Every finding on record at Jnh-Jefferson Inn

Based on observation, interview and record review, the facility failed to ensure residents received meals at regular intervals not exceeding 14 hours between the evening and morning meal, or 16 hours when a bedtime snack is provided, for residents residing in the facility for one (1) of three (3) days of survey. Findings include:On 10/09/2025 at 10: 05 AM, an observation revealed Residents in building #31 were eating breakfast.On 10/09/2025 at 10:28AM, during an interview the Director of Operations (DO) stated breakfast was serviced at 9:45 AM, two (2) hours later than scheduled times for the residents in building #31.On 10/09/2025 at 11:05 AM, the DO stated that snacks are served at 10 AM and 2 PM daily and given at night for the diabetic residents. Residents who are not diabetic have access to snacks if they ask. She further confirmed that if a non-diabetic resident did not ask for a snack on Wednesday night, they would have gone almost 17 hours without a meal until breakfast Thursday morning (10/9/25). She confirmed that Food Service Aide (FSA) states dinner was served at 5 PM Wednesday night. On 10/09/2025 11:15 AM, in an interview the FSA stated when he arrived at 10:05 AM today the resident was eating breakfast. He confirmed that the dinner was delivered to the building at 4:30 PM and was served to the residents at 4:55 PM on 10/8/25.A record review of Meal Times and Location for [NAME] INN building #31 revealed documented dinner time was 5:15 PM and Breakfast time is 7:45 AM.A record review of building #31 Food Temperature log dated 10/8/25 revealed arrival time for dinner was at 4:30 PM.On 10/09/2025 at 3:17 PM, in an interview with the Nursing Home Administrator (NHA) confirmed that she is aware of the meals being delivered late. She stated her expectations is the food be served on time, hot, looks and tastes appealing.

Based on observation, interview, and facility policy review the facility failed to ensure that food was prepared and served in a sanitary manner to prevent foodborne illness. Specifically, a food-service worker was observed failing to change gloves after touching a door handle while taking food temperatures. This failure demonstrated a breach of proper hand-hygiene and glove-use procedures and created a risk of cross-contamination for one (1) of four (4) dietary observations.Findings include: A record review of the facility's Food Storage policy (revised June 2025) revealed, Employees will maintain good personal-hygiene practices and safe food-handling procedures during food storage.A record review of the facility's Food Preparation and Meal Service policy (revised June 2025) revealed, Employees will observe safe-handling practices during preparation and service of food to residents and patients.An observation on October 9, 2025, at 8:09 AM, during breakfast temperature checks in the dietary department, the State Agency observed Dietary Member #2 (DM #2), who had been employed at the facility for 24 years, open the kitchen door while wearing gloves. DM #2 then returned to taking food temperatures without removing the gloves, washing her hands, or donning new gloves before resuming food handling.On October 9, 2025, at 8:15 AM, during an interview, DM #2 acknowledged that she should have removed her gloves, performed hand hygiene, and applied new gloves after touching the door handle which was a surface that may have been contaminated. DM #2 also stated that proper hand hygiene is important to prevent the spread of germs and to maintain food safety during food preparation and service.

Based on record review, staff interview, and facility policy review the facility failed to ensure accurate and complete documentation of dialysis weights for a resident receiving hemodialysis. Specifically, dialysis weights were not recorded on the dialysis communication form for four (4) of 30 dialysis treatment days during August 2025. Resident #9. Findings include:A record review of the facility's Hemodialysis Care policy, effective September 2024 revealed, .II. POLICY: When a resident or patient is determined by a physician or nurse practitioner to need hemodialysis . the outside medical facility will . exchange information with Mississippi State Hospital regarding the resident-specific dialysis care plan. III. PROCEDURE: .3. C. The nurse will document in the patient's or resident's medical record any significant psychological or physiological changes of a patient or resident receiving dialysis and report such changes immediately to the provider . Record review of Dialysis Communication forms revealed that no pre- or post-dialysis weights were documented for August 6, 8, 11, and 18, 2025.A record review of the Identification and Summary Sheet revealed Resident #9 was admitted to the facility on [DATE], with diagnoses that included End-Stage Renal Disease (ESRD), requiring routine dialysis. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD0 of July 30, 2025, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.A record review of Physician Orders dated 9/20/25 revealed dialysis treatments three times per week, a renal-high diet, and orders for vital signs weekly and as needed, and weights monthly and as needed.On October 8, 2025, at 3:05 PM, during an interview Registered Nurse (RN #3), who stated that nursing staff had never completed pre- and post-dialysis weights for residents receiving dialysis. She explained that dialysis-clinic nurses were responsible for documenting residents' pre- and post-treatment weights within the dialysis unit records and on the dialysis, communication forms, but facility nursing staff were expected to obtain dialysis weights.On October 8, 2025, at 3:33 PM, during an interview Charge Nurse (RN #2), stated that pre- and post-dialysis weights were completed by dialysis-clinic staff. RN #2 explained that when dialysis communication forms were returned without weight information, facility nurses assumed the omission indicated there were no concerns requiring communication. RN #2 acknowledged the incomplete documentation on the dialysis forms and confirmed that staff had not contacted the dialysis clinic to obtain the missing information, assuming no changes had occurred.On October 8, 2025, at 3:51 PM, during a phone interview with the local dialysis manager stated that dialysis communication forms are sent with the resident for each treatment and that pre- and post-treatment weights are recorded by the dialysis nurse or technician. The manager stated that if the form is incomplete, facility nurses can contact the dialysis center to have the completed form faxed or emailed. When asked whether the facility contacted the dialysis facility regarding missing documentation for August 6, 8, 11, or 18, 2025, the manager stated she had no knowledge of any such requests.On October 8, 2025, at 3:41 PM, during a phone interview with the dialysis center Social Worker, confirmed that pre- and post-dialysis weights are completed by the dialysis nurse or technician and that if the forms are incomplete, facility staff usually call or fax the dialysis center to obtain the missing information. She stated that in this case, she had not received any requests from the facility for follow-up.On October 9, 2025, at 8:50 AM, the Director of Nursing (DON) stated that communication between the facility and the dialysis clinic is maintained through written, verbal, or electronic means. She explained that dialysis information, including weights, graft function, and diet changes-is used by the interdisciplinary team to monitor the resident's progress and referenced to the medical director if significant. She acknowledged that Resident #9 was the facility's first dialysis resident and described the incident as an opportunity for staff learning. The DON stated that staff had not intentionally disregarded standards but lacked training on monitoring dialysis residents and completing related documentation. She stated her expectations for nursing staff are to remain professional, follow policy and procedure, and promptly communicate changes to the physician.On October 9, 2025, at 2:27 PM, Registered Nurse (RN #1), stated that when weights are not provided on the dialysis communication form, nursing staff should obtain the weights themselves or call the dialysis clinic to request them. She emphasized that dialysis weights are critical indicators for assessing changes in the residents' condition before and after dialysis.

Based on record review, staff interview, and facility policy review the facility failed to implement the resident's care plan for monitoring dialysis weights and identify changes in condition for one (1) of (32) sampled residents (Resident #9). Findings include: A record review of the facility policy Care Plan Policy, no date, revealed, .2.Policy: A comprehensive, person-centered care plan will be developed and implemented for each resident by the interdisciplinary team, (IDT), resident, and his/her legal representative to include measurable objective and timetables to meet the resident's physical, psychosocial, and functional needs.A record review of the Care Plan Report' with a date initiated of 7/30/2025 revealed Focus: ARF (At risk for) Altered nutritional status r/t (related to) CKD/ESRD (chronic kidney disease/End Stage Renal Disease) .Interventions/Taks.Notify MD (Medical Doctor)/RD (Registered Dietician)/Correspondent of any significant weight changes . However, there was no individualized care plan intervention to address the resident's ongoing need for dialysis, nor was there direction to monitor pre- and post-dialysis weights, communicate with the dialysis clinic, or evaluate trends in fluid balance-despite the resident's End Stage Renal Disease diagnosis.On 10/09/2025 at 2:27 PM, in an interview with Registered Nurse (RN) #1 who serves as the Care Plan Nurse, revealed the importance of the care plan is to set a baseline of care for residents clearly written so that any nurse could see, follow and know exactly what that resident needs are. RN #1 further stated the significance of having dialysis weights for care plan is to inform staff of significant changes in resident before and after dialysis.A record review of the Identification and Summary Sheet revealed Resident #9 was admitted to the facility on [DATE], with diagnoses that included End-Stage Renal Disease (ESRD).

Based on record review, interview, and facility policy review the facility failed to ensure completion and follow-up of resident communication forms used to coordinate care services, resulting in potential unmet resident needs in one (1) of (1) sampled resident receiving dialysis. Resident #9.Findings include:Record review of the facility policy Hemodialysis Care effective September 2024 revealed, .When a patient/resident is determined by a physician/nurse practitioner to need hemodialysis, the dialysis treatments will be provided by a contracted entity. The outside medical facility will arrange, develop, implement, and exchange information with Mississippi State Hospital (MSH) regarding the patient's/resident's specific dialysis care plan. A record review of the Identification and Summary Sheet revealed Resident #9 was admitted to the facility on [DATE], with diagnoses that included End-Stage Renal Disease (ESRD), requiring routine dialysis. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD0 of July 30, 2025, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.A record review of the Dialysis Communication Form revealed missing documentation of pre- and post-dialysis weights for August 6, 8, 11, and 18, 2025. On October 8, 2025, at 3:33 PM, Registered Nurse (RN) #2 was interviewed and stated that the dialysis nurses are responsible for completing the weights on the communication form. She acknowledged that when the forms were returned incomplete, facility staff assumed there were no issues requiring follow-up and did not request the missing information.On October 8, 2025, at 3:42 PM, the Dialysis Manager at the local dialysis center stated that the dialysis nurses or technicians are responsible for completing the communication form and returning it to the facility. She further stated that if forms are missing or incomplete, it is standard practice for the facility to call the dialysis center and request the missing information via fax or email. The Dialysis Manager had no knowledge of any request made by facility staff to obtain the missing data for Resident #9 for the listed dates.On October 9, 2025, at 8:50 AM, the Director of Nursing (DON), acknowledged that this was the facility's first dialysis resident and referred to the situation as a learning opportunity. She stated that her expectation is for staff to follow professional standards, policy and procedure and to ensure communication of any resident care concerns. The DON further stated she believes staff did not act with intentional neglect, but rather lacked training in monitoring dialysis residents, which contributed to the error.

Based on record review and staff interviews, the facility failed to ensure the provision of physician-ordered care and services for a resident receiving dialysis treatment. Specifically, the facility failed to accurately correspond, obtain, and document dialysis weights for one (1) of 32 sampled residents. (Resident #9).Findings include: A record review of the Identification and Summary Sheet revealed Resident #9 was admitted to the facility on [DATE], with diagnoses that included End-Stage Renal Disease (ESRD), requiring routine dialysis. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD0 of July 30, 2025, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. A record review of Resident #9's Dialysis Communication forms revealed that no pre- or post-dialysis weights were documented for August 6, 8, 11, and 18, 2025.A record review of the Physician Orders dated 9/20/25 revealed dialysis treatments three times per week, a renal-high diet, and orders for vital signs weekly and as needed, and weights monthly and as needed.During an interview on October 8, 2025, at 3:05 PM, Registered Nurse (RN) #3, stated that nursing staff had never completed pre- and post-dialysis weights for residents receiving dialysis. She explained that dialysis-clinic nurses were responsible for documenting residents' pre- and post-treatment weights within the dialysis unit records and on the dialysis, communication forms, but facility nursing staff were expected to obtain dialysis weights.During an interview on October 8, 2025, at 3:33 PM, Charge Nurse/Registered Nurse (RN) #2, stated that pre- and post-dialysis weights were completed by dialysis-clinic staff. RN #2 explained that when dialysis communication forms were returned without weight information, facility nurses assumed the omission indicated there were no concerns requiring communication. RN #2 acknowledged the incomplete documentation on the dialysis forms and confirmed that staff had not contacted the dialysis clinic to obtain the missing information, assuming no changes had occurred.During an interview on October 9, 2025, at 8:50 AM, the Director of Nursing (DON) stated that communication between the facility and the dialysis clinic is maintained through written, verbal, or electronic means. She explained that dialysis information, including weights, graft function, and diet changes-is used by the interdisciplinary team to monitor the resident's progress and referenced to the medical director if significant. She acknowledged that Resident #9 was the facility's first dialysis resident and described the incident as an opportunity for staff learning. The DON stated that staff had not intentionally disregarded standards but lacked training on monitoring dialysis residents and completing related documentation. She stated her expectations for nursing staff are to remain professional, follow policy and procedure, and promptly communicate changes to the physician.On October 9, 2025, at 2:27 PM, Registered Nurse (RN #1), emphasized that dialysis weights are critical indicators for assessing changes in the resident's condition before and after dialysis.

