Nurse stated it was extremely out of Resident #1's character to be that upset. The MDS Nurse revealed they didn't see anything being done about it (incident), so she called her Corporate person, and she then called the Regional Nurse Consultant. During an interview, on 01/02/20 at 2:00 PM, the Receptionist stated that she had taken the phone call that day (11/21/19), around 11:30 AM, from Resident #1's daughter (RP #2). The Receptionist confirmed RP #2 wanted to speak with the Administrator right away. The Receptionist revealed RP #2 told her she was upset, because she didn't like how RN #1 had talked to her mother (Resident #1). The Receptionist stated RP#2 stated she wanted somebody to take care of it. The Receptionist stated she told the Administrator right away, RP #2 had called and was upset. The Receptionist confirmed she didn't know if the situation was handled or not. Review of a document titled Position Description, dated 05/28/19 and signed by the Administrator, revealed: Serve as the center abuse coordinator. Strive to ensure the safety of all residents within the center; ensures education and understanding of all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect, or misappropriation by protecting, investigating and making any required reporting. Review of RN #1's personnel file, revealed he was hired on 09/23/19, and had no prior disciplines or any corrective actions in his employee file. RN #1 was allowed to work and was not suspended, until the SA made the Administrator aware of an allegation of verbal and mental abuse involving RN #1, on 12/30/19 at 1:10 PM. Review of an In-service Attendance record, dated 11/07/19, with a topic of Abuse, Neglect, Misappropriation, Exploitation Policy, revealed RN #1 signed as being in attendance for this in-service. Review of the Admission Record, revealed the facility admitted Resident #1 on 10/01/18. [DIAGNOSES REDACTED]. Review of the MDS Quarterly Assessment, with an Assessment Reference Date (ARD) of 11/25/19, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognitive skills for daily decision making. The facility submitted an acceptable Removal Plan on 12/31/19, for the I[NAME] Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit: 1. The facility failed to protect a resident from abuse and neglect on 11/21/19, when the Assistant Director of Nursing, Registered Nurse (RN) #1 would not place Resident #1 back to bed when she was crying and yelling in pain. RN #1 refused to allow the Certified Nurse Assistant (CNA) staff to assist the resident. RN #1 continued to practice in his role, after the resident suffered from mental anguish, which caused psychosocial harm to Resident #1. The Administrator knew of the incident on 11/21/19 but failed to protect the resident by suspending RN #1, thoroughly investigate the incident, or report the incident to the Mississippi State Department of Health within two hours of the allegation of abuse. 2. The Administrator (ADM) called the MS State Department of Health regarding an allegation of abuse and initiated an investigation on (MONTH) 30, 2019. 3. The Assistant Director of Nursing (ADNS)/RN#1 was suspended pending an investigation on (MONTH) 30, 2019 by the DNS. 4. The Mississippi State Board of Nursing was notified on (MONTH) 31, 2019 related to the ADNS's abuse and neglect. 5. Medical Director was notified by the Director of Clinical Education on (MONTH) 30, 2019 at 4:30 PM. 6. Psychological Services consult was ordered by the Medical Director for Resident #1 to be evaluated and provide care for any mental anguish. The Social Worker called the Psychological Services on (MONTH) 30, 2019 at 4:45 PM. 7. Resident #1's responsible party was notified by the Administrator on (MONTH) 30, 2019 at 6:00 PM of the abuse allegation and the request for psychological services to evaluate Resident #1. 8. Alert and oriented residents were interviewed on (MONTH) 30, 2019 between 4:00-6:00 PM for any feelings of mental anguish or concerns with care by the Social Worker (SW) and Director of Clinical Operations (DCO), the Health Information Coordinator and the Director of Care Coordination with no other allegations of abuse. 9. The Administrator reported the allegation of abuse to the Attorney General's office on (MONTH) 30, 2019 at 4:24 PM. 10. The Administrator was suspended by the Vice President of Operations pending an investigation on (MONTH) 31, 2019 at 1:30 PM. 11. The local Police Department was notified 2:45 PM on (MONTH) 31, 2019. 12. Six (6) Registered Nurses (RN), Five (5) Licensed Practical Nurses (LPNs), 13 Certified Nursing Assistants (CNAs), 1 Workforce Manager, and 1 Social Service Coordinator (SSC), 1 Human Resources (HR), 1 Business Office Manager (BOM), 8 Therapy staff, 1 Maintenance staff, were educated by the Director of Clinical Education (DCE) beginning (MONTH) 30, 2019 at 3:30 PM on Abuse and Neglect, Reporting and Investigations, Residents Rights and Preferences, and Customer Service. 13. No employee will work until education is completed. 14. The Administrator was educated on (MONTH) 30, 2019 at 5:30 PM by the Senior Director of Clinical Operations on Abuse and Neglect, Reporting and Investigations, Residents' Rights and Preferences and Customer Service. 15. Quality Assurance Performance Improvement (QAPI) meeting was held on (MONTH) 30, 2019 at 5:30 PM. Systemic changes and monitoring were developed, presented and approved by Administrator (Adm), Director of Nursing Services (DNS), Nurse Consultant and Clinical Education Nurse, and Medical Director. Systemic changes include monthly education and orientation by the Administrator or Director of Clinical Education to all staff regarding Abuse and Neglect, Reporting and Investigation allegations of abuse, customer service and residents' rights. Grievances and/or allegations will be reviewed and investigated at Daily Stand up by the Adm/DNS/Designee with follow up as needed. The facility alleges that the Immediate Jeopardy is removed as of (MONTH) 1, 2020. The SA validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ: 1. The State Agency validated that Resident #1 was free from abuse and neglect that occurred on 11/21/19 when the Assistant Director of Nursing/Registered Nurse (RN) #1 would not place Resident #1 back to bed when she was crying and yelling in pain and the ADNS refused to allow the Certified Nurse Assistants (C.N.A) staff to assist the resident. The ADNS continued to practice in his role after the resident suffered from mental anguish, which caused psychosocial harm to Resident #1. The Administrator knew of the incident on 11/21/19 and failed to protect the resident by suspending the ADNS, thoroughly investigate the incident, or report the incident to the Mississippi State Department of Health within two hours of the allegation of abuse. 2. The SA validated through record review and interviews the Quality Assurance Performance Improvement (QAPI) meeting was held on (MONTH) 30, 2019 at 5:30 PM. Systemic changes and monitoring were developed, presented and approved by Administrator (Adm), Director of Nursing Services (DNS), Nurse Consultant and Clinical Education Nurse, and Medical Director. Systemic changes include monthly education and orientation by the Administrator or Director of Clinical Education to all staff regarding Abuse and Neglect, Reporting and Investigation allegations of abuse, customer service and residents' rights. Grievances and/or allegations will be reviewed and investigated at Daily Stand up by the Adm/DNS/Designee with follow up as needed. The systemic changes were discussed at the QAPI meeting at 5:30 PM. 3. The SA validated through interview the Administrator (ADM) called the MS State Department of Health regarding an allegation of abuse and initiated an investigation on (MONTH) 30, 2019. 4. The SA validated through documentation the Assistant Director of Nursing (ADNS) was suspended pending an investigation on (MONTH) 30, 2019 by the DNS. 5. The SA validated through documentation the Mississippi State Board of Nursing was notified on (MONTH) 31, 2019 related to the ADNS's abuse and neglect. 6. The SA validated through interview the Medical Director was notified by the Director of Clinical Education on (MONTH) 30, 2019 at 4:30 PM. 7. The SA validated though documentation the Psychological Services consult was ordered by the Medical Director for Resident #1 to be evaluated and provided care for any mental anguish. The Social Worker called the Psychological Services on (MONTH) 30, 2019 at 4:45 PM. 8. The SA validated through interview Resident #1's responsible party was notified by the Administrator on (MONTH) 30, 2019 at 6:00 PM of the abuse allegation and the request for psychological services to evaluate Resident #1. 9. The SA validated through documentation and interviews alert and oriented residents were interviewed on (MONTH) 30, 2019 between 4:00-6:00 PM for any feelings of mental anguish or concerns with care by the Social Worker (SW) and Director of Clinical Operations (DCO), the Health Information Coordinator and the Director of Care Coordination with no other allegations of abuse. 10. The SA validated through documentation the Administrator reported the allegation of abuse to the Attorney General's office on (MONTH) 30, 2019 at 4:24 PM. 11. The SA validated through documentation the Administrator was suspended by the Vice President of Operations pending an investigation on (MONTH) 31, 2019 at 1:30 PM. 12. The SA validated through documentation the local Police Department was notified at 2:45 PM on (MONTH) 31, 2019. 13. The SA validated through interviews with the Nursing, Dietary, Housekeeping, Social Services, Therapy, Business Office and Maintenance and through documentation beginning (MONTH) 30, 2019 at 3:30 PM there were in-services regarding Abuse and Neglect, Reporting and Investigations, Residents Rights and Preferences, and Customer Service being held. 14. The SA validated the Administrator was educated on (MONTH) 30, 2019 at 5:30 PM by the Senior Director of Clinical Operations on Abuse and Neglect, Reporting and Investigations, Residents' Rights and Preferences and Customer Service. The SA validated that all corrective actions were completed as of 12/31/19 and the IJ was removed as of 01/01/20.