Based on observations, interviews, record reviews and facility policy review, the facility failed to prevent the possible spread of infection during wound care as evidenced by failure to implement proper use of Enhanced Barrier Precautions (EBP) during wound care for one (1) of three (3) care observations. Resident #11Findings include:A record review of the facility's Standard Precautions & Enhanced Barrier Precautions dated 6/2024 revealed 2. POLICY: All employees will utilize Standard Precautions or Enhanced Barrier Precautions when indicated, on all patients/residents at all times .3. Enhanced Barrier Precautions expands the use of Personal Protective Equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated. High contact resident care includes Wound care (any skin opening requiring a dressing. A record review of the EBP signage revealed .Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities .Wound care: any skin opening requires dressing.On 10/06/2025 at 2:43 PM, during initial tour, Licensed Practical Nurse (LPN) #1 was observed in Resident #11's room providing bilateral wound care on his legs. LPN#1 did not have a gown on while providing care.On 10/6/25 at 2:50 PM, during an interview LPN #1 confirmed she did not have a gown on doing wound care. She stated she was aware that she was supposed to wear a gown. She stated she did not look at the EBP signage by the door. She stated she forgot to put a gown on. She stated the purpose of the gown is to protect the residents from getting an infection from the outside. She stated her actions put the resident at risk for infection. On 10/8/25 at 10:13 AM, in an interview the Director of Nursing (DON) stated LPN #1 should have put a gown on. She stated there is a signage on the outside of the door alerting staff to use EBP when providing certain care. She stated she expects staff to follow policy and procedures while doing care. She stated the nurses have gowns on their cart.On 10/8/25 at 10:28 AM, in an interview with LPN #2 / Infection Preventionist (IP) nurse stated she expects staff to wear gowns and gloves when doing care. She stated she does in services and rounds in the facility every other month. She stated by LPN #1 not wearing a gown, that increased the risk of the resident getting an infection. She stated LPN#1 could have bacteria on her clothes and spread it to other residents. She stated when a resident has open areas there is a risk of spreading infection to the wound by not wearing a gown doing care.A record review of Resident #11 Identification and Summary Sheet revealed an admission date of 6/2/21 with diagnoses that included Peripheral Vascular Disease.A record review of Resident #11's Physician Order revealed an order dated 9/15/25 Clean lower extremities (Legs and feet) with NS (normal saline). Apply Silvadene to lower legs. Apply ABD (abdominal) pad and wrap and kerlix daily and PRN (as needed) if soiled until healed.A record review of Resident #11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/22/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure the residents' right to be treated with dignity and respect, as evidenced by staff provided incontinent care without providing privacy for two (2) of four (4) sampled residents. Resident #1 and Resident #2. Findings include:Record review of the facility policy titled, RIGHTS OF RESIDENTS, dated July 2023, revealed .All persons admitted to (Proper name of facility) will be assured that their legal rights will be protected and promoted. The resident will receive care consistent with basic human dignity.The resident has the right to a dignified existence .On 7/30/25 at 9:39 AM, during a pre-survey interview with the Complainant who is the facility Ombudsman stated that during a routine visit at this facility on 6/10/25, she walked down the hallway and noticed two aides with Resident #1 in the hallway and there was something going on that was not right. She stated that it appeared the staff were attempting to provide care for the resident in the hallway and that they put the resident into a Geri-recliner and took her into her room when they noticed her approach. On 7/31/25 at 2:48 PM, observation revealed that Certified Nursing Assistant (CNA) #3 was providing incontinent care for Resident #2 in the resident's room with the door open. There was no privacy curtain in use and the resident's perineal area was exposed. CNA # 3, the CNA Supervisor joined CNA #4 without providing instruction or correction on provision of privacy for incontinent care.On 7/31/25 at 3:00 PM, during an interview CNA #4 confirmed that it was not the correct procedure to provide incontinent care in the hallway and that privacy should be provided to maintain residents' dignity and ensure their rights. She confirmed that the facility provided in-service training regarding residents' rights, including the right to receive care in a dignified manner and incontinent care, including provision of privacy for care.On 7/31/25 at 3:10 PM, during an interview CNA #3 confirmed that she had the authority to provide instruction and correction to CNAs if she observed any problem with care. She said that it was not the correct procedure to provide incontinent care in the hallway and that privacy should be provided to maintain residents' dignity and ensure their rights. She confirmed that the facility provided in-service training regarding residents' rights, including the right to receive care in a dignified manner and incontinent care, including provision of privacy for care. On 7/31/25 at 6:22 PM, during a telephone interview, CNA #1 stated that she and CNA #2 were providing incontinent care for Resident #1 in the hallway outside the doorway of her room on 6/10/25 when the ombudsman came around the corner in the hallway and they took the resident into her room and provided incontinent care. She confirmed that it was not the correct procedure to provide incontinent care in the hallway and that privacy should be provided to maintain residents' dignity and ensure their rights. She confirmed that the facility provided in-service training regarding residents' rights, including the right to receive care in a dignified manner and incontinent care, including provision of privacy for care.On 8/01/25 at 9:20 AM, during an interview the Administrator confirmed that she was notified by a visitor to the facility on 6/10/25 that they had seen something that did not look right. She stated that she had interviewed the two staff involved, CNA #1 and CNA # 2, and that they had denied anything out of the ordinary. She stated she had interviewed Resident #1 and noted no change from baseline and nothing unusual. She said she saw Resident #1 daily and had not noted any change in condition, function or behavior since 6/10/25. She stated that it was not the correct procedure to provide incontinent care in the hallway and that privacy should be provided to maintain residents' dignity and ensure their rights. She confirmed that the facility provided in-service training regarding residents' rights, including the right to receive care in a dignified manner and incontinent care, including provision of privacy for care.On 8/01/25 at 10:15 AM, during an interview Licensed Practical Nurse (LPN) #1 revealed she was the Infection Preventionist (IP) for the facility. She stated that she provided in-service training for nursing staff including incontinent care. She stated she utilized direct observation of incontinent care and other tasks and competency checkoffs for CNA s and nurses. She stated that nursing staff are to take residents to the resident's room, shower room or bathroom to provide incontinent care and that was a big part of treating residents with respect and dignity and an infection control issue. It is not best practice to provide Activities of Daily Living (ADL) care in the hallway, especially incontinent care.On 8/01/25 at 11:32 AM, during a telephone interview, CNA #2 confirmed that Resident #1's incontinent brief was down, and her perineal area was exposed in the hallway when the ombudsman came down the hallway on 6/10/25. She confirmed that it was not the correct procedure to provide incontinent care in the hallway and that privacy should be provided to maintain residents' dignity and ensure their rights. She confirmed that the facility provided in-service training regarding residents' rights, including the right to receive care in a dignified manner and incontinent care, including provision of privacy for care. On 8/01/25 at 12:21 PM, during an interview the DON revealed that she and the IP and the Staffing Department Head of Nursing Services provided in-service training regarding Residents' Rights, including but not limited to the right of each resident to be treated with respect and dignity and provision of privacy for any care that included uncovering residents' bodies. She stated that she was unaware CNAs were providing incontinent care for residents in the hallways or without provision of privacy for the residents. On 8/01/25 at 1:30 PM, during an interview LPN #2 revealed that she was part of a program to train CNAs prior to certification for employment at the facility. She confirmed that the program provided instruction in incontinent care, and that the incontinent care training included assisting residents into their bed, not conducting the care in the hallway.Record review of the Identification and Summary Sheet for Resident #1 revealed the facility admitted the resident on 10/21/15 with diagnoses that included Schizoaffective disorder (bipolar type), Histrionic personality disorder and Chronic obstructive pulmonary disease (COPD).Record review of the Quarterly Minimum Data Set (MDS) for Resident #1 with an Assessment Reference Date (ARD) of 4/09/25 revealed the resident had no Brief Interview for Mental Status (BIMS) score with documentation that the resident was not able to participate in the interview because she rarely/never understood and she was dependent for toileting hygiene and all activities of daily living and was always incontinent of bowel and bladder.Resident #2Record review of the Identification and Summary Sheet for Resident #2 revealed the facility admitted the resident on 4/01/2019 with diagnoses that included Schizophrenia, Mood disorder and Dementia.Record review of the Quarterly MDS for Resident #2 with an ARD 2/05/25 revealed the resident had no BIMS score with documentation that the resident was not able to participate in the interview because she rarely/never understood and she was dependent for toileting hygiene and all activities of daily living and was always incontinent of bowel and bladder.

Based on observations, staff interviews record review and facility policy review, the facility failed to date medications that were opened and stored in two (2) of four (4) medication refrigerators in medication storage rooms. Findings Include: A record review of the facility policy titled MultiDose Vials, dated 11/21, revealed 1.This policy establishes the requirements to regulate the use of multidose vials to ensure stability and prevent contamination . 2. POLICY: The pharmacy attempts to supply injectable drugs in unit of use vials when practical, but many items are only available in multidose vials. 3. PROCEDURE: A. All multi-dose vials must be dated with a 28-day expiration date from the time of initial puncture . On 08/07/24 at 08:30 AM, during an observation of the medication room in Building 33 on the second floor with Licensed Practical Nurse (LPN) #1, the medication refrigerators were found to contain Novolin R vials that had been opened and not dated. On 08/07/24 at 08:35 AM, an interview with LPN #1 revealed that nurses were trained during orientation and at least yearly on medication labeling and storage, especially insulin. It was the responsibility of the nurse who opened the vial to date it. On 08/07/24 at 08:45 AM, during an observation of the medication room in Building 33 on the first floor with Registered Nurse (RN) #2, the medication refrigerators were found to contain vials of Novolin R and Levemir that had been opened and not dated. On 08/07/24 at 08:50 AM, an interview with RN #2 revealed it was the responsibility of the nurse to date the vial when it was opened. On 08/07/24 at 11:19 AM, an interview with the Director of Nursing (DON) of the facility, confirmed that nurses have received training regarding the importance of dating multidose vials when they are opened. The DON stated the nurses are to follow facility policy and date the vials as they are opened.

Based on observations, interviews, and record reviews the facility failed to follow physician orders for dietary supplements for one (1) of two (2) residents reviewed for nutrition. Resident #68 Findings Include: On 08/05/24 at 1:25 PM, an observation of Resident #68 eating lunch in the dining room revealed the resident could feed himself, using his left hand, after staff set up his tray. The resident consumed 100% of his meal, but there was no dietary supplement on his lunch tray. On 08/06/24 at 1:20 PM, an observation of Resident #68 eating lunch in the dining room revealed that Certified Nursing Assistant (CNA) #1 noted that there was no Boost on his tray, so she left the dining area and returned with the Boost in hand. The resident immediately picked it up and began to consume it. On 08/07/24 at 10:10 AM, in an interview with the Registered Dietitian (RD), she stated she expected the staff to honor residents' preferences and encourage them to eat. She mentioned she expected the staff to offer the Boost and noted the resident had gained some weight over the past couple of months. On 08/07/24 at 1:00 PM, an observation of Resident #68 eating in the dining room revealed Boost was not on the lunch tray. On 08/07/24 at 3:25 PM, in an interview, CNA #1 stated when a resident has an order for a supplement, it is usually placed on the resident's meal tray. On 08/07/24 at 4:15 PM, during an interview, the Director of Nursing (DON) stated when there is a nutritional change, the order form goes to the pantry so they will be informed of the changes. She stated the Registered Dietitian (RD), pantry person, nurse, and CNAs are all informed about it. She confirmed it was the nurse's responsibility to give the resident a supplement as ordered by the physician and to make sure that it is charted accurately. On 08/08/24 at 10:15 AM, during an interview, the RD stated she reviewed Resident #68's chart and had recently changed the order to double portion meals and Boost four (4) times a day (QID). She confirmed the resident should receive Boost four (4) times a day. On 08/08/24 at 10:32 AM, in an interview, CNA #2 stated she did not have access to get the supplement from the medication room. She stated Resident #68 was supposed to get Boost with every meal and emphasized it was the nurse's responsibility to give the resident his Boost. She noted she had observed it not being on the tray at times, but when she was there, she would ask the nurse for the Boost. A record review of Resident #68's Identification and Summary Sheet revealed an admitted [DATE] with diagnoses of Huntington's Disease, Depression, and Gastric Esophageal Reflux Disease. A record review of Resident #68's Physician Orders, dated 6/26/24 revealed an order for pureed diet x 2 (double portions) with Boost QID (four times a day) and when requested.

Based on interviews and record review, the facility failed to ensure a Certified Nurse Aide (CNA) followed the resident's care plan, which resulted in an unwitnessed fall from the bed for one (1) of three (3) the residents reviewed for accidents. Resident #1 Findings include: Record review of Care Plan, with a problem onset date of 5/10/2023 revealed : Requires the use of Siderails x 2 in bed r/t (related to) Profound IDD (Intellectual and Developmental Disability), Delusional Disorder, and Unaware of Safety Hazards .Approaches .Siderails up x 2 when in bed . On 3/20/24 at 11:02 AM, in an interview with the Administrator, she revealed CNA #1 did not follow Resident #1's care plan. The Administrator confirmed that she expects all staff to adhere to physician orders and to follow the resident's care plan, as the care plan is a guideline for how staff are to care for the residents and not following it puts the resident at harm. On 3/20/24 11:27 AM, in an interview with the Director of Nursing (DON), she revealed she has educated the CNA's on following the plan of care for resident care. She stated the ADL (Activities of Daily Living) guidebook, which is an extension of the care plan is specific to each resident's needs and is for CNAs to use while caring for their residents. She confirmed the siderail requirements, for Resident #1, were reflected in the guidebook, but CNA #1 did not follow the guidelines for the care of Resident #1. On 3/20/24 at 1:38 PM during the interview with CNA#1, she confirmed she uses the ADL guidebook to care for her residents and acknowledges the bedrail requirement for Resident #1 was in the guidebook. CNA #1 stated the night Resident #1 fell , she had decided to let the siderails down to prevent the resident from becoming agitated. On 3/20/24 at 2:13 PM, during a phone interview with Licensed Practical Nurse (LPN) #1, confirmed that she knows they must always follow the care plan. She said she assessed Resident #1 after the fall as per protocol, which included such as vital signs and neuro checks. During her assessment she stated she noticed the siderails were down. A record review of the Identification and Summary Sheet revealed Resident #1 was admitted by the facility on 4/27/23. Her diagnoses included Delusional Disorder, Atrial Fibrillation and Hypertension.

Based on interviews, record review, facility investigation, and facility policy review, the facility failed to ensure a dependent resident was supervised and physician ordered assistive devices were implemented to prevent an unwitnessed fall from bed for one (1) of three (3) the residents reviewed for accidents. Resident #1 Findings include: Record review of the facility's policy titled, Standards of Care, dated May 2022, revealed, 1. PURPOSE AND APPLICABILITY This policy identifies the designated nursing reference manual for licensed and unlicensed nursing staff . in all programs . 2. POLICY: .The certified nursing assistant textbook currently in use by Staff Education is the designated reference manual for unlicensed nursing staff 3. PROCEDURE . D. Prior to executing any clinical procedure, all nursing staff will: (1) Verify physician/nurse practitioner order for patient/resident . Record review of the Investigative Findings, dated March 8, 2024, revealed the investigation of a fall involving Resident #1. The initial concern identified in the investigation was that the fall of Resident #1 may have been related to the resident's unexpected death, due to the close proximity of the two (2) events. However, through the facility's investigation, the facility determined that the death of Resident #1 was unrelated to the fall. Further review of the facility's investigation revealed that on February 23, 2024, the Certified Nurse Aide (CNA) assigned to her care, failed to follow the physician's orders related to the use of siderails when the resident was in bed. Record review of RCA (Root Cause Analysis) Review dated February 26,2024 revealed .Concerns .2. There was a physician's order for the bed's side rails to be up, but they were not .Root Causes A. Fall The root cause for the resident's fall was the side rails of the bed were not raised in accordance with the physician's order . Record review of a handwritten Physicians Orders dated 2/9/24 revealed Siderails x 2 when in bed R/T (related to) Profound IDD (Intellectual and Developmental Disability), Delusional Disorder, Does not foresee potential hazards x 30 days . On 3/20/24 at 11:02 AM, in an interview with the Administrator she revealed that during their morning meeting, it was discovered that the CNA #1 put the siderails down while Resident #1 was in bed, which could have led to the fall of Resident #1. The Administrator revealed CNA #1 did not follow the physician orders and plan of care regarding the care of Resident #1. The Administrator stated she expects all staff to adhere to the physician orders. On 3/20/24 at 11:27 AM, in an interview with the Director of Nursing (DON), she revealed she has educated the CNA's on following the plan of care for residents. She stated the ADL (Activities of Daily Living) guidebook is specific to each resident's needs. The DON confirmed the CNAs are to use the guidebook, while caring for their residents. She confirmed that the siderail requirements for Resident #1 were reflected in the guidebook, however, CNA #1 did not follow the guidebook. On 3/20/24 at 1:38 PM during the interview with CNA#1, she confirmed she has been caring for Resident #1 since she was admitted a year ago by the facility as well as the night the resident fell out of bed. She indicated she uses the ADL guidebook to care for her residents and acknowledges the bedrail requirement for Resident #1 was in the guidebook. However, she explains that the resident was the type of resident who would do whatever she wanted, regardless of trying to redirect her. The CNA stated that when the siderails were up, the resident would kick, hit, or spit or just try to climb over the rails altogether. So, the night she fell , the CNA had decided to let them down to prevent the resident from becoming agitated. CNA# 1 revealed she had not notified the nurse on duty about the resident's behaviors or that she had let the siderails down for Resident#1. On 3/20/24 at 2:13 PM, during a phone interview with Licensed Practical Nurse (LPN) #1, she confirmed she was working the night Resident #1 fell . She revealed CNA #1 had reported to her that she had found the resident sitting up on the floor with the sheets around her feet. She said she assessed the resident as per protocol, which included such as vital signs and neuro checks. During this time, she noticed the siderails were down but when questioning the CNA #1, she never got a clear answer about how the siderails got down. LPN#1 admits that she knows they must always follow the physician orders and that nurses must contact the physician before making any changes to the resident's care. A record review of the Identification and Summary Sheet, revealed the facility admitted Resident #1 on 4/27/23. Her diagnoses included Delusional Disorder, Atrial Fibrillation, and Hypertension. A record review of the Minimum Date Set (MDS), for Resident #1, with an Assessment Reference Date (ARD) of 1/25/24, revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure the resident's meals maintained a palatable temperature. This had the potential to affect 34 of the 34 residents receiving meals in building 31. Findings include: Review of the facility's policy, Isolation Meals, Food Storage and Service, dated June 2021, revealed . This policy establishes procedures for the safe handling of meals during isolation and during food storage and service. It applies to all [NAME] Nursing Home (JNH) employees . Food delivered for meal service: .Length of time, rather than temperature levels, will be used to control, ready-to eat food from the resident pantries . Immediately on receipt of hot food in resident care buildings the temperature will be taken using the bimetallic stem thermometer and recorded on the MSH Food Temperature Log (MSH 51). The food will be placed in the pre-heated stem table to maintain a palatable temperature. The temperature should be at or above 135 degrees F (Fahrenheit). If the food is received below 135 degrees, reheat in microwave to 165 degrees F for 15 seconds or contact the Food Services Contractor to request additional food . An observation on 1/23/23 at 12:51 PM, revealed residents eating lunch that was served in individual Styrofoam plates. The SA was informed that the food was being transported on a cart from the main campus. The residents were served sloppy Joe's, potato chips, squash casserole, coleslaw, and marble cake. During interviews with Resident #44 and Resident #38 on 1/23/23, at 12:53 PM, both residents complained that their food was cold. The residents revealed that their food had been cold for the last six (6) days. During an observation with the Director of Nursing (DON) on 1/24/23, at 12:54 PM, the food was observed being brought in from the main campus on individual Styrofoam plates. The residents were received popcorn shrimp, oven fried crinkle cut fries, Capri vegetables, corn salad, rolls, and lemon shortbread bars. During an interview with residents in the dining room on 01/24/23, at 12:54 PM, they confirmed the food was cold when served. The Director of Nursing (DON) was present during the interviews. Resident # 38 gave the State Agency (SA) and the DON a piece of zucchini to touch. The zucchini felt cold to the touch. During an interview on 1/24/23 at 2:00 PM, with the DON and the Clinical Nursing Administrator, the DON confirmed the lunch was cold. The Clinical Nursing Administrator said maintenance was working on the pantry in this building (Building #31), which probably required the foods to be served in Styrofoam plates. The Clinical Nursing Administrator stated she was going to notify the Administrators. During an interview on 1/24/23 at 2:30 PM, with the Pantry Food Service Tech she stated did not know the food was cold. The Pantry Tech said she doesn't temp the food when it's sent to the building in individual Styrofoam trays. The Pantry Tech said it's the responsibility of the Certified Nursing Assistants (CNAs) to let her know the residents complained of cold food. During an interview on 1/24/23 at 3:00 PM, with the Administrator and the Director of the Nursing Home Administrator, they revealed the maintenance Department has been working on the pantry for the last 2 weeks. The Administrator said the resident's food is normally sent in steam pans and served by the pantry workers on regular plates. The Administrator stated that she was unaware the food was being served cold and will have the pantry workers warm the resident's food in the microwave until the pantry maintenance is completed. During an interview on 01/25/23 at 3:55 PM, CNA #1 confirmed the residents have complained about the food being cold and that she had previously reported the complaints to the pantry worker. A record review of the facility's Identification Summary Sheet, revealed, the facility admitted Resident #38 to the facility on [DATE], with diagnoses that included Arthritis and Hypothyroidism. A record review of the Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 11/10/22, for Resident #38 revealed, a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #38 was cognitively intact. A record review of the facility's Identification Summary Sheet, revealed, the facility admitted Resident #44 to the facility on [DATE], with diagnoses that included Diabetes Mellitus, Dementia and Hypertension. A record review of the Quarterly MDS, with the Assessment Reference Date (ARD) of 11/03/22, revealed Resident #44 had a BIMS score of 11, which indicated Resident #44 had moderate cognitive impairment.

Based on interviews, record review, and facility's policy review, the facility failed to designate a staff member of the interdisciplinary team responsible for working with the hospice representative to coordinate care provided by the hospice service and the facility for one (1) of one (1) sampled residents receiving hospice care. Resident #63 Findings include: A record review of the facility's policy, Routine Hospice Home Care Services, undated, revealed Based upon the needs of the Resident and family as determined and prior approved by Hospice, . services related to the management of the terminal illness will be provided to eligible Residents by Hospice . IV. Cooperation in Professional Management . 4.3 . d. Designate a member of the Nursing Home's interdisciplinary group to be responsible for working with Hospice representatives to coordinate care to the Resident provided by the Nursing Home and Hospice Staff . The designated interdisciplinary team member is responsible for the following: i. Collaborating with Hospice representatives and coordinated Nursing Home staff participation in the hospice care planning process for those residents receiving these services; ii. Communicating with Hospice representatives and other healthcare providers . to ensure quality of care for the patient and family; iii. Ensuring that the Nursing Home communicates with the Hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians . On 01/23/23 at 03:17 PM, during an interview with the Resident Representative (RR) of Resident #63, she explained Resident #63 has been receiving hospice services for several months. The RR revealed that although there are times that hospice and the facility correspond with her regarding the resident's care, it's not very often. On 01/24/23 at 09:15 AM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that she has worked at the facility through a contract agency for one (1) year. LPN #1 revealed that the hospice nurse comes and visits the resident regularly and informs the nurse who is working of the findings before leaving. On 01/25/23 at 10:10 AM, during an interview with LPN #2, she explained the Hospice nurse comes once a week and a certified nurse aide (CNA) comes three (3) times a week. Hospice also has a Chaplin and a Social Worker that come once a month. The nurse explained when the Hospice nurse and CNAs come and visit with Resident #63, they report to the nurse on duty. On 01/25/23, at 11:00 AM, during an interview with the Administrator, she revealed the facility does not have a Hospice Coordinator that coordinates the resident's care with hospice. The Administrator explained the doctor is the staff member who determines if hospice is appropriate for a resident and discusses his recommendations with the family. If the family decides that they are interested in hospice, a consult is sent to the hospice of the family's choice. The Administrator confirmed that the facility nurses working with the resident consult with the hospice nurse, aides, and physicians as needed. On 01/25/23, at 11:50 AM, during a phone interview with Registered Nurse (RN) #1/Hospice Nurse, she explained this has been her first week seeing Resident #63, but the resident has been on Hospice services since August 2021. She explained the resident is seen by a RN once a week and by a CNA three times a week. After each visit, RN #1 stated the hospice nurse should call family members and report any findings or changes. The hospice staff report to Resident #63's facility nurse after each visit. RN #1 revealed the facility has their own care plan meetings, with the Hospice staff attending when possible. She confirmed (Proper Name) Hospice has its own care plan meetings every two weeks and reports any changes to the facility nurse on their next visit. On 1/25/23 at 11:57 AM, during an interview with the facility's Director of Nursing (DON), she reported to her knowledge the facility does not have a staff member that is the facility's Hospice Coordinator. On 1/25/23 at 12:03 PM during an interview, the Administer revealed the hospice nurses do not attend the facility's care plan meetings for Resident #63. On 1/25/23 1:20 PM, during an interview with Social Services #1, she explained she sets up Resident #63's care plan meetings quarterly, and as needed. She explained (Proper Name) Hospice is invited to all the care plan meetings, but she doesn't recall that they have attended any of the meetings. She revealed that Resident #63's RR is invited and attends per telephone. Record review of Resident #63's Identification and Summary Sheet, revealed the facility admitted the resident to the facility on [DATE]. The resident's diagnoses included Advanced Huntington Disease, Depression, Psychosis, and Debility due to Chronic Disease. Record review of Resident #63's Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/16/22, revealed . Section C Staff Assessment for Mental Status revealed short-term and long-term memory problems . moderately impaired cognitive skills . Section O . resident received hospice care . Record review of Physician Orders revealed orders for DNR (Do Not Resuscitate), no hospitalization , comfort care only at nursing home, and (Proper Name) Hospice.

Based observations, interviews, record review, and facility policy review, the facility failed to implement an ongoing resident-centered activities program that incorporates the resident's interests for two (2) of 35 residents in building #31. Resident # 51, Resident # 64 Findings Include: Review of the facility's policy, Residents Rights, dated May 2021, revealed, The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . The resident has the right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interest, assessment, and plan of care. The resident has the right to interact with members of the community and participate in community activities both inside and outside the facility . The resident has the right to organize and participate in resident groups in the facility . The resident has the right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility . Review of the facility's Recreational Therapy guidelines, Procedure Guide, undated, revealed Recreational Therapy is a treatment service designed to restore, remediate and rehabilitate a person's level of functioning and independence in life activities, to promote health and wellness as well as reduce or eliminate the activity limitations and restrictions to participation in life situations caused by illness or disabling condition . A recreational therapist utilizes a wide range activity and community based interventions and techniques to improve the physical, cognitive, emotional, social, and leisure needs of their clients. Recreational therapists assist clients to develop skills, knowledge, and behaviors for daily living and community involvement. The therapist works with the client and their family to incorporate specific interests and community resources into therapy to achieve optimal outcome that transfer to their real life situation . Engaging in meaningful, purposeful activities, with roles and routines eliminate boredom, loneliness, improves self-esteem, independence and gives people something to look forward to every day. Resident # 51 A record review of the Resident Care Plan Update, for Resident #51, revealed a problem related to poor decision-making skills. The goals to address this identified problem was for the resident to improve his cognitive level and decision-making skills by participating in outdoor activities, board games, group therapy and a one-on-one weekly therapy session one (1) time a week for 30-45 minutes. A record review of the facility's, Quarterly Recreation Note, dated 12/8/22, revealed, The resident has made slight progress towards his care plan goal . The resident has been more active in activity group attending 2x (times) to 3x weekly for 25-30 minutes. The resident participates in chapel, art and crafts, special events and socials. The resident also enjoys being outside for leisure time. RT (Recreational Therapy) will continue to provide activities for leisure interests and socialization so that the resident won't become isolated. RT will continue to offer praise and encouragement for active participation in group activity . A record review of the facility's, Recreation Assessment, dated 12/8/22, revealed Resident #51's activity preference is church activities, small groups, music, one on one, large groups, watching TV and outdoor outings. Review of the facility's posted Activity Calendar, dated 1/23/23, revealed the Computer Lab was scheduled for 10:30 AM. During a general observation on 1/23/23, at 10:31 AM, several residents, including Resident #51 were observed propelling themselves in their wheelchairs up and down the hallway. Three (3) residents were observed coloring in the dining room. Several residents were observed lying in bed, with no activities noted. There were no other resident activities observed in progress. During an interview on 1/23/23, at 10:59 AM with Resident #51, he complained of boredom with nothing to do. Resident #51 revealed that he enjoyed cooking, listening to music, watching movies, reading newspapers, and going outside. Review of the Activity Calendar, dated 1/23/23, revealed popcorn/movies were scheduled for 2:00 PM. An observation on 1/23/23, at 2:00 PM, revealed Resident #51 propelling himself in his wheelchair up and down the hallway. There were no activities observed in the dining room. Review of the Activity Calendar, dated 1/23/23, revealed one on one bed visits were scheduled for 3:30 PM. There were no visits or activities observed at that time. An observation on 1/23/23, at 3:30 PM, revealed Resident #51 propelling himself up and down the hallway. Resident #51 was not observed interacting with peers. Review of the Activity Calendar, dated 1/24/23, revealed Art Therapy was scheduled for 10:30 AM. There were three (3) residents observed coloring in the dining room. An observation on 1/24/23, at 10:34 AM, revealed Resident #51 in the hallway, propelling himself in his wheelchair up and down the hallway. Review of the Activity Calendar, dated 1/24/23, revealed board games were scheduled for 2:00 PM. An observation on 1/24/23, at 2:15 PM, revealed Resident #51 propelling himself in his wheelchair up and down the hallway. Resident #51 was not observed interacting with his peers. Review of the Activity Calendar, dated 1/24/23, revealed card/table games were scheduled for 3:00 PM. An observation on 1/24/23, at 3:39 PM, revealed Resident #51 sitting in the hallway, not interacting with his peers. There were no activities observed taking place in the dining room. Review of the Activity Calendar,' dated 1/25/23, revealed a van ride was scheduled for 10:00 AM, and Computer Lab was scheduled for 10:30 AM. An observation on 1/25/23, at 10:30 AM, revealed Resident #51 propelling himself in his wheelchair up and down the hallway. There were no activities going on in the dining room. Review of the Activity Calendar, dated 1/25/23, reveal Crash/Cards were scheduled for 2:00 PM. An observation on 1/25/23, at 2:00 PM, revealed Resident #51 propelling himself in his wheelchair up and down the hallway. There were no activities observed taking place in the dining room. During an interview on 1/25/23, at 2:10 PM with the Director of Nursing (DON) and the Clinical Nursing Administrator, they confirmed Resident #51 had been propelling himself up and down the hallway all week. The Clinical Nursing Administrator said she didn't know why the Recreational Therapist had not been providing therapeutic activities, because she had the resources and special software to assist in selecting appropriate activities based on the resident's interest. Review of the Activity Calendar, dated 1/25/23, revealed Trivia/Crafts were scheduled for 3:00 PM. An observation on 1/25/23, at 3:40 PM, revealed Resident #51 propelling himself in his wheelchair up and down the hallway. There were no activities observed in the dining room. A record review of the Identification Summary Sheet, revealed the facility admitted Resident #51 to the facility on [DATE], with diagnoses that included Coronary Artery Disease, Advanced Dementia, and Hypertension. A record review of the Annual Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 3/10/22, revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of 9, that indicated Resident #51 had moderate cognitive impairment. Review of Section F, revealed it is very important for Resident #51 to have books, newspapers, and magazines to read, that he is able to listen to music, do group activity, go outside, and participate in religious services. Resident #64 A record review of the Resident Care Plan Update, for Resident #64 revealed a problem of low cognition functioning. The identified goal to address this problem included attending and participating in activities to improve his cognitive functioning. The activities identified to assist with reaching this goal included reminiscing, memory games, reality orientation, chapel, word trivia, music therapy, and word search twice weekly for 15- 35 minutes. A record review of the facility's, Quarterly Recreation Note, dated 12/12/22, revealed, . RT (Recreational Therapy) will continue to provide activities 2x to 3X weekly for 20-25 minutes for resident leisure interest and socialization. RT will continue to offer chapel, music therapy, arts and crafts, table games, card games (Crash), special events, and socials to help keep the resident engaged, and not become isolated . Review of the Activity Calendar, dated 1/23/23, revealed the Computer Lab was scheduled for 10:30 AM, however, there were no activities in progress at that time. During an interview on 1/23/23, at 11:19 AM, Resident #64 complained he was bored with nothing to do. Resident #64 said he sits in the dining room every day and watches the staff come in and out. The resident revealed he doesn't care for coloring, but he enjoys church services, music, arts and crafts, and card games. Review of the Activity Calendar, dated 1/23/23, revealed popcorn/movies were scheduled for 2:00 PM. An observation on 1/23/23, at 2:00 PM, revealed Resident #64 propelling himself in his wheelchair up and down the hallway. There were no activities observed in progress at this time. Review of the Activity Calendar, dated 1/23/23, revealed one on one bed visits were scheduled for 3:30 PM, however, there were no visits or activities observed at that time. An observation on 1/23/23, at 3:30 PM, revealed Resident #64 propelling himself in his wheelchair up and down the hallway. Review of the Activity Calendar, dated 1/24/23, revealed Art Therapy were scheduled for 10:30 AM. An observation on 1/24/23, at 10:34 AM, revealed Resident #64 sitting in dayroom. There were three (3) residents observed coloring in the dining room. Review of the Activity Calendar, dated 1/24/23, revealed board games were scheduled for 2:00 PM. An observation on 1/24/23, at 2:15 PM, revealed Resident #64 propelling himself in his wheelchair up and down the hallway. The resident was not observed interacting with his peers. Review of the Activity Calendar, dated 1/24/23, revealed card/table games were scheduled for 3:00 PM. An observation on 1/24/23, at 3:39 PM, revealed Resident #64 sitting in the hallway. There were no activities observed in progress. Review of the Activity Calendar, dated 1/25/23, revealed a van ride was scheduled for 10:00 AM, and Computer Lab at 10:30 AM. An observation on 1/25/23, at 10:30 AM, Resident #64 was observed sitting in his room. There were no activities observed in progress at this time. Review of the Activity Calendar, dated 1/25/23, revealed Crash/cards were scheduled for 2:00 PM. An observation on 1/25/23, at 2:00 PM, revealed Resident #64 propelling himself in his wheelchair up and down the hallway. There were no activities observed in progress at this time. Review of the Activity Calendar, dated 1/25/23, revealed Trivia/crafts were scheduled for 3:00 PM. An observation on 1/25/23, at 3:40 PM, revealed Resident #64 propelling himself in his wheelchair up and down the hallway. There were no activities observed at this time. A record review of the Identification and Summary Sheet, Resident #64 was admitted by the facility on 3/26/21, with diagnoses that included Alzheimer's Dementia, Schizoaffective Disorder, and Depression. A record review of the Annual MDS, with the ARD of 3/31/22, revealed Resident #64 had a BIMS score of 7, that indicated Resident #64 had severe cognitive impairment. Review of section F revealed it is very important for Resident #64 to have books, newspapers, and magazines to read, the ability to listen to music, be around pets and animals, do group activity, go outside, and participate in religious services. During an interview on 1/25/23, at 3:44 PM with the Recreational Therapist, she revealed she had included the van ride on the calendar. The Therapist stated it took two recreational employees to take one (1) resident around town, so no other residents received activities that day. However, she revealed that when the activity department is out of the building with residents, the Certified Nurse Aides (CNAs) are responsible for providing activities for the other residents. The Therapist also revealed that she only receives a budget of $140.00 a year for activities. As far as the one-on-one bed visits scheduled on the calendar for today, the Therapist confirmed she had other things to do and was unable to provide those visits today. The Therapist also revealed that if the residents don't come to the dining room, they don't get to participate in the activities that are done. In an interview on 1/25/23, at 3:55 PM with CNA #1, she confirmed she has not provided activities for residents, because she doesn't have time. CNA #1 said she has to bathe her residents, feed them, make beds, and keep them clean. During an interview on 1/25/23, at 4:04 PM with CNA #2, she said she turns the television on in the resident's room to provide activities. CNA #2 revealed she's busy most of the day providing Activities of Daily Living (ADL) care. The CNA stated the activity department needs to provide more activities for the residents. During an interview on 1/25/23, at 4:15 PM, the Administrator revealed the Recreational Therapist is supposed to provide a list of things needed for activities to the Administrator for approval. Once purchases are approved, the Administrator gives the recreational department a facility credit card to make the purchases. The Administrator said the Recreational Therapist is not limited to a yearly budget of $140.00 and has resources, but is not utilizing them. During an interview on 1/26/23, at 1:10 PM with the Director of Recreation and the Recreation Supervisor, they confirmed that calendars are done by each building Therapist and should be done according to each resident's interests. The Director revealed she doesn't know why the Therapists have not provided activities in building #31 because she has not been making rounds. The Director confirmed the yearly budget is not limited to $140.00. The Recreation Supervisor said she thought the therapist was following the calendar and providing activities for all the residents. Both the Recreational Director and the Supervisor confirmed all the residents in the facility should be provided activities of interests, even on days that the therapists take other residents on a ride in the van.