MS CI # Based on record review, staff interview, professional standards, and facility policy review, the facility failed to follow professional standards when facility nurses allowed unlicensed student nurses to administer medications unsupervised for two (2) of nine (9) residents reviewed resulting in two residents receiving the wrong medications. (Resident #2 and Resident #3) The facility failed to ensure residents received the correct medications as ordered by the physician. Two residents received the wrong medication when student nurses administered medications unsupervised. The incident placed these two residents and other residents of the facility in a situation that was likely to cause serious injury, harm, impairment, or death. Based on the facility's corrective action initiated prior to the State Agency facility entrance on 12/9/14, the State Agency determined the Immediate Jeopardy to be Past Non-Compliance. Findings Include: Review of the facility's policy entitled, "Medication Administration-Preparation and General Guidelines", dated 05/12, revealed, "3) Medications are administered in accordance with written orders of the prescriber. 5) The person who prepares the dose for administration is the person who administers the dose. 6) Residents are identified before medication is administered. Methods of identification include: a. Checking photograph attached to medical record. b. Checking an identification band. c. Calling resident by name (except in residents with cognitive impairment). d. Having the resident verify his/her last name. e. Verify resident identification with other facility personnel. Review of the Mississippi Board of Nursing's letter entitled "Delegation", revised 03/19/2009, revealed "SCOPE OF PRACTICE, According to Chapter III of the Mississippi Board of Nursing Rules and Regulations... 2. Assign the duties of administration of patient medications to other licensed nurses only either a Registered Nurse or Licensed Practical Nurse... Tasks Not Appropriate for Delegation to Auxiliary Workers/ Unlicensed Personnel:Including, but not limited to...7. medication administration". Resident #2 Review of the facility's incident report related to the medication error on 11/27/14 at approximately 8:00 AM revealed the facility nursing staff, Licensed Practical Nurse (LPN) #1, allowed unlicensed student nurses to administer medications. The facility nurses punched out medications for residents, then handed the student nurse a cup containing the medications to administer. LPN #1 failed to supervise an unlicensed student nurse while Student Nurse #1 administered medications to residents. A medication error occurred when Resident #2 received Resident #1's medication. LPN #1, who was a preceptor for the student nurse, gave Student Nurse #1 a cup containing Resident #1's medications labeled with Resident #1's name to administer to the resident. Student Nurse #1 misidentified the resident and administered Resident #1's medications to Resident #2 while unsupervised. Medications given in error included [MEDICATION NAME] 25 mg (milligram), [MEDICATION NAME] 25 mg, [MEDICATION NAME] 2.5 mg and [MEDICATION NAME] 50 mg. Review of Resident #2's Medication Administration Record [REDACTED]. Interview with LPN #1, on 12/10/14 at 10:26 AM, confirmed she allowed Student Nurse #1 to pass medications unsupervised. LPN #1 confirmed she pulled up Resident #1's medications and labeled the medication cup with Resident #1's name. LPN #1 stated she let Student Nurse #1 take the medication into the resident's room and did not follow. Student Nurse #1 returned to the cart and stated Resident #2 received Resident #1's medication by mistake. Interview with Student Nurse #1 on 12/10/14 at 4:34 PM confirmed she administered Resident #1's medication to Resident #2 by mistake. The facility's failure to follow standard nursing practice lead to Resident #2 receiving Resident #1's medications. Record review of the Admission Record revealed the facility admitted Resident #2 on 10/24/14. Resident #2's [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date of 11/3/14 revealed a Brief Interview for Mental Status (BIMS) score of 15 that indicated the resident was cognitively intact. Resident #3 Review of a second facility incident report related to another medication error on 11/27/14 at 6:13 PM. This constituted a significant medication error. LPN #2 allowed unlicensed Student Nurse #2 to administer medications. LPN #2 punched out medications for the resident, then handed the Student Nurse #2 a cup containing the medications to administer. LPN #2 failed to supervise unlicensed Student Nurse #2 while Student Nurse #2 administered medications to residents. Student Nurse #2 administered Resident #4's medications to Resident #3 in error. Student Nurse #2 administered the medications to Resident #3 unsupervised and misidentified the resident. Medications given in error included [MEDICATION NAME] 8 mg, [MEDICATION NAME] 10/325 mg, [MEDICATION NAME] 100 mg and [MEDICATION NAME] 1 gram (GM). Interview on 12/10/2014 with LPN #2 confirmed on 11/27/2014 Student Nurse #2 administered Resident #4's medications to Resident #3. The facility nurse (LPN #2) failed to follow standard nursing practice by allowing an unlicensed student nurse to administer resident medications unsupervised. This led to Resident #3 receiving Resident #4's medications. Record review revealed the facility admitted Resident #3 on 12/22/13. Resident #3's [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment reference date of 09/09/2014 revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete the interview. Staff Assessment of Cognitive skills for daily decision making revealed the resident was moderately impaired. The Corrective Action Plan implemented by the facility prior to the State Agency's facility entrance on 12/9/14 was: 1. The facility's investigation revealed on 11/27/2014 at 8:00 AM, Facility Nurse #1 and Student Nurse #1 were on C-hall administering AM medications. During medication pass Facility Nurse #1 was pulling up AM medications, with Student Nurse #1 assisting in verifying medications. Nurse #1 set up AM medications for Resident #1, after verifying medications, the Student Nurse #1 assured Nurse #1 that she knew who Resident #1 was. Student Nurse #1 administered the medications to the wrong resident, Resident #2. Student Nurse #1 immediately realized she had made an error and informed Facility Nurse #1 of the error. Medications given in error included [MEDICATION NAME] 25 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 2.5 mg, and [MEDICATION NAME] 50 mg. Student nurse #1 was not allowed to give medications without supervision after medication error occurred. The physician was notified on 11/27/14 at 8:40 AM. The resident was aware of the medication error at 9:45 AM on 11/27/14. He was cognitively intact and acted as his on responsible party. 2. On 11/27/14 at 6:13 PM, Facility Nurse #2 and Student Nurse #2 were administering medications. Resident #3 received the wrong evening medications from Student Nurse #2 when Resident #4, with the same last name as Resident #3, requested her medications. The medications given in error included [MEDICATION NAME] 8 mg, [MEDICATION NAME] 10/325 mg, [MEDICATION NAME] 100 mg, and [MEDICATION NAME] 1 gram. Student Nurse #2 was not allowed to give any more medications after error occurred. The Physician was notified on 11/27/14 at 6:20 PM. The responsible party was notified on 11/27/14 at 6:40 PM. 3. The Director of Nursing Services and Field Service Clinical Director reviewed facility policies including Proper Medications Administration and Critical Events on 11/28/2014 prior to the in service for all nursing staff. No revisions to the policies were necessary. 4. On 11/27/2014, Resident #2 displayed no signs of adverse reactions related to receiving wrong medications. Resident #3 displayed no s/s of adverse reactions r/t receiving wrong medications. 5. On 11/28/2014 at 9:00 AM, the Executive Director/Director of Nursing were notified of the medication errors. 6. On 11/28/2014 at 9:15 AM, Facility Director of Clinical Education began immediate in-services on management of nursing students/medication administration and abuse and neglect and immediate notification of the executive Director/Director of Nursing Services for medication errors. ***No staff were allowed to work until in-serviced.*** 7. On 11/28/2014 at 10:00 AM, Facility Nurse #3 checked [MEDICATION NAME] Time/International Normalized Ratio for Resident #3 with results of 12.8/1.1 that were within normal limits. The physician gave no new orders. 8. At 10:10 AM on 11/28/2014, Facility scheduler contacted facility Nurse #2 to come in for interview by Executive/Director of Nursing Services/Assistant Director of Nursing Services. Scheduler also attempted to contact facility Nurse #1 to come in for an interview. Message left to return call. 9. At 10:30 AM on 11/28/2014, Facility Director of Nursing Services contacted medical director, who was on vacation, via phone to notify of medication errors and initiate a phone Quality Assurance and Performance Improvement meeting. 10. On 11/28/2014 at 10:41 AM, Facility Nurse #3 notified [MEDICAL TREATMENT] nurse #1 of medication error that occurred on previous day for resident #3. [MEDICAL TREATMENT] nurse verbalized that she would continue to monitor while at [MEDICAL TREATMENT] also for any complications. She stated that they would cut her [MEDICATION NAME] dose today with her [MEDICAL TREATMENT] treatment. 11. On 11/28/2014 at 11:00 AM, Facility Executive Director notified the Community College Nursing instructor of incident. Nursing students removed from building. Contract suspended with school of nursing until investigation complete. Meeting scheduled with nursing instructors for 12/01/2014 at 10:00 AM. 12. On 11/28/2014 at 11:28 am, Facility Nurse #2 arrived at building. Medication competency initiated by facility Director of Clinical Education. After completion of medication competency, Facility Nurse #2 met with Executive Director, Director of Nursing Service, and Assistant Director of Nursing Service. After providing a statement, the facility decided to suspend Facility Nurse #2 until the investigation completed for 2.1-Failure to perform assigned duties in an appropriate manner and 2.2-Poor work quality or productivity. 