Based on interviews, record reviews, and facility policy review, the facility failed to protect a resident's right to be free from abuse for one (1) of five (5) residents sampled for abuse. Resident #1 Findings include: Review of the facility's policy titled INJURIES, ABUSE, NEGLECT, MISTREATMENT, MISAPPROPRIATION OF RESIDENT PROPERTY OR EXPLOITATION OF RESIDENTS, dated July 2021, revealed . (Proper name of facility) residents have a right to be free from abuse .Physical abuse includes hitting, slapping, pinching, and kicking . Record review of a document listing the facility's incidents and accidents, revealed an entry dated 2/17/22 at 3:30 PM, for Resident #1 with the description of the event/incident as It was reported that Resident (#1) was sitting in his wheelchair in the male dayroom when Certified Nurse Aide (CNA) #1 approached him. They began having a conversation when Resident (#1) began cursing. Staff heard CNA (#1) asking Resident (#1) What the (expletive) did I do to you? Resident #1 began to leave the dayroom when it was alleged that CNA (#1) kicked the back of his wheelchair. Staff was removed off the building, later placed on administrative leave until the conclusion of the investigation . Review of Investigative Findings dated 2/23/22, revealed that the Department of Safety & Investigative Services was advised of the possible physical abuse of Resident #1 on 2/17/22, at 3:20 PM. The four (4) employees that witnessed the incident were interviewed and although only two (2) of the witnesses were able to hear CNA #1 curse at the resident, all four (4) witnesses confirmed that they saw CNA #1 hit the back of his wheelchair with her foot with enough force to propel the wheelchair forward. The report revealed Finding: PHYSICAL ABUSE - SUBSTANTIATED. Upon completion of the investigation, the matter was referred to the Administrator and Human Resources Department for disposition. On 8/22/22 at 4:30 PM, an interview with the Administrator revealed she was aware of the allegation of abuse of Resident #1 by (CNA) #1. She stated a complete investigation was conducted and the allegation of abuse was confirmed. Immediately following the report of abuse to the nurse on 2/17/22, the CNA #1 was removed from resident care to ensure the protection of residents, pending the outcome of the investigation, and terminated upon completion. She confirmed she had reported the incident to the State Agency (SA) and the Attorney General's Office (AGO). On 8/23/22 at 10:30 AM, an interview with CNA #2 revealed was she working on 2/17/22 and witnessed CNA #1 enter the male day room and engage in conversation with Resident #1. CNA #2 said she heard Resident #1 getting loud and cursing and she verbalized a warning to CNA #1 to leave Resident #1 and let him calm down, but she said Resident #1 was so loud she did not think CNA #1 could hear her. She stated she did not see Resident #1 strike out at CNA #1, but she saw CNA #1 back away from Resident #1 abruptly and heard CNA #1 say to Resident #1 What the (expletive) did I do to you? She stated CNA #1 walked behind Resident #1, lifted her foot and kicked the back of Resident #1's wheelchair and it just took off across the room. CNA #2 said she immediately got up and went and reported the incident to RN #1. CNA #2 confirmed that CNA #1 was immediately removed from resident care and left the facility. CNA #2 confirmed she had participated in an investigation and completed a written witness statement. On 8/23/22 at 11:20 AM, an interview with CNA #3 revealed on 2/17/22, she heard Resident #1 yelling at CNA #1 and witnessed Resident #1 swing at CNA #1. She stated that she witnessed CNA #1 kick the back of Resident #1's wheelchair and the force of the kick sent Resident #1's wheelchair rolling across the room and his right knee bumped into the wall. Record review of the Identification and Summary Sheet for Resident #1 revealed he was admitted by the facility on 3/26/21. He had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly Minimum Data Set (MDS) with reference date (ARD) 6/30/22, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Record review of the employee file for CNA #1 revealed License/Certification/Registration Renewal Verification, dated 5/20/21, confirmed CNA held current certification as a Certified Nurse Aide. Review of the Nurse Aide Registry Verification dated 4/21/21 confirmed CNA #1 was originally certified on 3/30/21, as a Nurse Aide.

Based on staff interview, record review, and facility policy review, the facility failed to notify the Resident Representative of the facility bed hold policy following transfer to the hospital for one (1) of two (2) residents reviewed, Resident #69. Findings include: Review of facility policy titled Hospital or Therapeutic Leave Bed Hold Policy dated (MONTH) (YEAR), revealed the facility will provide each resident and his/her resident representative notice of the facility's policy regarding the holding of a resident's bed at the time of admission and when he/she goes on leave from the facility. This policy applied to all residents of the facility. Record review of a physician's orders [REDACTED]. Record Review of Resident #69's chart revealed there was no bed hold policy/letter provided to Resident #69 or their Resident Representative at the time Resident #69 was transferred to the hospital. An interview on 07/25/19 at 10:45 AM, with Resident #69's next of kin, revealed the Social Worker had been great to call and tell her when Resident #69 has gone out, but she had never received a letter from anyone about her going to the hospital, nor received a letter about the bed hold. She stated, I certainly would have remembered that because I would be afraid they were not going to let my niece go back there. I would have called them quick and ask about what they were talking about. An interview on 07/25/19 at 11:53 AM, with the Social Worker revealed she did not send Resident #69's Resident Representative a bed hold letter when she was transferred to the hospital. An interview on 07/25/19 at 03:45 PM, with the facility Administrator, revealed To my knowledge, we don't send a letter to notify the Resident Representative of a bed hold if a resident goes to the hospital.

Based on staff interview, record review, and facility policy review, the facility failed to notify a Resident Representative, in writing, of a transfer to the hospital for one (1) of two (2) residents reviewed for transfers, Resident #69. Findings include: Review of facility policy titled Hospital or Therapeutic Leave Bed Hold Policy, dated (MONTH) (YEAR), revealed: Before transfer of a resident from (the facility name) to a medical/care facility, the facility must notify the resident and, if known, the representative of the resident, of the transfer in writing and in a language and manner they understand. Record review of a physician's orders [REDACTED]. Record review of Resident #69's chart revealed there was no transfer letter/notice provided to Resident #69 or to their Resident Representative at the time of transfer to the hospital. An interview on 07/25/19 at 10:45 AM, with Resident #69's Resident Representative and next of kin, revealed, My sister (Resident #69's mother), passed away more than a year ago. I'm [AGE] years old but stepped in and have tried to help with my niece. The Social Worker has been great to call and tell me when she has gone out but I never received a letter from anyone about her going to the hospital. Now, they called me and told me, but I never got a written letter. An interview on 07/25/19 at 11:53 AM, with the Social Worker, revealed she did not send the family a letter stating that Resident #69 went out to the hospital, nor did she notify the Ombudsman. An interview on 07/25/19 at 03:45 PM, with the facility Administrator, revealed, We basically call the family when a resident leaves the facility for the hospital. We don't send a letter to anyone. To my knowledge, we don't send a letter to notify the Resident Representative of a bed hold if a resident goes to the hospital.

Based on staff interview, record review, and facility policy review, the facility failed to revise the Percutaneous Endoscopic Gastrostomy (PEG) Care Plan to reflect the resident frequently slumps in the bed and required more frequent checks for positioning to help prevent aspiration and other complications related to continuous PEG tube feeding for one (1) of three (3) Care Plans reviewed, Resident #9. Findings include: A review of a document provided by the facility Administrator revealed the facility does not have a policy regarding care plans, enteral feedings, and positioning body alignment. The document noted that Nursing staff refer to the Lippincot Manual of Nursing Procedures (Seventh Edition) for procedural steps for the following: Care Plans, Enteral Feeding, and Positioning Body Alignment. This was signed by the Administrator and dated 7/25/19. A review of the document provided by facility Administrator, who stated that the document was pages from the Lippincot Manuel and were used as guidelines in Percutaneous Endoscopic Gastrostomy (PEG) care and creating Care Plans, revealed, A care plan directs the patient's nursing care from admission to discharge. This written action plan is based on nursing [DIAGNOSES REDACTED]. Update and revise the plan throughout the patient's stay based on the patient's response. The document noted, Have the patient sit or maintain the head of the bed at an elevation of at least 30 degrees (45 degrees is preferred) unless contraindicated by the patient's condition to prevent [MEDICAL CONDITION] reflux and [MEDICAL CONDITION] aspiration of the feeding formula. The document also revealed to elevate the head of the bed a minimum of 30 degrees, preferably 45 degrees, to manage enteral tube feeding problems. The document also revealed various assistive devices can be used to maintain correct body alignment and to help prevent complications that commonly arise when a patient must be on prolonged bed rest. A review of the article titled Nutrition and [MEDICAL CONDITION]'s Disease dated 2010, released by the [MEDICAL CONDITION]'s Disease society of America revealed, to position the person so that he/she is sitting up, or at least so the upper body is above the level of the stomach. Record Review of the current Care Plan revealed Resident #9 was admitted to Hospice for a [DIAGNOSES REDACTED].#9's care plan documented a problem of totally dependent x two (2) persons for bed mobility, and a high risk for aspiration and choking related to PEG tube placement, and [MEDICAL CONDITION]'s disease. The Care Plan documented to reposition every two (2) hours and as needed. The Care plan did not document any interventions or frequent checks related to Resident #9's frequent repositioning ability to get herself flat in the bed. Observations on 07/23/19 at 09:55 AM, 7/24/19 at 8:21 AM, and 7/24/19 at 3:15 PM, revealed Resident #9 lying in bed. Two Cal 2.0 feeding formula was infusing at 45 cubic centimeters per hour (cc/hr) via feeding pump. The head of Resident #9's bed frame was elevated at approximately 20 degrees and 45 degrees. There was a wide wedge at the head of the bed located under the sheet with a pillow on top of the wedge on the outside of the sheet. Resident #9's body was slumped down in the bed at a flat angle on all three (3) occasions and/or with the upper body at the same angle as the stomach. An observation on 07/25/19 at 06:55 AM, revealed Resident #9 was lying in bed with her head towards the right side of the bed railing and off the pillow and wedge. Two Cal 2.0 was infusing continuously at 45 cc/hr via feeding pump. Resident #9's legs were lying towards the left side of the bed railing with the head of bed (HOB) at approximately 45 degrees. Resident #9's body was slumped down in the bed with her left shoulder slightly elevated with edge of the pillow with the upper body at the same angle of the stomach. Licensed Practical Nurse (LPN) #1 entered Resident #9's room and the feeding pump was beeping. LPN #1 stated that Resident #9 was always slumped to the right side of the bed because the resident had End Stage [MEDICAL CONDITION]'s Disease and that was how she always lay in bed. LPN #1 stated that Resident #9 always moved around in bed as part of her [MEDICAL CONDITION]'s. During an interview on 07/25/19 at 03:15 PM, the Director of Nursing (DON) stated, The Care Plan is an on-going plan of care for a resident. You should be able to read the care plan and know what to do for a resident. We are supposed to do everything for our residents. I can't say yes or no that positioning of Resident #9 should be revised on the care plan. We can straighten Resident #9 up in bed and she gets into positions herself. I'll see what therapy can offer for her. During an interview on 07/25/19 at 04:15 PM, RN #3, Care Plan Nurse, revealed that a care plan is a plan to be able to care for a resident. RN #3 stated that Resident #9 positioning down in the bed makes the resident a high risk for aspiration with continuous tube feeding. She stated, The Care Plan should be revised to add positioning issues and interventions to help with positioning. RN #3 stated that Resident #9 also has End Stage [MEDICAL CONDITION]'s Disease and that too would make her a high risk for aspiration. RN #3 stated that she felt the Enteral Feeding Care Plan should be revised for maybe 15 minute checks because of the [MEDICAL CONDITION]'s disease and the spasmodic movements caused by that disease. RN #3 revealed that Any nurse who takes care of a resident should be able to look at a care plan and know exactly what a resident needs. The Care Plan just should have been revised. I will contact the physician and see what he thinks about therapy.

Based on staff interview, record review, and facility policy review, the facility failed to position a resident who received Percutaneous Endoscopic Gastrostomy (PEG) tube feedings to help prevent complications such as aspiration for one (1) of three (3) residents reviewed for positioning, Resident #9. Findings include: A review of a document provided by the facility Administrator revealed the facility does not have a policy regarding enteral feedings and positioning body alignment. The document noted that Nursing staff refer to the Lippincot Manual of Nursing Procedures (Seventh Edition) for procedural steps for Enteral Feeding and Positioning Body Alignment. This was signed by the Administrator and dated 7/25/19. A review of a document, provided by the Administrator, revealed the document was pages from the Lippincot Manuel and were used as guidelines in Percutaneous Endoscopic Gastrostomy (PEG) care. The document noted, Have the patient sit or maintain the head of the bed at an elevation of at least 30 degrees (45 degrees is preferred) unless contraindicated by the patient's condition to prevent [MEDICAL CONDITION] reflux and [MEDICAL CONDITION] aspiration of the feeding formula. The document also revealed to elevate the head of the bed a minimum of 30 degrees, preferably 45 degrees, to manage enteral tube feeding problems. The document also revealed various assistive devices can be used to maintain correct body alignment and to help prevent complications that commonly arise when a patient must be on prolonged bed rest. A review of the article titled Nutrition and [MEDICAL CONDITION]'s Disease, dated 2010, released by the [MEDICAL CONDITION]'s Disease society of America revealed, to position the person so that he/she is sitting up, or at least so the upper body is above the level of the stomach. A review of the article titled Oral feeding in [MEDICAL CONDITION]'s Disease: a guideline document for speech and language therapists dated 2012, revealed, Involuntary movements create increasing difficulties in Late stage [MEDICAL CONDITION]'s Disease. Dietary modifications, the use of compensatory swallowing techniques, the manipulation of head or body postures and maneuvers to support safe and efficient swallowing should continue. All caregivers should be in receipt of specific instructions on positioning and postures. Regular monitoring of the individual with [MEDICAL CONDITION]'s Disease weight, hydration, nutrition and occurrence of aspiration pneumonia is a key at this stage in the disease. An observation on 07/23/19 at 09:55 AM, revealed Resident #9 lying in bed. Two Cal 2.0 feeding formula was infusing at 45 cubic centimeters (cc) per (/) hour (hr) via feeding pump. The head of Resident #9's bed frame was elevated at approximately 20 degrees. There was a wide wedge at the head of the bed located under the sheet with a pillow on top of the wedge on the outside of the sheet. The Resident's head was lying off of the pillow and wedge against the right side rails of the bed. Resident #9's body was slumped down in the bed at a flat angle. An observation on 07/24/19 at 08:21 AM, revealed Resident #9 was lying in the bed with her head off the pillow and wedge. Resident #9 body was slumped down in the bed with her left shoulder slightly elevated in the bed by the edge of the pillow with the upper body at the same angle as to stomach. Two Cal 2.0 feeding was continuously infusing at 45 cc/hr via feeding pump. The head of bed (HOB) was approximately 45 degrees. An observation at 7/24/19 at 03:15 PM, revealed Resident #9 was lying in bed. The HOB was elevated at 45 degrees. There was a wide wedge at the head of the bed located under the sheet with a pillow on top of the wedge on the outside of the sheet. Resident #9's body was slumped down in the bed with her head at the right side of the bed against the side rails. Resident #9's head was off the pillow and the wedge and her body was at a flat angle in bed. Two Cal was continuously infusing at 45 cc/hr via PEG tube. An observation on 07/25/19 at 06:55 AM, revealed Resident #9 was lying in bed with her head towards the right side of the bed railing and off of the pillow and wedge, with Two Cal 2.0 infusing continuously at 45 cc/hr via feeding pump. Resident #9's legs were lying towards the left side of the bed railing with the head of bed (HOB) at approximately 45 degrees. Resident #9's body was slumped down in the bed with her left shoulder slightly elevated with the edge of the pillow with the upper body at the same angle of the stomach. Licensed Practical Nurse (LPN) #1 entered Resident #9's room and the feeding pump was beeping. LPN #1 stated that Resident #9 is always slumped to the right side of the bed. LPN #1 stated that Resident #9 had End Stage [MEDICAL CONDITION]'s Disease and that was how she always lay in bed. LPN #1 stated that Resident #9 always moves around in bed. That's part of her [MEDICAL CONDITION]'s. An interview on 07/25/19 at 03:15 PM, with the Director of Nursing (DON), revealed We are supposed to do everything for our residents .We can straighten Resident #9 up in bed and she gets into positions herself. I'll see what therapy can offer for her. An interview on 07/25/19 at 04:15 PM, with RN #3, Care Plan Nurse, revealed that Resident #9 positioning down in the bed makes her a high risk for aspiration with the continuous formula feeding. RN #3 stated that Resident #9 also has End Stage [MEDICAL CONDITION]'s Disease and that too would make her a high risk for aspiration.

Based on policy review, record review, observation, interview, and facility investigation review, the facility failed to ensure that one (1) of five (5) residents (Resident #1) was free from verbal and mental abuse when CNA #1 spoke in a loud threatening tone to Resident #1, forcibly removed the resident's lunch tray before the resident was finished eating, and rolled the resident from the dining room into the elevator and sent Resident #1 to the first floor which resulted in mental anguish to Resident #1. CNA #1 was not immediately removed from providing care to other residents but continued to provide care for the remainder of the shift to other residents, some of whom had witnessed the abuse of Resident #1 on 3/3/14 in the dining room. Findings include: Review of the facility's policy entitled, "Injury, Abuse, Neglect, Mistreatment, or Exploitation of Residents" with the date of June 2012 revealed the following: 1. Purpose and applicability. The purpose of this policy is to affirm that Jaquith Nursing Home (JNH) residents have a right to be free from abuse, neglect, sexual battery, mistreatment, exploitation, and misappropriation of property and to outline procedure for complying with Centers for Medicare Medicaid Services (CMS) and the Mississippi Vulnerable Adults Act of 1986 as annotated. This policy applies to all JNH residents and staff. Section D. Identification: "Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Review of the facility's report to the State Survey Agency, of the investigation on 3/3/14 involving the allegation of abuse by CNA #1 of Resident #1 revealed in section C, "Details, Observations, Belief concerning the incident:" that "On 3/3/14 (Proper Name) Licensed Practical Nurse (LPN) #1 reported to (Proper Name) Registered Nurse (RN) #1, that at approximately 1:00 PM, during the lunch meal (Proper Name) CNA #1 verbally abused Resident (Proper Name) #1. CNA #1 allegedly responded to Resident #1 in a loud voice when Resident #1 kept cursing CNA #1 and calling her a [***] in a very loud voice. CNA #1 asked Resident #1 to stop and that we could not have that type of behavior in the dining room. When CNA #1 reached for Resident #1's tray Resident #1 jerked it back, and threw water on CNA #1. Resident #1 then threw a blanket and hit CNA #1 in the face. CNA #1 rolled Resident #1 out of the dining room and put her on the elevator and sent her downstairs. Resident #1 was offered her tray but refused to eat. RN #1 was notified and examined Resident #1. There were no visible injuries to Resident #1. RN #1 gave Resident #1 a sandwich and coffee to drink." The report of the investigation stated that the facility substantiated allegations of verbal/mental abuse of Resident #1 by CNA #1. Interview on 3/26/14 at 1:20 PM with RN #1 revealed that she had not witnessed the 3/3/14 incident but about 12:45 PM or 1:00 PM she heard Resident #1 when she got off the elevator cursing and calling RN #1's name. RN #1 stated she talked with the resident and calmed her down. The resident was offered a sandwich and coffee and did consume these. The facility psychologist was coming into the building about the time of the incident and talked with Resident #1. Review of the "Psychology Note" dated 3/3/14 at 2:43 PM for Resident #1 regarding "mental anguish" revealed that "(Proper Name) Resident #1 reported that she is "Scared to death" of a certain CNA. She reported that the CNA had "took my food away", "told me she would take it away if I cussed", "I called her a [***] ". She said this started when the CNA "snatched" the blanket out of her lap and said "You don't need no cover" and threw the blanket on the floor. This led to the incident in the dining hall. Resident #1 then reported "she (CNA #1) pushed me HARD" out of the dining hall. She (Resident #1) says she feels unsafe around this CNA and would feel better if "you fired her". "Call the police". I (Psychologist) and RN #1 informed her of the procedure we have to follow. Encouraged her to maintain her distance from this CNA. She agreed." The note continued saying "Resident #1's mood appeared upset with congruent affect. Her complaint appears valid and she does appear distressed by this one particular CNA. No other changes noted in mental status. She is able to stay focused with prompts. She has a tendency to start making multiple complaints, but reminded to stay with this particular incident, she will. She does have frequent derailment." Interview on 3/27/14 at 9:28 AM with the facility Psychologist confirmed that Resident #1 did appear upset and afraid of the CNA when she assessed her after the 3/3/14 incident. Review of a handwritten and signed report of the 3/3/14 incident by LPN #1 who had witnessed the altercation between Resident #1 and CNA #1 revealed, "witnessed CNA staff member, (Proper Name) CNA #1 yelling at resident, (Proper Name) Resident #1 in upstairs dining room. Resident called CNA a "[***] " continuously while waiting to get her tray to eat. CNA raised voice to resident stating "Don't call me that!" While resident received her tray, she continued to call the CNA a "[***] " and the CNA told the resident that she would take her tray away if she continued to curse in the dining room. The nurse (LPN #1) informed CNA that the resident will only continue to curse if she continued to receive attention for it and that it was best to just ignore the behavior. Resident continued to curse and CNA reached over to grab her tray and resident jerked tray and threw her water on the CNA. Resident then threw her blanket that was in her lap at the CNA while cursing CNA. The CNA went behind the resident and pushed her out of the dining room and onto the elevator while yelling loudly to the resident stating that she wasn't going to sit up in the dining room and curse like that. The resident refused to eat from tray or even go back upstairs. Head nurse was informed of incident, psychology was also informed immediately after the incident." Interview on 3/26/14 at 4:30 PM per phone with LPN #1 confirmed the aforementioned findings and stated the resident was so upset she could be heard screaming downstairs. The LPN stated that the CNA had not responded to her request to "drop it". LPN #1 stated the CNA had continued to work on the second floor with the remaining residents but Resident #1 was on first floor away from CNA #1. Review of the 3/3/14 nurse notes for 1:00 PM for Resident #1 revealed that "Resident became upset with CNA staff upstairs and refused to eat from tray upstairs. Head Nurse gave resident a sandwich & coffee. Consumed all. Resident rolling up & down hallway talking to self & cursing. Redirected resident, behavior improved. Will continue to monitor." Observation on 3/27/14 at 1:15 PM revealed that approximately 17 residents were eating in the second floor dining room where the 3/3/14 incident occurred. Interview on 3/27/14 at 9:40 AM with RN #2, Safety and Investigative Services, revealed that she had talked with CNA #1 on 3/5/14 about the incident on 3/3/14 with Resident #1. The CNA was still upset. RN #2 stated the CNA, prior to the dining room incident, had told Resident #1 that she did not need a blanket. Interview on 3/26/14 at 6:17 PM with the Director Of Nursing (DON) of the facility stated that she was informed of the 3/3/14 incident after the CNA had clocked out on that day. The DON stated when she read the report of the incident the following morning (3/4/14) she recognized abuse of Resident #1 and looked for CNA #1 to remove her from the building. She determined that the CNA was off that day and was not in the building caring for residents. During an interview on 3/26/14 at 3:30 PM, the NHA was questioned about CNA remaining on the time clock from 1:00 PM incident until 3:38 PM on 3/3/14. He stated that the CNA would have been moved to a non-resident care area. He did not immediately know where the CNA had been reassigned but would find out. Interview on 3/27/14 at 8:25 AM with the NHA revealed that the CNA had been allowed to remain in the building on the second floor and that she had continued to provide resident care. Review of a handwritten statement given by CNA #1 on 3/5/14 regarding the 3/3/14 incident revealed, "On March 3, 2014 I was upstairs by myself. (Proper Name) Resident #1 was using the b word, mf word. I'm still feeding my resident. Resident #1 kept cursing and I asked Resident #1 to stop. Resident #1 wouldn't stop and I asked again. So then I got up and asked her to stop because people are trying to eat. Then she threw some of her drink. Then I got on the opposite side, then she threw the sheets on the table and slung food. I kindly redirected her three times and she still cursing and I pulled her in the hallway and then she tried to hit another resident. Then I go to the intercom to call another resident. The resident she tried to hit was trying to get on the elevator and I told her stop and I ran around the corner ant then the nurse came and let Resident #1 go ahead downstairs and then the other resident went. I took her tray after she threw and picked her sandwich up and threw some food." Interview on 3/27/14 at 2:10 PM with CNA #1 revealed that the resident was known to have behaviors and that the CNAs are used to that. The CNA stated that she had quietly tried to redirect Resident #1 and did not raise her voice. CNA #1 stated that the incident must not have been such a "big deal" because she was allowed to complete her shift and remained on the second floor giving resident care. She also was allowed to attend annual training on 3/5/14 and 3/6/14 which required that she go to the facility to clock in and out. The CNA further stated the facility waited three (3) days to put her on leave (3/6/14). CNA #1 stated that Resident #1 had finished eating when she took away the lunch tray and that she had assisted the resident out of the dining room and the resident put herself on the elevator to the first floor. Review of CNA #1's employee file confirmed the facility placed CNA #1 on administrative leave on 3/6/14. The CNA submitted a letter of resignation on 3/24/14 with effective date 3/25/14, which was subsequently accepted by the facility on 3/25/14. Record review for Resident #1 revealed that she was [AGE] years old and the facility admitted her on 7/16/13 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for this resident dated 1/3/14 revealed that the resident had minimal difficulty hearing, had unclear speech, was usually understood by others, and clearly understood the verbal communication of others. The Brief Interview for Mental Status (BIMS) for this resident was 6 which indicated the resident was moderately cognitively impaired. The resident required supervision with bed mobility and locomotion on and off the unit. For dressing the resident required limited assistance of one person. Review of the current care plan for Resident #1 revealed that on 7/19/13 the problems of "Inappropriate Behaviors R/T (related to) refusing snacks, therapy, refusing adl (activities of daily living) care assist, curses peers/staff, delusional thoughts, speaks with those unseen, hx (history) of believing dead people wear her clothes & will throw them away, tears nametags and activity board down, refuses to wear socks or shoes, does not like people in her personal space (will roll away screaming), hx of urinating on floor and in bed, refuses to use sheets on her bed, hx of racial slurs, sexually inappropriate comments" were identified. Approaches for this problem included "Report problem behaviors to nurse", "If meal/snack or ADL care refused re-approach, change staff member, offer conversation, redirect then re-attempt", and "DO NOT get into her personal space when talking with her". Following an allegation of verbal and mental abuse by a Certified Nurse Aide (CNA) #1 on 3/3/14 the care plan was updated on 3/4/14 to identify the problem of "Resident calls staff/residents derogatory names", and "uses racial slurs on a consistent basis, unprovoked" Approaches to manage this problem included "Refer to investigative services as needed" and "Monitor situations which might lead to allegations". Observation of Resident #1 on 3/26/14 at 11:30 AM revealed that she was small, clean, and appropriately dressed. She was in a wheelchair and carried a blanket in her lap. When the resident was asked if surveyor could talk with her she asked why. After it was explained to the resident the purpose of the interview, she responded no, that she did not want to talk.