13. On 11/28/2014, the State Department of Health was notified of medication errors via complaint hotline at 1:19 PM. 14. On 11/28/2014 at 2:15 PM, Facility Nurse #1 returned call. Facility nurse #1 arrived at building 3:05 PM. Medication competency initiated by facility director of clinical education. After completion of the medication competency, Facility Nurse #1 met with Executive Director, Director of Nursing Service, and Assistant Director of Nursing Service. After Facility Nurse #1 provided her statement, she was placed on suspension until investigation was complete for 2.1-Failure to perform assigned duties in appropriate manner and 2.2-Poor work quality or productivity. 15. On 11/28/2014, the Attorney General's office was notified of medication errors via e-form for Resident #3 at 1:37 PM and Resident #2 at 3:34 PM. 16. On 11/28/2014 at 4:30 PM, Facility Director of Nursing Service and Facility Director of Clinical Education audited 100% of residents' charts who were administered medications by the nursing students with no additional negative findings. 17. On 11/28/2014, Resident #2 displayed no signs and symptoms (s/s) of adverse reactions related to receiving wrong medications. Resident #3 displayed no s/s of adverse reactions of receiving wrong medications. 18. On 11/29/14 at 10:00 AM, Facility Nurse #4 checked [MEDICATION NAME] Time/International Normalized Ratio for Resident #3 with results of 19.2/1.6 and within normal limits. The on-call physician was notified of results with no new orders given. No active bleeding , bruising, tarry stools, or any other changes in condition. 19. On 11/29/2014 at 11:30 AM, the facility notified the Consulting Pharmacist by facility Director of Nursing Services of medication errors. Pharmacist visited facility on 12/01/2014. 20. On 11/29/2014 at 2:00 PM, Facility Nurse #4 completed 100% audit of all residents receiving [MEDICATION NAME] therapy with no negative findings. 21. On 11/29/2014 3-11/11-7 shifts, Resident #2 displayed no signs and symptoms of adverse reactions related to receiving wrong medications. Resident #3 displayed no adverse reactions related to receiving wrong medications. 22. On 11/30/2014 at 9:45 AM, Facility Nurse #4 checked [MEDICATION NAME] Time/International Normalized Ratio for Resident #3 with results of 16.1/1.3 within normal limits, on-call physician notified with no new orders given, No active bleeding, bruising, tarry stools, or any other changes in condition 23. On 11/30/2014 3-11/11-7 shifts, Resident #2 displayed no signs and symptoms of adverse reactions related to receiving wrong medications. Resident #3 displayed no signs and symptoms of adverse reactions related to receiving wrong medications. 24. On 12/01/2014 at 10:00 AM, a meeting held with Facility Executive Director, Facility Director of Nursing Services, Facility Nurse consultant, and Community College Instructor #1 and Instructor #2. 25. On 12/01/2014 at 10:00 AM, Consultant pharmacist reviewed Resident #2 and Resident #3 record with no new recommendations and no negative findings. 26. On 2/01/2014 at 10:00 AM, the contract with school of nursing remained suspended and under review by Golden Living Corporate Legal Department to ensure the relationships and duties of the parties, including student supervision, were clearly enumerated and allow the facility to ensure a safe environment for residents at all times. 27. Quality Assurance Performance Improvement meeting held on 12/01/2014 at 1:30 PM with the Facility Medical Director, the Facility Executive Director, the Facility Director of Nursing Services, the Field Service Clinical Director and the Facility Assistant Director of Nursing Services in attendance. The Quality Assurance Performance Improvement meeting summary included, measures to assure the nursing school instructors always accompany nursing students when in the building, requiring nursing school instructors to be accountable and provide oversight of all nursing students, facility nurses will neither be responsible nor precept future nursing students, notification of facility administrative staff immediately of critical incidents, necessity to follow standards of practice with medication administration ,submission of nursing school contract to company legal team for review and revision to protect the health and safety of our residents. After errors, the Director of Nurses will monitor medication administration on various shifts with various nurses weekly for four weeks to assure nurses were not delegating medication administration to unlicensed personnel. All negative findings will be corrected immediately and reported to Quality Assurance and Performance Improvement for root cause analysis. All medication errors will be monitored for trending. 28. On 12/01/2014, the facility noted no negative outcomes related to medication errors with either Resident #2 or Resident #3 29. On 12/01/2014, the Board of Nursing was notified via phone at 3:57 PM. 30. On 12/01/2014 at 4:30 pm, Facility Nurse #1 and Facility Nurse #2 were both in-serviced on management of nursing student/medication administration, abuse/neglect. Both were also coached on notification of supervisor, Director of Nursing Services, Executive Director of all medication errors. After completion of training both nurses were reinstated. 31. On 12/02/2014, after all corrective actions had been implemented, the facility believed the jeopardy was removed. The State Agency validated the facility's corrective action on 12/12/2014. 1. The State Agency (SA) validated the facility's investigation of the medication errors on 11/27/14 by record review and interviews. 2. The SA verified by interview with the Director of Nursing Services and the Field Service Clinical Director that the policies for proper medication administration and critical events were reviewed on 11/28/2014 with no changes. 3. The SA validated by record review of nurses notes that the facility assessed Resident #2 and Resident #3 from 11/27/14 through 12/2/14 for signs and symptoms of adverse effects related to the medication errors. The SA verified through documentation of nurses that Resident #2 and Resident #3 showed no signs and symptoms of adverse reactions. 4. The SA validated the Executive Director and the Director of Nursing were notified of the medication errors on 11/28/2014 at 9:00 AM. 5. The SA surveyor validated by interview with the Director of Clinical Education that staff in-services began on 11/28/14. Review of the in-service content and signature sheet validated the facility in-serviced the nursing staff on management of nursing students, medication administration, abuse and neglect, and immediate notification of the Executive Director and the Director of Nursing Services for medication errors. 6. The SA validated by record review that the facility obtained [MEDICATION NAME] Times (PT) and International Normalization Ratios (INR) for Resident #3. Review of the lab report confirmed the results were within normal limits, and the physician gave no new orders. 7. The SA validated that the Director of Nursing Services contacted the Medical Director regarding the medication errors and initiated a Quality Assurance and Performance Improvement meeting. 8. The SA validated by interview with Nurse #3 and record review of written documentation that Facility Nurse #3 notified [MEDICAL TREATMENT] Nurse #1 of the medication error with Resident #3 on 11/28/14. 9. The SA verified by interview with the facility's Executive Director that on 11/28/14, the facility notified the instructor at the Community College of the medication error on 11/27/14, and that the facility required removal of the nursing students from the building on 11/28/14. Interview with the Executive Director verified suspension of the contract with the Community College and the facility held a meeting with the Community College instructors of the student nurses on 12/01/2014. 10. Upon review of the Medication Administration Competency Tests administered by the facility, the SA validated Facility Nurse #1 and Facility Nurse #2 passed the test. The SA verified by review of the employee files that Facility Nurse #2 was suspended following the incident. 11. The SA verified the facility notified the Department of Health of the medication errors via Hotline on 11/28/2014. 12. The SA verified the facility notified the Attorney General's office on 11/28/2014 via E form of the medication errors. 13. Interview with the Director of Clinical Education validated a 100% audit of residents who received medications. 14. The SA verified with facility Consultant Pharmacist that notification was made of the medication errors for Resident #2 and Resident #3. The SA verified the Pharmacist visited the facility on 12/01/2014. 15. The SA verified by record review that the facility conducted a 100% audit of all residents on [MEDICATION NAME] with no negative findings documented. 16. The SA verified a meeting on 12/01/2014 with the facility's Executive Director, the facility's Director of Nursing Services, the facility's Nurse Consultant, and the Community College Instructors #1 and #2 by interview with the facility's Executive Director. 17. Interview with the Consultant Pharmacist confirmed the pharmacist reviewed Resident #2 and Resident #3's medical records with no negative findings. 18. The SA verified by record review that the facility held a Quality Assurance Performance Improvement meeting on 12/01/2014. The SA verified by interviews and checklist reviews that medication administration was monitored on different shifts. 19. The SA validated by review of the documentation that the facility notified the Board of Nursing of the medication errors on 12/01/2014. 20. Interview and record review by the SA verified Facility Nurse #1 and Facility Nurse #2 were in-serviced on management of nursing students, abuse and neglect, medication administration, and notification of nursing administration regarding medication errors. The facility reinstated both nurses. The SA identified the Immediate Jeopardy and Substandard Quality of Care as Past Non-Compliance beginning 11/27/14 through 12/1/14. The facility provided sufficient evidence to show the facility corrected the non-compliance and was in substantial compliance with regulatory requirements as of 12/2/14 prior to the SA entering the facility on 12/9/14.