Based on record review, interview, observation, policy review, and facility investigation review, the facility failed to implement its Injury, Abuse, Neglect, Mistreatment, or Exploitation of Residents policy for two (1) of five (5) residents reviewed for abuse with regard to the required components of recognizing abuse, reporting to Administration for investigation and appropriate action. The facility's Administrative (supervising) staff failed to immediately remove Certified Nurse Aide (CNA) #1 from providing resident care, after she verbally and mentally abused Resident #1, causing mental anguish to Resident #1, in the presence of approximately 17 residents in the second floor dining room on 3/3/14. In addition, the facility's supervising staff failed to recognize and subsequently report on 02/14/14, an allegation of abuse to Administration for investigation when CNA #1 became upset with Resident #5 when he turned over his tray during lunch, and verbally told the resident he was not going to eat and attempted to push his geri-chair out of dining room. Findings include: Review of the facility's established policy Injury, Abuse, Neglect, Mistreatment, or Exploitation of Residents with the date of June 2012 date revealed the following required components: Section D. Identification: "Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Section E: Investigation: When notified of suspected abuse the Nursing Home Administrator (NHA) , Administrative Officer of the Day (AOD), or covering Administrator will immediately notify the MSH (Mississippi State Hospital) Department of Safety and Investigative Services, the Campus Police Department, and the Human Resources Department. The NHA will assist the MSH Department of Safety and Investigative Services, the Campus Police Department, and the Human Resource Department in any way possible to ensure a thorough investigation is completed. Section F. Protection: (1) When alleged abuse is reported, the Nursing Supervisor on direction of the NHA will take immediate action to protect the resident and/or residents. Protective action may include, but not be limited to, separation of the resident and/or residents from any potential or perceived threat by placing the employee on administrative leave and/or removal of an employee in accordance with State Personnel Board Policy and Procedures. Section G. Reporting/Response (1) Employees who have knowledge of or reasonable cause to believe resident abuse has occurred, will immediately make an oral report to the assigned Nursing Home Administrator NHA or the Administrator on duty in the absence of the assigned administrator. Resident #1 Review of the facility's investigation of the 3/3/14 allegation of verbal and mental abuse of Resident #1 by Certified Nurse Aide (CNA) #1 documented that the facility substantiated the abuse of the resident. The investigation stated that on 3/3/14 at approximately 1:00 PM the CNA talked to the resident in a loud voice and had taken the resident's tray from her before the resident had finished eating, and had removed the resident from the dining room and placed the resident on the elevator and sent her to the first floor. Interview on 3/26/14 at 1:20 PM with RN #1 revealed that she had not removed the CNA #1 from the floor and that CNA#1 continued to provide care to other residents on the 2nd floor. She stated that she followed the facility policy and reported the 3/3/14 incident to the Nursing Home Administrator (NHA). Interview on 3/27/14 at 10:10 AM with RN #1 revealed that she had not felt free to remove CNA #1 from providing resident care. Interview on 3/27/14 at 2:10 PM with CNA #1 stated that the incident must not have been such a "big deal" because she was allowed to complete her shift and remained on the second floor giving resident care. CNA #1 stated she came to the facility to attend annual training on 3/5/14 and 3/6/14. Review of the time card for CNA #1 confirmed that she had continued to work until 3:38 PM on 3/3/14 rather than immediately being suspended. On 3/3/14, the date of the 1:00 PM incident, she worked from 7:01 AM to 3:38 PM. On 3/4/14 she was off. On 3/5/14 she clocked in at 7:30 AM and clocked out at 4:07 PM. On 3/6/14 she clocked in at 7:34 AM and clocked out at 9:44 AM. During an interview on 3/27/14 at 9:40 AM with RN #2, she expressed her concern that CNA #1 was allowed to attend an annual in-service requiring that she come to the facility to clock in and out. Interview on 3/27/14 at 8:25 AM with the Administrator of the facility confirmed that CNA #1 was allowed to remain on the building after the incident of abuse rather than immediately being suspended. Resident #5 Review of a Personnel Incident Employee Response dated 2/14/14 at 1:10 PM provided by the facility regarding Resident #5 stated "Verbal counsel with above CNA (Certified Nurse Aide) (CNA #1) concerning resident Proper Name Initials (Resident #5). Resident was upset and turned over tray during lunch. CNA told resident since he threw tray, he was not going to eat and attempted to push his geri-chair out of dining room. Explained to CNA, food cannot be withheld from resident r/t (related to) behaviors. CNA argumentative during counseling." Interview on 3/27/14 at 3:35 PM with the facility Director of Nursing revealed that this incident was not reported to anyone so there was no investigation. Interview on 3/27/14 at 3:50 PM with RN #1, the staff person who completed the Personnel Incident Employee Response, revealed that this could have been an incident (of abuse) with Resident #5 but that she (RN #1) had intervened. The resident did not go without food. She did not remember the particulars of the incident. This was not reported because she felt that the situation was handled.

Based on record review, interview, policy review, and facility investigation review, the facility's Administrator failed to ensure that the facility effectively maintained the highest psychosocial well being for two (2) of five (5) residents reviewed for abuse as evidenced by the facility's Administrator ' s failure to follow the established facility policy for recognizing, investigating, reporting, and subsequently protecting other residents from abuse once an allegation of abuse had been identified. The facility's Administrator failed to ensure immediate removal of Certified Nurse Aide (CNA) #1 from providing resident care, after she verbally and mentally abused Resident #1 in the presence of approximately 17 residents in the second floor dining room on 3/3/14 resulting in mental anguish to Resident #1. In addition, the facility's Administrator failed to ensure Supervisory staff recognized and subsequently reported on 02/14/14, an allegation of abuse for investigation when CNA #1 became upset with Resident #5 when Resident #5 turned over his tray during lunch, and CNA #1verbally told the resident that he (Resident #5) was not going to get to eat, and attempted to push his geri-chair out of dining room. Findings include: Review of the facility's established policy for abuse revealed the purpose of the policy was to affirm that Jaquith Nursing Home (JNH) residents have a right to be free from abuse, neglect, sexual battery, mistreatment, exploitation, and misappropriation of property and that the policy applied to all JNH residents and staff. The components of the policy included the definition of abuse, and guidance for identification which stated, "Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. It also included guidelines for investigation, protection, and reporting/response as follows: When notified of suspected abuse the Nursing Home Administrator (NHA), Administrative Officer of the Day (AOD), or covering Administrator will immediately notify the MSH (Mississippi State Hospital) Department of Safety and Investigative Services, the Campus Police Department, and the Human Resources Department. The NHA will assist the MSH Department of Safety and Investigative Services, the Campus Police Department, and the Human Resource Department in any way possible to ensure a thorough investigation is completed. When alleged abuse is reported, the Nursing Supervisor, on direction of the NHA, will take immediate action to protect the resident and/or residents. Protective action may include, but not be limited to, separation of the resident and/or residents from any potential or perceived threat by placing the employee on administrative leave and/or removal of an employee in accordance with State Personnel Board Policy and Procedures. With regard to reporting, the policy stated that employees who have knowledge of, or reasonable cause to believe resident abuse has occurred, will immediately make an oral report to the assigned Nursing Home Administrator ( NHA) or the Administrator on duty in the absence of the assigned administrator. Resident #1 Review of the facility's investigation of the 3/3/14 allegation of verbal and mental abuse of Resident #1 by Certified Nurse Aide (CNA) #1 documented that the facility substantiated the abuse of the resident. Interview on 3/26/14 at 3:30PM with the Administrator revealed when he was asked about why CNA #1 remained on the time clock after the incident of 3/3/14, he stated that she would have been moved to a non-resident care area. He was not sure where CNA #1 was moved from the time of the incident to 3:38PM that day, but he stated that he would find out. Interview on 3/26/14 at 1:20 PM with RN #1 revealed that she had not removed the CNA #1 from the floor and that CNA#1 continued to provide care to other residents on the 2nd floor. She stated that she followed the facility policy and reported the 3/3/14 incident by email to the Nursing Home Administrator (NHA) in which she requested that CNA #1 be removed from her building. Interview on 3/27/14 at 10:10 AM with RN #1 revealed that she had not felt free to remove CNA #1 from providing resident care. Interview on 3/27/14 at 2:10 PM with CNA #1 revealed that CNA#1 stated the incident (which occurred on 3/3/14 with Resident #1) must not have been such a "big deal" because she was allowed to complete her shift and remained on the second floor giving resident care. CNA #1 stated she had not been placed on administrative leave until three (3) days (3/6/14) after the incident, and was allowed to come into the facility to attend annual training on 3/5/14 and 3/6/14. Review of CNA #1's employee file revealed the facility notified CNA #1 that effective 3/6/14 she was placed on administrative leave pending the results of an investigation. Further review revealed a letter of resignation signed by CNA #1 with an effective date of 3/25/14. During an interview on 3/27/14 at 9:40 AM with RN #2, she expressed her concern that CNA #1 was allowed to attend an annual in-service (on 3/5/14 and 3/6/14) requiring that she come into the facility to clock in and out. Interview on 3/27/14 at 8:25 AM with the Administrator of the facility confirmed that CNA #1 was allowed to remain in the building after the incident of abuse, rather than immediately being suspended. No other explanation was given as to why CNA #1was not removed immediately from direct patient care following the abuse incident that occurred. Resident #5 Review of a Personnel Incident Employee Response dated 2/14/14 at 1:10 PM provided by the facility revealed the facility failed to follow their established policy. The incident was not identified as abuse, and subsequently reported and investigated. The document stated, "Verbal counsel with above CNA (Certified Nurse Aide) (CNA #1) concerning resident Proper Name Initials (Resident #5). Resident was upset and turned over tray during lunch. CNA told resident since he threw tray, he was not going to eat and attempted to push his geri-chair out of dining room. Explained to CNA, food cannot be withheld from resident r/t (related to) behaviors. CNA argumentative during counseling." Interview on 3/27/14 at 3:35 PM with the facility Director of Nursing (DON) revealed that this incident was not reported to anyone, so there was no investigation. Interview on 3/27/14 at 3:50 PM with RN #1, (the staff person who completed the Personnel Incident Employee Response), revealed that this could have been an incident (of abuse) with Resident #5 but that she (RN #1) had intervened. The resident did not go without food. She did not remember the particulars of the incident. This was not reported because she felt that the situation was handled.

CI MS # *** Per instructions from Centers for Medicare and Medicaid Services (CMS) on December 13, 2012, as a result of the settle agreement, a revised 2567 is being re-issued to reflect that F-323 was raised from a scope and severity of a "G" to a "J. Based on observation, record review and staff interview, the facility failed to provide adequate supervision to prevent Resident #1 from leaving the facility without authorization and without staff supervision. This is for one (1) of three (3) residents reviewed, Resident #1. Resident #1 traveled approximately one (1) and two (2) tenths (1.2) miles, climbed a cyclone fence, and sustained a scratch to his left palm (no documented measurement) and to his right thigh (no documented measurement). Findings Include: Review of a statement submitted to the State Agency by the the facility revealed that on 12/30/11 at 10:05 a.m. Resident #1 was not located during building rounds. The statement also noted that Resident #1 was last seen at 10:00 a.m. on the front porch of the building. Staff began searching the building and facility grounds. At approximately 10:18 a.m. Resident #1 was returned to the facility by Mississippi State Hospital (MSH) Campus Police. At this time Registered Nurse (RN) #1 was notified that Resident #1 was back on the building. RN #1 assessed Resident #1 and found that Resident #1 had sustained a scratch to his left palm and his right thigh. The report stated "When asked where he was going (name) Resident #1 responded "I was going home. (name) Resident #1 told the campus police that he received his injuries from climbing a fence." Review of Resident #1's "Supervisor's Investigation Report" dated 12/30/11 at 10:30 a.m. revealed "Resident has a scratch on his L (left) thigh and R (right) hand, on the palm. Resident climbed fence behind Building 90. He sustained a scratch to his L hand on the palm & his R thigh. Resident tore his pants." (Note conflicting information regarding site of Resident #1's injury. Registered Nurse (RN) #2 confirmed that Resident #1's injury was to his left hand and right thigh.) Observation of Resident #1 on 1/24/12 at 11:30 a.m. revealed that Resident #1 was fairly tall, thin, and young in appearance. Resident #1 was ambulatory in the hallway with the supervision of staff. He exhibited the random involuntary movements that are typical of persons with Huntington's Disease. Resident #1 stated that he had lived at the facility about a month. He stated that he loved it there. Review of Resident #1's "Identification and Summary Sheet" revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/3/12 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of Section G of this assessment, the Functional Status section, revealed that Resident #1 required "supervision (oversite, encouragement or cueing) for locomotion on the unit." For locomotion off the unit Resident #1 required "supervision with the physical assist of one person." Resident #1's balance when moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfer were all coded as "not steady, but able to stabilize without human assistance." Review of Resident #1's "Nurse Notes" revealed: "12/23/11 6:20 a.m. Resident up in day room @ (at) this time. ambulatory c (with) shaky gait et (and) exaggerated movements. 12/24/11 3-11 shift. Pt. (patient) shaky c exaggerated movements, gait. 12/30/11 11:10 a.m. Resident stated "I was going home," when brought back by campus police. They said he climbed a fence behind building 90. He sustained a scratch on his L (left) hand, on the palm & his R (right) thigh. First aide given & cover applied to L hand. 12/30/11 10:30 p. (p.m.) Resident remains on 1:1 for elopement risk." Review of Resident #1's "Social History and Assessment" dated "D.O.A. (date of admisison) to JNH: 12/2/11. D.O.A. to MSH: 11/4/11" revealed: "Onset of Illness: (name) Resident #1 was admitted to MSH because he was constantly falling leaving the house at night. (name) Resident #1 was neglecting his hygiene and he was being incontinent of bowel and bladder. He also threatened to kill himself and others. (name) Resident #1 was discharged from Building 87 and then admitted to Jefferson Inn, Building 29." Interview with Certified Nurse Aide (CNA) #1 on 1/25/12 at 10:55 a.m. revealed that she had last seen Resident #1 on 12/30/11 at 9:30 a.m. on the front porch. When CNA #1 made building rounds about 10:00 a.m. Resident #1 was not on the second floor. She stated that she checked the front porch and did not locate Resident #1. CNA #1 notified CNA #2 and Licensed Practical Nurse (LPN) #1 that Resident #1 was not found. CNA #1 and CNA #2 checked the building and the facility grounds. When Resident #1 was not located the two (2) CNA's (CNA #1 and CNA #2) drove around the campus but did not see Resident #1. CNA #1 stated that as the two (2) CNAs drove by the locked back gate which is close to the campus campground she saw the campus police on the other side of the gate but she did not know why the police were there. The two (2) CNAs drove back to Jefferson Inn (Building 29) and were notified en-route by LPN #1 that campus police had Resident #1. Interview on 1/25/12 at 11:30 a.m. with CNA #2 revealed that Resident #1 was on the front porch at 9:30 a.m. on 12/30/11 and was told not to leave the porch. CNA #2 stated that she was told that Resident #1 had ground privileges but that he had to be in a wheelchair. CNA #2 confirmed that she and CNA #1 had searched the facility, facility grounds, and the campus without finding Resident #1. Interview on 1/25/12 at 2:00 p.m. with LPN #1 revealed that she was working on the first floor on 12/30/11 when CNA #1 told her that Resident #1 was not accounted for. LPN #1 searched the building, then she went outside to search the facility grounds. Campus police drove up and asked LPN #1 if she was looking for a resident and that they had located him (Resident #1). Interview on 1/25/12 at 2:10 p.m. with MSH Officer #1 revealed that Officer #1 assisted in clocking the distance from the facility to the site near the campus campground where she and a fell ow officer had picked up Resident #1. The facility Administrator was also present during the observation of where Resident #1 was found and the clocking of the distance. As the route Resident #1 had taken was not known, the officer pointed out the shortest route, per campus roads, to the site at the campus campground. The distance per automobile odometer was one (1) and two (2) tenths (1.2) miles from Jefferson Inn. Officer #1 indicated the cyclone fence behind Building 90 and that Resident #1 had said that he had climbed. Officer #1 stated that Resident #1 was tired and sweating. Review of the weather history for the facility area revealed "History for Jackson, MS Friday, December 30, 2011 9:54 a.m. 60.1 F (Fahrenheit) degrees." Review of a hand signed typed statement from Officer #1 dated 1/9/12 revealed "On December 30, 2011 at 1018 (10:18 a.m.) MSH police officers (name) Officer #1 and (name) Officer #2 were patrolling MSH campus when we noticed a black male on Pecan Drive near the camp ground at the back lake. Resident #1 (name) had left Building 29, and he stated to officers that he was going home. The above officers questioned resident about being at the back lake. Resident stated that he climbed over the fence behind Building 90. The above officers transported resident back to Building 29 in vehicle T-519. First aid was given and photos were taken of his injuries." Interview with Registered Nurse (RN) #1 on 1/26/12 at 10:50 a.m. confirmed that she had assessed Resident #1 when he was returned to the building on 12/30/11. She stated that there was a tiny scratch to Resident #1's left palm that she cleaned with normal saline and covered with a bandaid. The scratch to Resident #1's right thigh was cleaned with normal saline but did not require a covering. These two areas required no ongoing treatment. Review of RN #1's signed hand written statement dated 12/30/11 revealed: "(name) Resident #1 was not found on building. The police pulled up in front of the building, saying they had found (name) Resident #1 by the pond. (name) Resident #1 was sweaty and out of breath. He had ripped his pants, trying to climb a fence. He has scratch on his right thigh and left hand." Interview on 1/26/12 at 9:45 a.m. with the Director of Nursing (DON) of the facility revealed that Resident #1 did not require the care of a physician for the scratches he received on 12/30/11. The Medical Officer of the Day (MOD) was notified by phone of the incident and of the RN assessment and telephone orders were given. The DON stated that had Resident #1 needed to be seen by the physician, the usual procedure was to transfer the resident to the campus hospital where the physician would have the necessary supplies and equipment. The MOD would visit the buildings when on call only in cases of extreme emergency. The DON stated that there was no physician progress notes [REDACTED]. No skin assessment form was completed due to the superficial nature of the scratches that healed after the first day.

CI MS #9722 Based on record review, staff interview, document review and policy review, the facility failed to ensure two (2) of 10 residents reviewed were provided with the necessary care and services to attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Resident #1 was not provided with Visual Contact (VC) while awake as ordered and Resident #2 was not provided with weekly accuchecks as ordered. Findings include: Review of a facility self reported incident dated 08/23/11 revealed, "On 08/20/2011 at 10:30 p.m. Resident (#1) fell in the restroom and sustained a small cut to the back of the head. Resident (#1) was originally ordered on visual contact from 7:00 a.m. to 7:00 p.m. On 08/18/2011 at 8:20 a.m. LPN #5 received a verbal telephone order to place Resident #1 on visual contact while awake. LPN #5 and LPN #3 who discovered the order on 08/19/2011 failed to pass this information to the appropriate staff. " Record review revealed that Resident #1 was admitted to the facility 09/28/2007 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an assessment reference date of 06/24/2011 revealed that Resident #1 had severe cognitive impairment with a history of verbal aggression, cussing and threatening staff and other residents. Resident #1 refused to wear socks and/or shoes, refused treatments, Activities of Daily Living (ADLs), lab work, medications and assessments. He frequently refused hygiene and refused to wear an armband. He had an unsteady gait requiring the use of a wheelchair (w/c) and a rolling walker. He wore adult briefs due to incontinence but could toilet himself when he wanted to. Resident #1 had a history of [REDACTED]. Resident #1 refused to be interviewed on 09/08/11 and 09/09/11. Review of Resident #1's physician's orders [REDACTED]. 06/30/11 He was readmitted to the facility from a Senior Care Center, where he had been sent for inappropriate behavior. 07/05/11 VC (visual contact) R/T (related to) resident protection R/T his cussing others and other residents wanting to hit him. 08/17/11 D/C (discontinue) VC around the clock. Start VC 7a-7p -- Continue until next treatment team meeting 08/18/11. 08/18/11 D/C VC 7a - 7p Start VC while awake. 08/20/11 VC at all times. 08/22/11 Clarification of 08/20/11 order. VC at all times for observation of status until seen by building doctor. 08/22/11 VC at all times R/T aggressive behavior R/T cussing, refusing meds and meals and treatments, other residents wanting to harm him, striking staff members. Review of the 8/18/11 at 08:20 a.m. verbal physician's orders [REDACTED].#5. LPN #5 failed to pass the VC order change onto the next shift. On 08/19/11 LPN #3 discovered the 08/18/11 change in VC order but failed to pass the order change onto the next shift. On 08/20 11 at 10:30 p.m. Resident #1 fell in the second floor's common restroom. Registered Nurse (RN) #3 was notified, treated Resident #1 for a small cut to the back of his head and started Neurological Checks. The resident was assessed by the Medical Doctor on call on 08/20/11 at 11:01 p.m. and placed on 24 hour VC until he was assessed by the building physician/Medical Director on 08/22/11. At that time the physician elected for the resident to remain on 24 hour VC. Review of Nurse's Notes (NN) revealed: "08/20/11 10:30 p.m. Called to resident's bathroom per CNA (Certified Nurses Aide) staff. Resident noted lying in floor behind bathroom door with his head positioned up against the wall. Assessed resident. Resident noted with a laceration to the back of his head about 1 (one) inch long. Resident able to move all extremities. No other apparent injury @ (at) this time. Staff assisted resident up off floor and back into wheelchair. There was blood noted on the wall where resident's head was positioned. Staff assisted resident to his room and into his bed. First aid administered to laceration @ the back of resident's head. Refused vital signs." This was signed by LPN #2, an Agency contracted nurse. "08/20/11 10:50 p.m. Resident assessed in bed. 3/4 inch laceration assessed on right upper occipital area - upper back of right side of head. The wound was not very deep and did not appear to need sutures...He was alert and responsive with his usual move and affect...able to follow commands and move all extremities. He denied any discomfort. The resident's physician orders [REDACTED].@ 8:20 a.m. the resident was to be placed on visual contact while awake. The staff was under the impression that the resident was on visual contact from 7a-7p. However, (LPN #3), reported that she had discovered the order this AM and reported it to (RN #2). When (LPN #3) returned to work @ 3p.m. there was no follow up on the order. The CNAs and (Agency LPN #2) all claim that they had no new knowledge of the new orders. There was no documentation in the nurses notes or any documentation on the shift reports since the new order was written on the 18th." This was signed by RN #3. The building Administrator was notified of the incident at 11:18 p.m. and the Director of Nurses (DON) was notified at 12:15 a.m. On 09/08/11 at 10:05 a.m. an interview with the DON and the MDS nurse revealed that they both were aware of the 08/20/11 incident concerning Resident #1. They both agreed that the resident's original order for VC from 7a.m. to 7p.m. was changed on 08/18/11 to VC while awake but was not passed on to the next shift. The new order was found 08/19/11 and was not passed on to the next shift again. On 09/08/11 at 2:50 p.m. an interview with the Administrator revealed that it was documented on the 08/18/11 bedcheck sheet that Resident #1 had been in bed asleep prior to calling to the nurses station for assistance. CNA #1 saw him heading for the bathroom then heard him fall and got the nurse. Review of the 08/18/11 Bed check Sheet revealed that at 9:30 p.m. he was asleep. At the 10:00 p.m., 10:30 p.m. and 11:00 p.m. bed check it was documented that Resident #1 was awake. At 11:30 p.m. Resident #1 was asleep. Review of a hand written statement by CNA #1 dated 08/20/11 revealed: "The incident occurred on August 20, 2011 dealing with (Resident #1). All that we knew was that (Resident #1) was on VC from 7am -7pm. We didn't know that he was a VC while awake until the agency nurse (LPN #2) said something. (Resident #1) called and the nurse answered. I couldn't understand what he was saying. (LPN #2) talked to (Resident #1) on the call light. I was sitting down doing my book (ADL Care Book). (Unsampled Resident A) was sitting right beside me and he keeps getting up trying to walk when he can fall. His alarm needs new batteries when he was getting up today the alarm wasn't going off all day. The nurse was at the desk and said she was headed to do her treatment on (Resident #1's roommate)...(Resident #1) was still in his room when she went down there. I was fixing to get up and go see about him. (Unsampled Resident A) wants to get out of his chair going forward. I asked (Resident #1) to come here cause I was dealing with (Unsampled Resident A)...(Resident #1) asked me for some assistance." Interview with CNA #1 on 09/08/11 at 3:30 p.m. revealed that on 08/20/11 she was working on the second floor of Building #29 on the B shift from 3 p.m. to 11:30 p.m. The CNA stated, "All we knew was that (Resident #1) was VC from 7 a.m. to 7 p.m.. No one told us that he was VC while awake. If I had known I would have been in there watching him when he woke up at 10 p.m." The Agency LPN (#2) was not working and not available for interview during the survey. There was no answer to her phone when called and she did not return the message left on 09/09/11 for her to call back. On 09/09/11 at 1:40 p.m. an interview with RN #1 revealed that on 08/20/2011 she was not on Building #29 when the incident with Resident #1 occurred. At that time, accompanied by RN #1, the distance from Resident #1's room to the 2nd floor hall bathroom was ' stepped off ' . The distance was 15 steps. It was another 15 steps from the bathroom to the chair in front of the nurse's station where CNAs sit at night to chart. Resident #1's doorway can be observed from the nurse's station and from the chair that CNA #1 stated she was sitting in charting on the night of 08/20/11. Interview with LPN #4 on 09/09/11 at 1:55 p.m. revealed that on 08/18/11 she was working on the 2nd floor and LPN #5 was working on the 1st floor. The verbal MD order was taken by LPN #5 to change Resident #1's VC order to while awake. LPN #4 stated that she was not told anything about Resident #1's VC order being changed to while awake so they continued to do VC from 7 a.m. to 7 p.m. The next day, 08/19/11, the LPNs changed floors, with LPN #4 working the 1st floor and LPN #5 working the 2nd floor. LPN #4 stated that on 08/19/11 she was not told of any order change for Resident #1 and that she was not working on the evening that Resident #1 fell . LPN #4 stated that she was told of the 08/20/11 incident on 08/22/11 when she returned to work. Resident #2 Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an assessment reference date of 5/23/11, revealed that Resident #2 scored a 15 on the Brief Interview for Mental Status (BIMS) which indicates cognitively intact. Record review revealed care plan for Diabetes dated 10/27/09 with last revision dated 9/8/11. Record review on 9/7/11 of current physician orders [REDACTED]. Review of record on 9/7/11 revealed no documentation of the blood glucose weekly result. Interview was conducted on 9/7/11 at 4:30 p.m. with the DON requesting documentation of accu-chek results. In an interview on 9/8/11 at 8:45 a.m. the DON stated "we may have a problem, I'm unable to locate accu-chek logs". She continued saying she is still reviewing the record for data and also having the thinned record brought over for review of data. She stated she will get back with the surveyor as soon as possible on this issue. In an interview on 9/8/11 at 10:15 a.m. the DON stated "the order for weekly accu-checks had been discontinued December 2010 and was lined out but when the new orders printed, it was not lined out". Review of physician orders [REDACTED]. The physician orders [REDACTED]. The DON said she had talked with the Medical Director today about the orders and he stated to her "he did not want the resident to have weekly accu-cheks". DON also stated "they had checked residents' blood sugar level and it was within normal limits and the result was reported to the Medical Director". Surveyor submitted accu-chek records for September 2011 revealing results on 9/5/11 at 6:00 a.m. of 137 mg/dl and on August 2011 revealing no results documented and stated "this was all the documentation she could find". On 9/8/11 at 10:30 a.m. surveyor spoke with the DON and requested to speak with Medical Director. She stated she would page him. In an interview on 9/8/11 at 10:55 a.m. with Medical Director concerning physician orders [REDACTED]. He said he is very thorough with his Diabetic residents and her blood sugars have been quote "stone cold normal". He stated he did not intend for her to have weekly accu-cheks past his discontinued order dated 12/16/10. He stated "he is the only person at fault and the resident is fine". Record review revealed new orders on 9/8/11 to "D/C finger stick and sliding scale" and new order for "finger stick for BS PRN". Record review revealed Hemoglobin A1c levels on 6/17/11=5.5; 3/24/11=5.3; and 12/9/10=4.7 all within normal limits per Ref Range/Females on lab report. Interview conducted with LPN #1 on 9/9/11 from 1:58 p.m. to 2:07 p.m. concerning transcribing orders, medical administration orders (MAR) from one month to the next and shift report. LPN#1 stated "orders are noted and added to the MAR indicated [REDACTED]. The surveyor asked what the 24 hour chart check meant. LPN #1 stated "it means the chart has been checked and is up-to-date and correct". Record review revealed 24 hour chart checks on 8/28/11, 9/01/11, 9/2/11, 9/3/11, 9/4/11 and 9/8/11. No other documentation was submitted on 24 hour chart checks. No documentation was submitted for shift report on 12/16/10. On 9/9/11 at 2:45 p.m. the DON submitted policy and procedure on [DIAGNOSES REDACTED]/[MEDICAL CONDITION], Transcribing/Noting physician's orders [REDACTED]. The policy for [DIAGNOSES REDACTED]/[MEDICAL CONDITION] reads ...page number one, item (2.) All patients/resident with a [DIAGNOSES REDACTED]. Accu-cheks can be performed without practitioner's orders if hypo/[MEDICAL CONDITION] is suspected ... and page number 2, item (c) A nurse's not will be completed to reflect symptoms, physician's notification, and actions taken. Blood glucose levels will be documented on the Fingerstick Glucose Record, Accu-chek Record, or Diabetic Record. The policy for transcribing/noting physician's orders [REDACTED]." The 24 hour chart check reads ...page 1, item 3(A) the C shift nurse will check to ensure all physician orders [REDACTED].