MS CI # Based on record review, care plan review, staff interview, and facility policy review, the facility failed to ensure care plans were implemented for administration of the correct medication for two (2) of nine(9) residents reviewed. (Resident # 2 and Resident #3). On 11/27/14 at approximately 8:00 AM and again on 11/27/14 at 6:13 PM, the facility nursing staff, Licensed Practical Nurse (LPN) #1 and LPN #2, failed to follow the residents' care plans by allowing nursing students to administer wrong medications to residents. The facility failed to ensure residents received the correct medications as ordered by the physician. Two residents received the wrong medication when student nurses administered medications unsupervised. The incident placed these two residents and other residents of the facility in a situation that was likely to cause serious injury, harm, impairment, or death. Based on the facility's corrective action initiated prior to the State Agency facility entrance on 12/9/14, the State Agency determined the Immediate Jeopardy to be Past Non-Compliance. Findings include: Review of the facility policy entitled, "RAI (Resident Assessment Instrument) Process," dated 11/13/2013, revealed, "Adhere to all CMS regulations which are considered the definitive source in completion of the RAI process. This includes coding the MDS, completion of the care area assessments (CAA's) and the development of the comprehensive plan of care." Resident #2 Review of Resident #2's care plans revealed a care plan with a focus area for potential adverse drug reactions", initiated 11/3/14, listed an intervention, dated 10/25/14, for "Medication as ordered and observe use and effect." Record review of the facility incident report revealed the facility failed to follow the care plan intervention to administer medications as ordered by the physician. Review of the facility's 11/28/14 incident report revealed on 11/27/14 at approximately 8:00 AM, Resident #2 received Resident #1's medications in error. Nurse #1 handed Student Nurse #1 a cup labeled with Resident #1's name. Student Nurse #1 then misidentified Resident #2 and administered Resident #1's medication to Resident #2. This occurred without supervision of Nurse #1, the preceptor. The report listed medications given in error as [MEDICATION NAME] 25 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 2.5 mg and [MEDICATION NAME] 50 mg. Interview with the Assistant Director of Nurses (ADON) on 12/12/14 at 4:30 PM, confirmed documentation to administer medications as ordered was on the resident's care plans. Record review revealed the facility admitted Resident #2 on 10/24/14. Resident #2's [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date of 11/3/14 revealed a Brief Interview for Mental Status (BIMS) score of 15 that indicated the resident was cognitively intact. Resident #3 Review of Resident #3's care plans revealed a care plan with a focus area for "risk for drug related complications", initiated 9/9/14, listed an intervention, dated 6/11/14, for "Provide medications as ordered by physician and evaluate for effectiveness and side effect." Review of the incident report prepared by the facility and dated 11/28/14 revealed the facility failed to follow the care plan intervention to administer medications as ordered by the physician. Review of the typed facility report, dated 11/28/14, revealed on 11/27/14 at 6:13 PM, Student Nurse #2 administered Resident #4's medications to Resident #3 in error while unsupervised by the facility Nurse Preceptor (LPN #2). Medications given in error included [MEDICATION NAME] 8 mg, [MEDICATION NAME] 10/325 mg, [MEDICATION NAME] 100 mg, and [MEDICATION NAME] 1 gram (GM). Record review revealed the facility admitted Resident #3 on 12/22/13. Resident #3's [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment reference date of 09/09/2014 revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete the interview. Staff Assessment of Cognitive skills for daily decision making revealed the resident was moderately impaired. The Corrective Action Plan implemented by the facility prior to the State Agency's facility entrance on 12/9/14 was: 1. The facility's investigation revealed on 11/27/2014 at 8:00 AM, Facility Nurse #1 and Student Nurse #1 were on C-hall administering AM medications. During medication pass Facility Nurse #1 was pulling up AM medications, with Student Nurse #1 assisting in verifying medications. Nurse #1 set up AM medications for Resident #1, after verifying medications, the Student Nurse #1 assured Nurse #1 that she knew who Resident #1 was. Student Nurse #1 administered the medications to the wrong resident, Resident #2. Student Nurse #1 immediately realized she had made an error and informed Facility Nurse #1 of the error. Medications given in error included [MEDICATION NAME] 25 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 2.5 mg, and [MEDICATION NAME] 50 mg. Student nurse #1 was not allowed to give medications without supervision after medication error occurred. The physician was notified on 11/27/14 at 8:40 AM. The resident was aware of the medication error at 9:45 AM on 11/27/14. He was cognitively intact and acted as his on responsible party. 2. On 11/27/14 at 6:13 PM, Facility Nurse #2 and Student Nurse #2 were administering medications. Resident #3 received the wrong evening medications from Student Nurse #2 when Resident #4, with the same last name as Resident #3, requested her medications. The medications given in error included [MEDICATION NAME] 8 mg, [MEDICATION NAME] 10/325 mg, [MEDICATION NAME] 100 mg, and [MEDICATION NAME] 1 gram. Student Nurse #2 was not allowed to give any more medications after error occurred. The Physician was notified on 11/27/14 at 6:20 PM. The responsible party was notified on 11/27/14 at 6:40 PM. 3. The Director of Nursing Services and Field Service Clinical Director reviewed facility policies including Proper Medications Administration and Critical Events on 11/28/2014 prior to the in service for all nursing staff. No revisions to the policies were necessary. 4. On 11/27/2014, Resident #2 displayed no signs of adverse reactions related to receiving wrong medications. Resident #3 displayed no s/s of adverse reactions r/t receiving wrong medications. 5. On 11/28/2014 at 9:00 AM, the Executive Director/Director of Nursing were notified of the medication errors. 6. On 11/28/2014 at 9:15 AM, Facility Director of Clinical Education began immediate in-services on management of nursing students/medication administration and abuse and neglect and immediate notification of the executive Director/Director of Nursing Services for medication errors. ***No staff were allowed to work until in-serviced.*** 7. On 11/28/2014 at 10:00 AM, Facility Nurse #3 checked [MEDICATION NAME] Time/International Normalized Ratio for Resident #3 with results of 12.8/1.1 that were within normal limits. The physician gave no new orders. 8. At 10:10 AM on 11/28/2014, Facility scheduler contacted facility Nurse #2 to come in for interview by Executive/Director of Nursing Services/Assistant Director of Nursing Services. Scheduler also attempted to contact facility Nurse #1 to come in for an interview. Message left to return call. 9. At 10:30 AM on 11/28/2014, Facility Director of Nursing Services contacted medical director, who was on vacation, via phone to notify of medication errors and initiate a phone Quality Assurance and Performance Improvement meeting. 10. On 11/28/2014 at 10:41 AM, Facility Nurse #3 notified [MEDICAL TREATMENT] nurse #1 of medication error that occurred on previous day for resident #3. [MEDICAL TREATMENT] nurse verbalized that she would continue to monitor while at [MEDICAL TREATMENT] also for any complications. She stated that they would cut her [MEDICATION NAME] dose today with her [MEDICAL TREATMENT] treatment. 11. On 11/28/2014 at 11:00 AM, Facility Executive Director notified the Community College Nursing instructor of incident. Nursing students removed from building. Contract suspended with school of nursing until investigation complete. Meeting scheduled with nursing instructors for 12/01/2014 at 10:00 AM. 12. On 11/28/2014 at 11:28 am, Facility Nurse #2 arrived at building. Medication competency initiated by facility Director of Clinical Education. After completion of medication competency, Facility Nurse #2 met with Executive Director, Director of Nursing Service, and Assistant Director of Nursing Service. After providing a statement, the facility decided to suspend Facility Nurse #2 until the investigation completed for 2.1-Failure to perform assigned duties in an appropriate manner and 2.2-Poor work quality or productivity. 13. On 11/28/2014, the State Department of Health was notified of medication errors via complaint hotline at 1:19 PM. 14. On 11/28/2014 at 2:15 PM, Facility Nurse #1 returned call. Facility nurse #1 arrived at building 3:05 PM. Medication competency initiated by facility director of clinical education. After completion of the medication competency, Facility Nurse #1 met with Executive Director, Director of Nursing Service, and Assistant Director of Nursing Service. After Facility Nurse #1 provided her statement, she was placed on suspension until investigation was complete for 2.1-Failure to perform assigned duties in appropriate manner and 2.2-Poor work quality or productivity. 15. On 11/28/2014, the Attorney General's office was notified of medication errors via e-form for Resident #3 at 1:37 PM and Resident #2 at 3:34 PM. 16. On 11/28/2014 at 4:30 PM, Facility Director of Nursing Service and Facility Director of Clinical Education audited 100% of residents' charts who were administered medications by the nursing students with no additional negative findings. 17. On 11/28/2014 , Resident #2 displayed no signs and symptoms (s/s) of adverse reactions related to receiving wrong medications. Resident #3 displayed no s/s of adverse reactions of receiving wrong medications. 18. On 11/29/14 at 10:00 AM, Facility Nurse #4 checked [MEDICATION NAME] Time/International Normalized Ratio for Resident #3 with results of 19.2/1.6 and within normal limits. The on-call physician was notified of results with no new orders given. No active bleeding , bruising, tarry stools, or any other changes in condition. 19. On 11/29/2014 at 11:30 AM, the facility notified the Consulting Pharmacist by facility Director of Nursing Services of medication errors. Pharmacist visited facility on 12/01/2014. 20. On 11/29/2014 at 2:00 PM, Facility Nurse #4 completed 100% audit of all residents receiving [MEDICATION NAME] therapy with no negative findings. 21. On 11/29/2014 3-11/11-7 shifts, Resident #2 displayed no signs and symptoms of adverse reactions related to receiving wrong medications. Resident #3 displayed no adverse reactions related to receiving wrong medications. 22. On 11/30/2014 at 9:45 AM, Facility Nurse #4 checked [MEDICATION NAME] Time/International Normalized Ratio for Resident #3 with results of 16.1/1.3 within normal limits, on-call physician notified with no new orders given, No active bleeding, bruising, tarry stools, or any other changes in condition 23. On 11/30/2014 3-11/11-7 shifts, Resident #2 displayed no signs and symptoms of adverse reactions related to receiving wrong medications. Resident #3 displayed no signs and symptoms of adverse reactions related to receiving wrong medications. 24. On 12/01/2014 at 10:00 AM, a meeting held with Facility Executive Director, Facility Director of Nursing Services, Facility Nurse consultant, and Community College instructor #1 and instructor #2. 25. On 12/01/2014 at 10:00 AM, Consultant pharmacist reviewed Resident #2 and Resident #3 record with no new recommendations and no negative findings. 26. On 12/01/2014 at 10:00 AM, the contract with school of nursing remained suspended and under review by Golden Living Corporate Legal Department to ensure the relationships and duties of the parties, including student supervision, were clearly enumerated and allow the facility to ensure a safe environment for residents at all times. 27. Quality Assurance Performance Improvement meeting held on 12/01/2014 at 1:30 PM with the Facility Medical Director, the Facility Executive Director, the Facility Director of Nursing Services, the Field Service Clinical Director and the Facility Assistant Director of Nursing Services in attendance. The Quality Assurance Performance Improvement meeting summary included, measures to assure the nursing school instructors always accompany nursing students when in the building, requiring nursing school instructors to be accountable and provide oversight of all nursing students, facility nurses will neither be responsible nor precept future nursing students, notification of facility administrative staff immediately of critical incidents, necessity to follow standards of practice with medication administration ,submission of nursing school contract to company legal team for review and revision to protect the health and safety of our residents. After errors, the Director of Nurses will monitor medication administration on various shifts with various nurses weekly for four weeks to assure nurses were not delegating medication administration to unlicensed personnel. All negative findings will be corrected immediately and reported to Quality Assurance and Performance Improvement for root cause analysis. All medication errors will be monitored for trending. 28. On 12/01/2014, the facility noted no negative outcomes related to medication errors with either Resident #2 or Resident #3. 29. On 12/01/2014 The Board of Nursing was notified via phone at 3:57 PM. 30. On 12/01/2014 at 4:30 pm, Facility Nurse #1 and Facility Nurse #2 were both in-serviced on management of nursing student/medication administration, abuse/neglect. Both were also coached on notification of supervisor, Director of Nursing Services, Executive Director of all medication errors. After completion of training both nurses were reinstated. 31. On 12/02/2014 after all corrective actions had been implemented, the facility believed the jeopardy was removed. The State Agency validated the facility's corrective action on 12/12/2014. 1. The State Agency (SA) validated the facility's investigation of the medication errors on 11/27/14 by record review and interviews. 2. The SA verified by interview with the Director of Nursing Services and the Field Service Clinical Director that the policies for proper medication administration and critical events were reviewed on 11/28/2014 with no changes. 3. The SA validated by record review of nurses notes that the facility assessed Resident #2 and Resident #3 from 11/27/14 through 12/2/14 for signs and symptoms of adverse effects related to the medication errors. The SA verified through documentation of nurses that Resident #2 and Resident #3 showed no signs and symptoms of adverse reactions. 4. The SA validated the Executive Director and the Director of Nursing were notified of the medication errors on 11/28/2014 at 9:00 AM. 5. The SA surveyor validated by interview with the Director of Clinical Education that staff in-services began on 11/28/14. Review of the in-service content and signature sheet validated the facility in-serviced the nursing staff on management of nursing students, medication administration, abuse and neglect, and immediate notification of the Executive Director and the Director of Nursing Services for medication errors. 6. The SA validated by record review that the facility obtained [MEDICATION NAME] Times (PT) and International Normalization Ratios (INR) for Resident #3. Review of the lab report confirmed the results were within normal limits, and the physician gave no new orders. 7. The SA validated that the Director of Nursing Services contacted the Medical Director regarding the medication errors and initiated a Quality Assurance and Performance Improvement meeting. 8. The SA validated by interview with Nurse #3 and record review of written documentation that Facility Nurse #3 notified [MEDICAL TREATMENT] Nurse #1 of the medication error with Resident #3 on 11/28/14. 9. The SA verified by interview with the facility's Executive Director that on 11/28/14, the facility notified the instructor at the Community College of the medication error on 11/27/14, and that the facility required removal of the nursing students from the building on 11/28/14. Interview with the Executive Director verified suspension of the contract with the Community College and the facility held a meeting with the Community College instructors of the student nurses on 12/01/2014. 10. Upon review of the Medication Administration Competency Tests administered by the facility, the SA validated Facility Nurse #1 and Facility Nurse #2 passed the test. The SA verified by review of the employee files that Facility Nurse #2 was suspended following the incident. 11. The SA verified the facility notified the Department of Health of the medication errors via Hotline on 11/28/2014. 12. The SA verified the facility notified the Attorney General's office on 11/28/2014 via E form of the medication errors. 13. Interview with the Director of Clinical Education validated a 100% audit of residents who received medications. 14. The SA verified with facility Consultant Pharmacist that notification was made of the medication errors for Resident #2 and Resident #3. The SA verified the Pharmacist visited the facility on 12/01/2014. 15. The SA verified by record review that the facility conducted a 100% audit of all residents on [MEDICATION NAME] with no negative findings documented. 16. The SA verified a meeting on 12/01/2014 with the facility's Executive Director, the facility's Director of Nursing Services, the facility's Nurse Consultant, and the Community College Instructors #1 and #2 by interview with the facility's Executive Director. 17. Interview with the Consultant Pharmacist confirmed the pharmacist reviewed Resident #2 and Resident #3's medical records with no negative findings. 18. The SA verified by record review that the facility held a Quality Assurance Performance Improvement meeting on 12/01/2014. The SA verified by interviews and checklist reviews that medication administration was monitored on different shifts. 19. The SA validated by review of the documentation that the facility notified the Board of Nursing of the medication errors on 12/01/2014. 20. Interview and record review by the SA verified Facility Nurse #1 and Facility Nurse #2 were in-serviced on management of nursing students, abuse and neglect, medication administration, and notification of nursing administration regarding medication errors. The facility reinstated both nurses. The SA identified the Immediate Jeopardy and Substandard Quality of Care as Past Non-Compliance beginning 11/27/14 through 12/1/14. The facility provided sufficient evidence to show the facility corrected the non-compliance and was in substantial compliance with regulatory requirements as of 12/2/14 prior to the SA entering the facility on 12/9/14.

MS CI # Based on record review, facility investigation review, staff interview, and facility policy review, the facility failed to remain free of significant medication errors for one (1) of nine (9) residents reviewed as evidenced by Resident #3 received a blood thinner and a narcotic that was not prescribed for the resident. (Resident #3) On 11/27/2014 at 6:13 PM during medication pass, Resident #3 received Resident #4's medications when a student nurse administered the medications in error. Licensed Practical Nurse (LPN) #2 gave Resident #4's medication to Student Nurse #2 to administer to the resident. While administering the medications, unsupervised, Student Nurse #2 administered the medications to Resident #3 instead of Resident #4 as ordered. The medications given in error included [MEDICATION NAME] 8 milligrams (mg), [MEDICATION NAME] 10/325 mg, [MEDICATION NAME] 100 mg and [MEDICATION NAME] 1 gram (GM). The incident placed this resident and other residents of the facility in a situation that was likely to cause serious injury, harm, impairment, or death. Based on the facility's corrective action initiated prior to the State Agency facility entrance on 12/9/14, the State Agency determined Immediate Jeopardy and Substandard Quality of Care to be Past Non-Compliance. Findings Include: Review of the facility's policy entitled "Medication Administration-General Guidelines", dated 05/12, revealed, "Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly orientated to the medication management system in the facility." Review of the facility's investigation revealed, on 11/27/2014 Resident #3 received another resident's evening medications. Student Nurse #2 administered Resident #4's medication to Resident #3. The medications administered in error included [MEDICATION NAME] (blood thinner) 8 mg, [MEDICATION NAME] (narcotic pain medication)10/325 mg, [MEDICATION NAME] (stool softener) 100 mg, and [MEDICATION NAME] (stomach ulcer medication) 1 gram. Interview on 12/10/14 with LPN #2 confirmed that on 11/27/14 Student Nurse #2 administered Resident #4's medications to Resident #3. A written statement from Student Nurse #2, dated 12/1/14, acknowledged Resident #3 did receive Resident #4's medications in error. Review of Resident #3's physician's orders [REDACTED]., [MEDICATION NAME] 20 mg one at bedtime, [MEDICATION NAME] 5 ml two times daily. Record review revealed the facility admitted Resident #3 on 12/22/13. [DIAGNOSES REDACTED]. Review of the latest Minimum Data Set with an Assessment Reference Date (ARD) of 09/09/14 indicated Resident #3 was moderately impaired in the staff assessment of cognitive skills for daily decision making. The Corrective Action Plan implemented by the facility prior to the State Agency's facility entrance on 12/9/14 was: 1. The facility's investigation revealed on 11/27/2014 at 8:00 AM, Facility Nurse #1 and Student Nurse #1 were on C-hall administering AM medications. During medication pass Facility Nurse #1 was pulling up AM medications, with Student Nurse #1 assisting in verifying medications. Nurse #1 set up AM medications for Resident #1, after verifying medications, the Student Nurse #1 assured Nurse #1 that she knew who Resident #1 was. Student Nurse #1 administered the medications to the wrong resident, Resident #2. Student Nurse #1 immediately realized she had made an error and informed Facility Nurse #1 of the error. Medications given in error included [MEDICATION NAME] 25 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 2.5 mg, and [MEDICATION NAME] 50 mg. Student nurse #1 was not allowed to give medications without supervision after medication error occurred. The physician was notified on 11/27/14 at 8:40 AM. The resident was aware of the medication error at 9:45 AM on 11/27/14. He was cognitively intact and acted as his on responsible party. 2. On 11/27/14 at 6:13 PM, Facility Nurse #2 and Student Nurse #2 were administering medications. Resident #3 received the wrong evening medications from Student Nurse #2 when Resident #4, with the same last name as Resident #3, requested her medications. The medications given in error included [MEDICATION NAME] 8 mg, [MEDICATION NAME] 10/325 mg, [MEDICATION NAME] 100 mg, and [MEDICATION NAME] 1 gram. Student Nurse #2 was not allowed to give any more medications after error occurred. The Physician was notified on 11/27/14 at 6:20 PM. The responsible party was notified on 11/27/14 at 6:40 PM. 3. The Director of Nursing Services and Field Service Clinical Director reviewed facility policies including Proper Medications Administration and Critical Events on 11/28/2014 prior to the in service for all nursing staff. No revisions to the policies were necessary. 4. On 11/27/2014, Resident #2 displayed no signs of adverse reactions related to receiving wrong medications. Resident #3 displayed no s/s of adverse reactions r/t receiving wrong medications. 5. On 11/28/2014 at 9:00 AM, the Executive Director/Director of Nursing were notified of the medication errors. 6. On 11/28/2014 at 9:15 AM, Facility Director of Clinical Education began immediate in-services on management of nursing students/medication administration and abuse and neglect and immediate notification of the executive Director/Director of Nursing Services for medication errors. ***No staff were allowed to work until in-serviced.*** 7. On 11/28/2014 at 10:00 AM, Facility Nurse #3 checked [MEDICATION NAME] Time/International Normalized Ratio for Resident #3 with results of 12.8/1.1 that were within normal limits. The physician gave no new orders. 8. At 10:10 AM on 11/28/2014, Facility scheduler contacted facility Nurse #2 to come in for interview by Executive/Director of Nursing Services/Assistant Director of Nursing Services. Scheduler also attempted to contact facility Nurse #1 to come in for an interview. Message left to return call. 9. At 10:30 AM on 11/28/2014, Facility Director of Nursing Services contacted medical director, who was on vacation, via phone to notify of medication errors and initiate a phone Quality Assurance and Performance Improvement meeting. 10. On 11/28/2014 at 10:41 AM, Facility Nurse #3 notified [MEDICAL TREATMENT] nurse #1 of medication error that occurred on previous day for resident #3. [MEDICAL TREATMENT] nurse verbalized that she would continue to monitor while at [MEDICAL TREATMENT] also for any complications. She stated that they would cut her [MEDICATION NAME] dose today with her [MEDICAL TREATMENT] treatment. 11. On 11/28/2014 at 11:00 AM, Facility Executive Director notified the Community College Nursing instructor of incident. Nursing students removed from building. Contract suspended with school of nursing until investigation complete. Meeting scheduled with nursing instructors for 12/01/2014 at 10:00 AM. 12. On 11/28/2014 at 11:28 am, Facility Nurse #2 arrived at building. Medication competency initiated by facility Director of Clinical Education. After completion of medication competency, Facility Nurse #2 met with Executive Director, Director of Nursing Service, and Assistant Director of Nursing Service. After providing a statement, the facility decided to suspend Facility Nurse #2 until the investigation completed for 2.1-Failure to perform assigned duties in an appropriate manner and 2.2-Poor work quality or productivity. 13. On 11/28/2014, the State Department of Health was notified of medication errors via complaint hotline at 1:19 PM. 14. On 11/28/2014 at 2:15 PM, Facility Nurse #1 returned call. Facility nurse #1 arrived at building 3:05 PM. Medication competency initiated by facility director of clinical education. After completion of the medication competency, Facility Nurse #1 met with Executive Director, Director of Nursing Service, and Assistant Director of Nursing Service. After Facility Nurse #1 provided her statement, she was placed on suspension until investigation was complete for 2.1-Failure to perform assigned duties in appropriate manner and 2.2-Poor work quality or productivity. 15. On 11/28/2014, the Attorney General's office was notified of medication errors via e-form for Resident #3 at 1:37 PM and Resident #2 at 3:34 PM. 16. On 11/28/2014 at 4:30 PM, Facility Director of Nursing Service and Facility Director of Clinical Education audited 100% of residents' charts who were administered medications by the nursing students with no additional negative findings. 17. On 11/28/2014 , Resident #2 displayed no signs and symptoms (s/s) of adverse reactions related to receiving wrong medications. Resident #3 displayed no s/s of adverse reactions of receiving wrong medications. 18. On 11/29/14 at 10:00 AM, Facility Nurse #4 checked [MEDICATION NAME] Time/International Normalized Ratio for Resident #3 with results of 19.2/1.6 and within normal limits. The on-call physician was notified of results with no new orders given. No active bleeding , bruising, tarry stools, or any other changes in condition. 19. On 11/29/2014 at 11:30 AM, the facility notified the Consulting Pharmacist by facility Director of Nursing Services of medication errors. Pharmacist visited facility on 12/01/2014. 20. On 11/29/2014 at 2:00 PM, Facility Nurse #4 completed 100% audit of all residents receiving [MEDICATION NAME] therapy with no negative findings. 21. On 11/29/2014 3-11/11-7 shifts, Resident #2 displayed no signs and symptoms of adverse reactions related to receiving wrong medications. Resident #3 displayed no adverse reactions related to receiving wrong medications. 22. On 11/30/2014 at 9:45 AM, Facility Nurse #4 checked [MEDICATION NAME] Time/International Normalized Ratio for Resident #3 with results of 16.1/1.3 within normal limits, on-call physician notified with no new orders given, No active bleeding, bruising, tarry stools, or any other changes in condition 23. On 11/30/2014 3-11/11-7 shifts, Resident #2 displayed no signs and symptoms of adverse reactions related to receiving wrong medications. Resident #3 displayed no signs and symptoms of adverse reactions related to receiving wrong medications. 24. On 12/01/2014 at 10:00 AM, a meeting held with Facility Executive Director, Facility Director of Nursing Services, Facility Nurse consultant, and Community College instructor #1 and instructor #2. 25. On 12/01/2014 at 10:00 AM, Consultant pharmacist reviewed Resident #2 and Resident #3 record with no new recommendations and no negative findings. 26. On 12/01/2014 at 10:00 AM, the contract with school of nursing remained suspended and under review by Golden Living Corporate Legal Department to ensure the relationships and duties of the parties, including student supervision, were clearly enumerated and allow the facility to ensure a safe environment for residents at all times. 27. Quality Assurance Performance Improvement meeting held on 12/01/2014 at 1:30 PM with the Facility Medical Director, the Facility Executive Director, the Facility Director of Nursing Services, the Field Service Clinical Director and the Facility Assistant Director of Nursing Services in attendance. The Quality Assurance Performance Improvement meeting summary included, measures to assure the nursing school instructors always accompany nursing students when in the building, requiring nursing school instructors to be accountable and provide oversight of all nursing students, facility nurses will neither be responsible nor precept future nursing students, notification of facility administrative staff immediately of critical incidents, necessity to follow standards of practice with medication administration ,submission of nursing school contract to company legal team for review and revision to protect the health and safety of our residents. After errors, the Director of Nurses will monitor medication administration on various shifts with various nurses weekly for four weeks to assure nurses were not delegating medication administration to unlicensed personnel. All negative findings will be corrected immediately and reported to Quality Assurance and Performance Improvement for root cause analysis. All medication errors will be monitored for trending. 28. On 12/01/2014, the facility noted no negative outcomes related to medication errors with either Resident #2 or Resident #3 29. On 12/01/2014, the Board of Nursing was notified via phone at 3:57 PM. 30. On 12/01/2014 at 4:30 PM, Facility Nurse #1 and Facility Nurse #2 were both in-serviced on management of nursing student/medication administration, abuse/neglect. Both were also coached on notification of supervisor, Director of Nursing Services, Executive Director of all medication errors. After completion of training both nurses were reinstated. 31. On 12/02/2014 after all corrective actions had been implemented, the facility believed the jeopardy was removed. The State Agency validated the facility's corrective action on 12/12/2014. 1. The State Agency (SA) validated the facility's investigation of the medication errors on 11/27/14 by record review and interviews. 2. The SA verified by interview with the Director of Nursing Services and the Field Service Clinical Director that the policies for proper medication administration and critical events were reviewed on 11/28/2014 with no changes. 3. The SA validated by record review of nurses notes that the facility assessed Resident #2 and Resident #3 from 11/27/14 through 12/2/14 for signs and symptoms of adverse effects related to the medication errors. The SA verified through documentation of nurses that Resident #2 and Resident #3 showed no signs and symptoms of adverse reactions. 4. The SA validated the Executive Director and the Director of Nursing were notified of the medication errors on 11/28/2014 at 9:00 AM. 5. The SA surveyor validated by interview with the Director of Clinical Education that staff in-services began on 11/28/14. Review of the in-service content and signature sheet validated the facility in-serviced the nursing staff on management of nursing students, medication administration, abuse and neglect, and immediate notification of the Executive Director and the Director of Nursing Services for medication errors. 6. The SA validated by record review that the facility obtained [MEDICATION NAME] Times (PT) and International Normalization Ratios (INR) for Resident #3. Review of the lab report confirmed the results were within normal limits, and the physician gave no new orders. 7. The SA validated that the Director of Nursing Services contacted the Medical Director regarding the medication errors and initiated a Quality Assurance and Performance Improvement meeting. 8. The SA validated by interview with Nurse #3 and record review of written documentation that Facility Nurse #3 notified [MEDICAL TREATMENT] Nurse #1 of the medication error with Resident #3 on 11/28/14. 9. The SA verified by interview with the facility's Executive Director that on 11/28/14, the facility notified the instructor at the Community College of the medication error on 11/27/14, and that the facility required removal of the nursing students from the building on 11/28/14. Interview with the Executive Director verified suspension of the contract with the Community College and the facility held a meeting with the Community College instructors of the student nurses on 12/01/2014. 10. Upon review of the Medication Administration Competency Tests administered by the facility, the SA validated Facility Nurse #1 and Facility Nurse #2 passed the test. The SA verified by review of the employee files that Facility Nurse #2 was suspended following the incident. 11. The SA verified the facility notified the Department of Health of the medication errors via Hotline on 11/28/2014. 12. The SA verified the facility notified the Attorney General's office on 11/28/2014 via E form of the medication errors. 13. Interview with the Director of Clinical Education validated a 100% audit of residents who received medications. 14. The SA verified with facility Consultant Pharmacist that notification was made of the medication errors for Resident #2 and Resident #3. The SA verified the Pharmacist visited the facility on 12/01/2014. 15. The SA verified by record review that the facility conducted a 100% audit of all residents on [MEDICATION NAME] with no negative findings documented. 16. The SA verified a meeting on 12/01/2014 with the facility's Executive Director, the facility's Director of Nursing Services, the facility's Nurse Consultant, and the Community College Instructors #1 and #2 by interview with the facility's Executive Director. 17. Interview with the Consultant Pharmacist confirmed the pharmacist reviewed Resident #2 and Resident #3's medical records with no negative findings. 18. The SA verified by record review that the facility held a Quality Assurance Performance Improvement meeting on 12/01/2014. The SA verified by interviews and checklist reviews that medication administration was monitored on different shifts. 19. The SA validated by review of the documentation that the facility notified the Board of Nursing of the medication errors on 12/01/2014. 20. Interview and record review by the SA verified Facility Nurse #1 and Facility Nurse #2 were in-serviced on management of nursing students, abuse and neglect, medication administration, and notification of nursing administration regarding medication errors. The facility reinstated both nurses. The SA identified the Immediate Jeopardy and Substandard Quality of Care as Past Non-Compliance beginning 11/27/14 through 12/1/14. The facility provided sufficient evidence to show the facility corrected the non-compliance and was in substantial compliance with regulatory requirements as of 12/2/14 prior to the SA entering the facility on 12/9/14.

Based on observation, staff and resident interview, record review and facility policy review, the facility failed to ensure the physician was notified of a change in condition for one (1) of 19 residents (Resident #16). Findings include: Resident #16 Record review revealed Resident #16 was admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #16's initial Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/19/13, revealed that Resident #16 had a Brief Interview Mental Status (BIMS) score of 15, which indicated Resident #16 was cognitively intact. Review of the Mood section of this MDS revealed a severity score of 10, and no behaviors were assessed. There were no documented hours that psychological services had been provided during assessment period. Interview on 9/5/13 at 11:15 a.m. with the Unit Manager confirmed with the Social Services Director that no psychological consults had been ordered by physician for Resident #16. The Unit Manager and the Social Services Director confirmed that they were not aware if the physician had been notified of Resident #16 biting his fingertips. Interview on 9/5/13 at 3:25 p.m. with Resident #16's physician, by phone, revealed the physician stated that Resident #16 was placed in his care upon admission to the facility. The physician confirmed that he was not aware of Resident #16's biting his fingertips, and stated, "I don't think that I was aware of that. I have only seen him a few times and I didn't notice that on physical exam back in July (2013)." The physician was asked what recommendations he would have made if he had been contacted, and stated, "I would have wanted to talk to him first. That's self mutilation. I think that psych (psychology) would need to get involved."

Based on observation, staff and resident interview, record review and facility policy review, the facility failed to provide medically related social services to maintain the highest practical mental and psychosocial well being as evidenced by failure to provide a proper assessment of the behavior of biting fingertips, and failure to refer to appropriate resources for evaluation and treatment by mental health professional for one (1) of 19 records reviewed (Resident #16). Findings include: Resident #16 Record review revealed Resident #16 was admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #16's initial Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/19/13, revealed that Resident #16 had a Brief Interview Mental Status (BIMS) score of 15, which indicated Resident #16 was cognitively intact. Review of the Mood section of this MDS revealed a severity score of 10, and no behaviors were assessed. There were no documented hours that psychological services had been provided during assessment period. Review of Resident #16's Significant Change Minimum Data Set with an Assessment Reference Date of 7/9/13, revealed a Brief Interview for Mental Status score of 15, which indicated that Resident #16 was cognitively intact. Review of the Mood section of this MDS revealed a severity score of 08, and no behaviors assessed. Zero (0) hours of psychological services had been provided. Review of Social Services notes for 4/19/13, 5/22/13, and 7/9/13, revealed the Social Service Director (SSD) documented that no behaviors were observed. The Social Services Director documented the following statement on 4/19/13 and 7/9/13, "Resident has no noted behavior issues at this time. Resident feels down. No energy. Has trouble sleeping. Moves slowly." There was no other documentation provided by the facility in which the Social Worker documented Resident #16 biting fingertips, or exhibiting signs and symptoms of anxiety since admission to the facility. Interview with the Unit Manager (UM #1) and Social Services Director on 9/5/13 at 11:15 a.m., revealed the Social Services Director confirmed awareness of Resident #16's behavior of biting fingertips, and [DIAGNOSES REDACTED]. He just need his meds (medication) adjusted but we have to be careful with him because of his situation. The Social Services Director confirmed that biting fingernails/tips was often an indicator of anxiety. The Social Services Director confirmed that she completed the Minimum Data Set Mood Assessment on each resident. The Social Services Director revealed that residents exhibiting behaviors, signs and symptoms of anxiety and/or depression she would refer them to the local mental health service or for a psychological consult. The Social Services Director stated, "I think they (local mental health services) have seen him, and they just played cards once." The Social Services Director confirmed that psychological services had not been provided for Resident #16, and that she had not referred Resident #16 to any services that would assist with treating his self harming behaviors of biting his fingertips, and assess Resident #16 for any necessary medication changes in a safe manner. The Unit Manager confirmed with the Social Services Director that no psychological consults had been ordered by physician for Resident #16. The Unit Manager and the Social Services Director confirmed that they were not aware if the physician had been notified, or if Resident #16's Responsible Party (RP) had been notified. Observation and interview with Resident #16 on 9/5/13 at 11:35 a.m. revealed Resident #16 was lying in bed without clothing to torso. Resident #16 was observed with bright red blood like substance above the mouth, and blood was observed on Resident #16's fingertips. Resident #16 was asked about the blood on his mouth and fingertips and Resident #16 stated that he bites his fingertips. When asked why he feels that he does this, Resident #16 stated, "Nerves. Stress." When asked what causes his stress, Resident #16 stated, "Just in general, stuff. I was on valium before I came here." Resident #16 confirmed that he would like to receive assistance to stop biting his fingertips, by stating "Yes I would." Resident #16 was unable to recall facility staff discussing options for his receiving assistance with this behavior and his anxiety. Interview with Resident #16's Responsible Party (RP) by phone on 9/5/13 at 3:20 p.m. confirmed that he has visited Resident #16 this past Sunday (9/1/13). The RP stated that Resident #16's biting his fingertips has been an ongoing issue, stated that he does not attend care plan meetings and stated that he was not able to recall staff contacting him regarding Resident #16 biting and chewing on his fingers. The RP stated that he received the information that he had regarding this from Resident #16 during last visit. The RP stated he feels that the biting and chewing by Resident #16 was from having a hard time communicating. The RP stated, "I am sure that laying there I am not sure what all I would have going on with me." Review of the facility's Job Description for Social Service Coordinator, revised 9/30/04, revealed the following departmental job function for social service department, "Duties: Develop a social history, social assessment and care plan which identifies pertinent problems and needs, realistic goals, to be accomplished and the specific action to be taken in resolution of the problem and/or needs upon admission of each new resident." Interview with the Unit Manager (UM #1) and Social Services Director on 9/5/13 at 11:15 a.m., revealed the Social Services Director confirmed awareness of Resident #16's behavior of biting fingertips, and [DIAGNOSES REDACTED]. He just need his meds (medication) adjusted but we have to be careful with him because of his situation. The Social Services Director confirmed that biting fingernails/tips was often an indicator of anxiety. The Social Services Director confirmed that she completed the Minimum Data Set Mood Assessment on each resident. The Social Services Director revealed that residents exhibiting behaviors, signs and symptoms of anxiety and/or depression she would refer them to the local mental health service or for a psychological consult. The Social Services Director stated, "I think they (local mental health services) have seen him, and they just played cards once." The Social Services Director confirmed that psychological services had not been provided for Resident #16, and that she had not referred Resident #16 to any services that would assist with treating his self harming behaviors of biting his fingertips, and assess Resident #16 for any necessary medication changes in a safe manner. The Unit Manager confirmed with the Social Services Director that no psychological consults had been ordered by physician for Resident #16. The Unit Manager and the Social Services Director confirmed that they were not aware if the physician had been notified, or if Resident #16's Responsible Party (RP) had been notified. Observation of an interview with Resident #16 on 9/5/13 at 11:35 a.m. revealed Resident #16 was lying in bed without clothing to torso. Resident #16 was observed with bright red blood like substance above the mouth, and blood was observed on Resident #16's fingertips. Resident #16 was asked about the blood on his mouth and fingertips and Resident #16 stated that he bites his fingertips. When asked why he feels that he does this, Resident #16 stated, "Nerves. Stress." When asked what causes his stress, Resident #16 stated, "Just in general, stuff. I was on valium before I came here." Resident #16 confirmed that he would like to receive assistance to stop biting his fingertips, by stating "Yes I would." Resident #16 was unable to recall facility staff discussing options for his receiving assistance with this behavior and his anxiety. Interview with Resident #16's Responsible Party (RP) by phone on 9/5/13 at 3:20 p.m. confirmed that he has visited Resident #16 this past Sunday (9/1/13). The RP stated that Resident #16's biting his fingertips has been an ongoing issue, stated that he does not attend care plan meetings and stated that he was not able to recall staff contacting him regarding Resident #16 biting and chewing on his fingers. The RP stated that he received the information that he had regarding this from Resident #16 during last visit. The RP stated he feels that the biting and chewing by Resident #16 was from having a hard time communicating. The RP stated, "I am sure that laying there I am not sure what all I would have going on with me." Interview with the physician for Resident #16 on 9/5/13 at 3:25 p.m., by phone, revealed the physician stated that Resident #16 was placed in his care upon admission to the facility. The physician confirmed that he was unaware of Resident #16's biting his fingertips, and stated, "I don't think that I was aware of that. I have only seen him a few times and I didn't notice that on physical exam back in July (2013)." The physician was asked what recommendations he would have made if he had been contacted, and stated, "I would have wanted to talk to him first. That's self mutilation. I think that psych (psychology) would need to get involved." Review of the facility's Job Description for Social Service Coordinator, revised 9/30/04, revealed the following departmental job function for social service department, "Duties: Develop a social history, social assessment and care plan which identifies pertinent problems and needs, realistic goals, to be accomplished and the specific action to be taken in resolution of the problem and/or needs upon admission of each new resident. Actively participate in interdisciplinary Care Plan meetings, Document progress notes which relate to each resident's care plan when necessary and within policy timeframes."

Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to develop an appropriate care plan with interventions and measurable objectives to address one (1) of 19 resident's psychosocial needs and behavior of biting fingertips (Resident #16). Findings include: Resident #16 Record review revealed the care plan interventions failed to describe measureable interventions that can be implement to address the root cause of Resident #16's behavior of biting his fingertips and the identified problems associated with this continued behavior of skin integrity, [MEDICAL CONDITION] medication, and anxiety/depression and pain management. Record review revealed Resident #16 was admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #16's initial Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/19/13, revealed that Resident #16 had a Brief Interview Mental Status (BIMS) score of 15, which indicated Resident #16 was cognitively intact. Review of Resident #16's care plan, initiated 4/19/13, revealed problem onset for Impaired skin integrity. The care plan was updated on 7/25/13 to include that the resident chews on fingertips and occasionally will cause bleeding. Interventions included skin observed daily during routine care with concerns reported to the physician. Review of Resident #16's care plan related to potential drug complications, initiated on 4/19/13, and updated on 7/23/13, to include episodes of anxiety with chewing on fingertips and causing raw areas with episodes of bleeding to site. (Has very small movements to arm/hands has chewed fingers on right hand, little finger drawn to nub, band aid to other digits. Has been offered and refused mits (mitts) for protection of hands. Interventions included treatment as ordered, notify physician as needed, and administer medications as ordered (antidepressant/antianxiety). Review of Resident #16's care plan for anxiety and depression, initiated 4/19/13, updated on 8/3/13, revealed, "Has been offered and declined mit (mitt) for protection to rt. (right) hand. Interview with Unit Manager (UM #1) and Social Services Director (SSD) on 9/5/13 at 11:15 am, SSD confirmed awareness of Resident #16's behavior of biting fingertips and [DIAGNOSES REDACTED]. He just needs meds (medication) adjusted but we have to be careful with him because of his situation." The Unit Manager #1 confirmed with Social Services Direct that they were not aware if the physician or the Responsible Party (RP) had been notified as identified as an intervention in the care plan. Observation and interview on 9/5/13 at 11:35 a.m. revealed Resident #16 was lying in bed without clothing to torso. Resident #16 was observed with bright red blood like substance above his mouth and on his fingertips. Resident #16 questioned regarding this observation. Resident #16 stated that he bites his fingertips due to nerves and stress. Interview with MDS Registered Nurses (RN) #2 and RN #3 on 9/5/13 at 3:00 p.m. confirmed that interventions on care plan do not include resident receiving referral or assessments from psychological services or to monitor for signs and symptoms of increased anxiety or depression. Interview with Resident #16's Responsible Party by phone on 9/5/13, RP stated that resident biting fingertips has been an ongoing issue, stated that he does not attend care plan meetings. Review of the facility's policy entitled "Resident Assessment", revised 2006, revealed, "Care Plan Documentation Guidelines Problem: Identify the resident's problems and strengths, Consider listing possible risks and complications Goal: List Measureable goals to be accomplished List target dates Approaches: The underlying cause of problems should be investigated for maximum effectiveness of care planning."

Based on observation, interview, and record review, the facility failed to assess and implement treatment for [REDACTED].#16). Findings include: Resident #16 Record review revealed Resident #16 was admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #16's initial Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/19/13, revealed that Resident #16 had a Brief Interview Mental Status (BIMS) score of 15, which indicated Resident #16 was cognitively intact. The facility failed to develop a plan of care in which to implement interventions that assess, treat, and monitor the root cause of Resident #16's behaviors of biting fingertips. Interview with the Unit Manager (UM #1) and the Social Services Director (SSD) on 9/5/13 at 11:15 a.m. confirmed that the resident was exhibiting behaviors, signs and symptoms of anxiety and/or depression should be referred to Region IV (mental health) services or for a psychological consult. The SSD stated, "I think they (Region IV mental health services) have seen him just to play cards once." The SSD confirmed that psychological services have not been provided to Resident #16, and that she has not referred Resident #16 to any services that would assist with treating his self harming behaviors of biting his fingertips, or assess Resident #16 for any necessary medication changes in a safe manner. Interview on 9/5/13 at 11:35 a.m. with Resident #16 revealed Resident #16 observed with bright red blood like substance above mouth, and blood observed to Resident #16's fingertips. Resident #16 stated that he does bite his fingertips and Resident #16 stated he does this because of his nerves and stress. Resident #16 confirmed that he would like to receive assistance to stop biting his fingertips. Interview with Registered Nurse (RN) #4 on 9/5/13 at 2:30 p.m. revealed RN #4 stated, "He just recently started getting bad with the chewing about a month to a month and a half ago. He just has his days, he told me it was his nerves. RN #4 stated that she informed the Nurse Practitioner and the Director of Nursing. RN #4 stated that the Nurse Practitioner didn't say anything to do. RN #4 stated she was not aware if the physician was informed, and had not been able to reach Resident #16's Responsible Party. Interview with Minimum Data Set Nurse, Registered Nurse #2 and Registered Nurse #3 on 9/5/13 at 3:00 p.m., revealed interventions attempted by staff for Resident #16's behavior of biting was to redirect him and offer him mitts, which the resident refused. RN #2 stated, "He is aware that he is doing it." RN #3 stated, "I spoke with him about it the other day, and he told me that he doesn't feel pain. He will take off the dressings and gnaw on it (fingers)." RN #2 and RN #3 both stated they were not aware if physician had been notified regarding Resident #16's behaviors. Both confirm that interventions on care plan did not include resident receiving referral or assessments from psychological services or to monitor for signs and symptoms of increased anxiety or depression. Interview with Resident #16's Responsible Party (RP) by phone on 9/5/13 at 3:20 p.m. confirmed that he has visited Resident #16 this past Sunday (9/1/13). The RP stated that Resident #16's biting his fingertips has been an ongoing issue, stated that he does not attend care plan meetings and stated that he was not able to recall staff contacting him regarding Resident #16 biting and chewing on his fingers. The RP stated that he received the information that he had regarding this from Resident #16 during last visit. The RP stated he feels that the biting and chewing by Resident #16 was from having a hard time communicating. The RP stated, "I am sure that laying there I am not sure what all I would have going on with me." Interview with the physician for Resident #16 on 9/5/13 at 3:25 p.m., by phone, revealed the physician stated that Resident #16 was placed in his care upon admission to the facility. The physician confirmed that he was not aware of Resident #16's biting his fingertips, and stated, "I don't think that I was aware of that. I have only seen him a few times and I didn't notice that on physical exam back in July (2013)." The physician was asked what recommendations he would have made if he had been contacted, and stated, "I would have wanted to talk to him first. That's self mutilation. I think that psych (psychology) would need to get involved."