CI MS #9654 Based on record review, staff interviews and policy review, the facility failed to provide services that meet professional standards of quality, for one (1) of seven (7) resident's reviewed, Resident #1. The facility failed to provide resuscitative procedures and activate the emergency medical protocol for Resident #1 who was found unresponsive with no pulse or respiration on [DATE] at approximately 11:50 p.m. Resident #1's airway was not secured (opened). The facility failed to initiate rescue breathing. Oral suctioning was not performed to clear the airway of Resident #1, who had vomited. Certified Nurse Assistant (CNA) # 7 failed to initiate Caridiopulmonary Resuscitation procedures as directed by Licensed Practical Nurse (LPN) #4. Resident #1, unresponsive (no pulse or respirations) was left unattended while staff left out of his room searching for an Ambu Bag. LPN #4 failed to initiate and delegate the facility emergency medical procedures. Staff failed to perform rescue breathing for Resident #1 who had no pulse or respirations. Resident #1 was pronounced dead on site at 12:10 a.m. on [DATE]. The lack of the implementation of CPR (Cardiopulmonary Resuscitation), oral suctioning to secure Resident #1's airway and follow proper emergency procedures to ensure that adequate life saving measures were implemented for Resident #1, was deemed as an Immediate Jeopardy (IJ) on [DATE] at 4:15 p.m. The Administrator and Director of Nursing of the facility were notified at that time. The IJ was determined to begin on [DATE] and was removed on [DATE]. The facility submitted an acceptable credible Allegation of Compliance (AoC) on [DATE] at 6:00 p.m. Based on the verification of the facility's corrective action that was validated, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings Include: On [DATE] the State Agency received a self reported incident from the facility which stated, "On [DATE], at approximately 11:50 p.m. Certified Nursing Assistant (CNA) #7 noted that (Resident #1) was coughing and raised the head of his bed and reported that resident "looked sick in the face." CNA #7 went to get the nurse. When Licensed Practical Nurse (LPN #4) arrived in resident's room he was not breathing and did not have a pulse. CPR (cardiopulmonary resuscitation) was initiated and (Physician #1) was called at approximately 11:52 p.m. (Physician #1) arrived on building with CPR still in progress and AED (automatic external defibrillator) advised no shock. (Physician #1) pronounced (Resident #1) death at 12:10 a.m." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #1 did not occur as Resident #1 expired on [DATE] at 12:10 a.m. Resident #1 was a closed record review. Observation on [DATE] between 2:25 p.m. and 2:45 p.m. revealed that the Ambu bag and the AED were located in a rack on the wall inside the first floor nurses station and the second floor nurses station. Interview on [DATE] at 9:10 a.m. with Registered Nurse (RN) #2, revealed that all staff are trained in the Code Blue policy, AED's and where the equipment is located. RN #2 stated that the Ambu bag and AED are always kept inside the first and second floor nurse's station. RN #2 stated that the suction was located in the first floor treatment room. Interview on [DATE] at 9:25 a.m. with the RN Investigator, revealed that LPN #4 and CNA #7 had conflicting accounts of Resident #1's death. The RN Investigator stated that the investigation revealed that both the LPN #4 and CNA #7 left Resident #1 unattended for a period of time. Also, that the facility staff did not secure Resident #1's (who had vomited) airway. Resident #1 was not suctioned and staff did not follow the proper Code Blue protocol for an unresponsive resident. Interview on [DATE] at 10:40 a.m. with RN #4, revealed that she received a call for Code Blue at approximately 12:08 a.m. When she arrived at the facility the physician was on the scene. Several minutes later the physician stopped CPR about 12:10 a.m. and Resident #1 was pronounced dead at that time. RN #4 stated that the Code Blue policy was not followed and she conducted an on-site in-service (verbal) with LPN #4 and CNA #7 that night. Interview on [DATE] at 11:02 a.m. with the physician on duty (Physician #1), revealed that she had received a call on [DATE] (documented record time at 11:29 p.m.) for an order for [REDACTED]. When she arrived Resident #1 had no vital signs and CPR was in progress. Physician #1 stated that the AED was connected to the resident and it advised no shock. Resident #1 had no pulse or respirations and his eyes were fixed and dilated. Physician #1 stated that Resident #1 was pronounced dead at 12:10 a.m. from aspiration. Physician #1 stated that Resident #1 had vomited copious amounts of liquid material all on the floor, in his throat and beard. Physician #1 further stated that there was not a suction device in the room. Physician #1 stated that staff tried to clear the airway by turning the resident's head to the side but he was probably not getting enough air due to the vomit. Physician #1 stated that the staff could not tell her anything about Resident #1 and she had to get his chart. Physician #1 stated "there seemed to be some confusion." Interview on [DATE] at 11:20 a.m. with CNA #7, revealed that around 11:30 p.m. she was making her rounds and saw B-Shift nurse going into Resident #1's room with towels. LPN #6 had informed CNA #7 that Resident #1 had thrown up. CNA #7 stated that she had told LPN #6 that she (CNA #7) would clean up Resident #1. CNA #7 stated that she went to the first floor nurse's station to call for assist with the resident, as he was a wheelchair resident and she knew she would need assistance. CNA #7 stated a few minutes later she went to Resident #1's room and found him gagging and coughing, his eyes opened wide and he was pale. CNA #7 raised the head of his bed and went to the first floor nurse's station to inform LPN #4. CNA #7 stated at about 11:45 p.m. she and LPN #4 went back to Resident #1's room and found him dead. CNA #7 stated that she and LPN #4 got Resident #1 to the floor on a sheet and LPN #4 told her to start CPR while he called the doctor. CNA #7 stated that LPN #4 left the room and was gone several minutes. CNA #4 stated that she did not start CPR because as she had been taught after you do a cycle of chest compressions you had to deliver breaths and she did not have the Ambu bag to do this. CNA #7 stated that she left the room heading up the hall to the first floor nurse's station yelling "(LPN #4's name) I need the ambu bag." CNA #7 stated that a CNA from upstairs (CNA #1) was getting off the elevator and she told her (CNA #1) to get the nurse "we have a code blue." CNA #7 stated that she continued to the first floor nurse's station and as she got there LPN #4 was coming out with the ambu bag and the AED. CNA #7 stated that she looked at the clock on the wall and it was about 11:50 p.m. She and LPN #4 went to Resident #1's room and started CPR. She stated that Resident #1 had vomited and during chest compressions fluid was coming from his nose and mouth. CNA #7 stated that they did not have the suction machine with them in Resident #1's room. CNA #7 stated that after about ,[DATE] minutes of doing CPR the Physician #1 came and pronounced Resident #1 death. She stated that she remembers other staff including a CNA and an upstairs nurse being there but things were hectic. CNA #7 stated that she had been trained many times on the code blue policy and knew that she should not have left Resident #1. Interview on [DATE] at 11:45 a.m. with LPN #4, revealed that he was at the first floor nurse's station at approximately 11:50 p.m. CNA #7 came to the desk and reported that Resident #1 needed some assistance. We went to his room and found him unresponsive with no pulse or respiration so we lowered him to the floor. LPN #4 stated that he started chest compressions and told CNA #7 to get the ambu bag. He stated that after several minutes the CNA #7 returned and stated that she could not find the ambu bag. LPN #4 stated that CNA #7 then took over chest compressions while he left the room to get the ambu bag. He returned to the room a few minutes later with the ambu bag and CPR was continued. LPN #4 stated that after several minutes of CPR he told CNA #7 to continue CPR he was going to get the AED. LPN #4 went to the first floor nurse's station got the AED and while there phoned the doctor. LPN #4 stated that shortly after 12:00 midnight the doctor got there, CPR was continued for a few minutes then she (Physician #1) told us to stop. LPN #4 stated that Resident #1 had vomited and with each chest compression fluid came out of his mouth. LPN #4 stated that they did not bring the suction machine with them into Resident #1's room. LPN #4 stated that the suction machine was always kept in the first floor treatment room and the AED and ambu bag in a rack at the first floor nurse's station. LPN #4 stated that he had been trained in code blue policy and knew that he should have called 2911 (911), designated staff to get equipment and that he should not have left the resident alone. Interview on [DATE] at 12:50 p.m. with the Medical Director (MD), revealed that he had been informed of the incident and Resident #1's incident had been brought before the Quality Assurance (QA) committee for discussion. The MD stated that protocol was to assess a resident for unresponsiveness, call for help, secure the airway initiate breathing and chest compressions and when help arrives someone call 2911 (911) for a code blue. The MD stated that the ABC's (airway, breathing, circulation) guideline is being taught to staff, the facility has not started the new CPR guidelines. The MD stated that he would have to really scold LPN #4 as he was the leader and should have taken control of the situation. The MD stated that he felt there was confusion about where the equipment was located and with the code. Interview on [DATE] at 3:27 p.m. with LPN #5, revealed that she was assigned to the second floor unit. LPN #5 stated that about 11:45 p.m. she received a call from CNA #7 stating that she needed assistance with a resident. LPN #5 sent her trainee down to help and she returned stating that a nurse was needed as they had a code. LPN #5 stated that she went to the room and CNA #7 was doing chest compressions and she did not see LPN #4. She asked if a code had been called and was told "no" so she left the room for the first floor nurse's station to call security. LPN #5 stated that she called security and went back to the room. LPN #4 came in with the ambu bag and the AED. The AED was connected to the resident and it advised no shock. Shortly after 12:00 a.m. the doctor arrived and pronounced the resident. LPN #5 stated that the resident had vomited and that there was no suction machine in the room. Interview on [DATE] at 4:30 p.m. with LPN #6, revealed that she had worked the B-shift that evening and about 11:25 p.m. she checked Resident #1 and he had spit up some frothy white secretions with yellow mucus, but had not vomited. LPN #6 stated that Resident #1 had no temperature and his vital signs were stable. LPN #6 called Physician #1 and got an order for [REDACTED].#7 had asked her what was wrong. LPN #6 stated that she told CNA #7 that Resident #1 had spit up. LPN #6 stated that about 11:35 p.m. she left Resident #1 in bed and pale but otherwise okay. Observation and paced steps on [DATE] at 8:30 a.m., from Resident #1's room on the first floor of the building to the first floor nurse's station was approximately 50 steps. Casual pace from the room to the first floor nurse's station and back to the room took approximately one minute. Resident #1's Physician's orders dated [DATE] revealed "Code Status: Full Code." Review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed that the Brief Interview of Mental Status (BIMS) score was two (2). A score ,[DATE] indicates severe cognitive skills for daily decision making. Review of Resident #1's physician order dated [DATE] at 11:29 p.m. revealed, "[MEDICATION NAME] 10 ml (millilers) po (by mouth) now x (times) 1 for spitting up mucus and sore throat." Review of Resident #1's nurse's note dated [DATE] at 11:29 p.m. revealed, "received doctors orders for [MEDICATION NAME] 10 ml now x 1 for excessive mucus/sore throat. Will monitor." Review of Resident #1's nurse's note dated [DATE] at 2:05 a.m. revealed, "At 11:50 p.m. on [DATE] CNA #7 came to nurse's station and said Resident #1 need to see you. When we got to his room bed side resident was not breathing and had no pulse. We then lowered him to the floor and began CPR. I then after about 2 minutes of CPR went to nurse's station while CNA #7 was doing chest compression to call the operator to call and connect me with the (Physician #1). I was going to get the AED also. The operator connected me with (Physician #1) and I told her that resident did not have a pulse and that CPR was being performed. She asked was the AED applied. I told her I was going down to apply the AED now. (Physician #1) hung up. After applying the AED it said no shock advised. CPR was continued. After about ,[DATE] minutes (Physician #1) arrived on bldg (building 29). The AED had advised no shock ,[DATE] times prior to (Physician #1) arrival and once while she was on the bldg. (Physician #1) pronounced resident expired at 12:10 a.m. [DATE]." Review of physician progress notes [REDACTED]. Given [MEDICATION NAME] and shortly thereafter vomited then was noted to have a cough and difficulty breathing. Nurse was notified and on assessment pt. (patient) was not breathing, CPR was initiated at approximately 11:50 p.m. and AED was applied with no shock advised. On my initial assessment patient was without respirations with cool cyanotic extremities, no pulse, pupils fixed/dilated with large amount of vomit on floor, in mouth, in hair, face and neck. Resuscitative measures were stopped at 12:10 a.m. on Bldg 29." Review of the Certificate of Death for Resident #1 dated [DATE] at 12:10 a.m. revealed the immediate cause of death "Aspiration/Vomiting." Review of a statement written and signed by LPN #4 on [DATE] at 7:30 a.m., revealed "While going get the AED I said to myself why not call the MOD which I did. I fail to say Code Blue because the resident had no pulse or respiration." Review of the statement written and signed by LPN #4 on [DATE] revealed "On [DATE] at 11:50 P.M. (CNA #7) came to the first floor nurse's station and said Resident #1 need to see you. 11:51 p.m. we arrived in his room and I notice that he was not breathing and had no pulse. I asked her to help me lower him to the floor. 11:52 p.m. I then began chest compression and told her to get the Ambu bag. 11:54 p.m. after about 2 minutes she came and said she could not find the Ambu bag and I told her that I would get it. 11:55 p.m. I got the Ambu bag and we began CPR. We did CPR for about 2 minutes and I said I was going to get the AED and for her to continue CPR. 11:58 p.m. I got the AED and decided to call the Dr. (Physician #1) and let her know that we had a resident with no pulse or respiration. 12:07 a.m. (Physician #1) arrived on bldg and assessed resident the AED had said no shock advise twice before and once when (Physician #1) arrived. 12:10 a.m. (Physician #1) said we can cease CPR. (Physician #1) pronounced him expired." Review of the statement dated [DATE] and signed by CNA #7 revealed "About 11:25 p.m. I was checking the residents on the east end of the hall, when I started checking on the west end I saw B-shift nurse (LPN #6) getting some towels out of the linen closet. I asked her what is it? She said (Resident #1) had threw up, this was about 11:35 p.m. I turned around went into the first floor nurses station and called upstairs I talked with the nurse (LPN #5). I asked her to tell one (1) of the CNA's to come downstairs and assist me with one of the residents, this was about 11:37 p.m. I continued checking the residents, came to (Resident #1) room about 11:40 p.m. (Resident #1) was coughing, I could see in his face he was in distress. I let the head of his bed up and went got (LPN #4), this was about 11:43 p.m. LPN #4 and I went back to his room, this was about 11:45 p.m. and found him unresponsive. LPN #4 and I placed Resident #1 on the floor, LPN #4 went to call the (Physician #1) and told me to start CPR. I got down on the floor and realized I needed the Ambu bag, as I was coming down the hall the Direct Care Trainee (DCT) got off the elevator I told her I needed the nurse and CNA we have a Code blue. I continued up the hall calling I need the Ambu bag. I got near the water fountain when LPN #4 was coming out of the first floor nurses station with the Ambu bag. I noticed the clock on the wall it had 11:50 p.m. LPN #4 and I went back to (Resident #1) room, I was in front of him, I went in he came behind me. I got down on the floor starting chest compression while he was giving the breath with the Ambu bag, this was about 11:53 p.m. LPN #4 and I were doing CPR when the CNA and nurse came to assist us from upstairs. We continue the CPR the doctor came into the room about 12:00 midnight we still continue CPR until the (Physician #1)doctor told us to stop this was about 12:06 a.m. to 12:07 a.m. but I did not have a watch on." Review of LPN #5's statement dated [DATE] at 4:45 p.m. sent by e-mail revealed "On [DATE] I arrived on building for my ,[DATE] shift at approximately 11:00 p.m. I was responsible for the residents on the upper level (second floor) of the building. Shortly after making my rounds at 11:45 p.m. the phone rang and a lady stated "I need some assistance." I then asked her did she need a nurse or a cna? She stated to me "either one will do." I then asked one of the three cna's to assist the caller. Shortly after, the cna returned and stated "Ms. (CNA #7) needs a nurse downstairs, the resident is not breathing. I immediately ran downstairs and did not see the nurse when I got to the residents room. At approximately 11:48 p.m. (CNA #7) was doing chest compression on the resident (Resident #1 on the floor) I then asked where was the nurse? She informed me that the nurse had went and got the AED. I then asked, has a code been called? and if so; I didn't hear it. At 11:50 p.m. I immediately ran to the phone and called operator. I explained to her we had a man down and CPR was being performed and we needed an ambulance. As I was headed back to the room LPN #4 entered residents room with the AED and Ambu bag. CNA #7 was still doing chest compression when Dr. (Physician #1) arrived and LPN #4 was bagging the resident. Upon nursing supervisor arrival to the building she asked LPN #4 was there a code called and he informed her he called the physician on discovery of residents change in LOC (level of consciousness)." Review of a facility document "Shift Dispatch/Paging Log" dated [DATE] revealed at 11:52 p.m. a call was received from LPN #4 requesting the doctor on duty. At 12:03 a.m. another call was received by LPN #5 requesting medical transport, police and nurse supervisor. Review of in-service training records for LPN #4 revealed that the LPN #4 was certified in CPR on [DATE] and trained on the Code Blue policy on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of in-service training records for CNA #7 revealed that the CNA #7 was certified in CPR on [DATE] and trained on the Code Blue policy on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of facility policy "Patient/Resident Foreign-Body Airway Obstruction/Code Blue/CPR/AED" and dated [DATE] revealed "The purpose of this policy is to establish guidelines for initiating measures to remove foreign-body airway obstruction, initiating a code blue (cardiac/respiratory arrest), initiating Cardiopulmonary Resuscitation (CPR) and using the Automated External Defibrillator (AED). This policy applies to all MSH staff trained in CPR to provide external defibrillation to patients and residents, herein after referred to patient(s), experiencing [MEDICAL CONDITION]. Policy. During New Employee Orientation and Annual Training, all employees of MSH will be instructed in foreign-body airway obstruction management, educated about the signs/symptoms of impending cardiac/respiratory arrest and the initiation of a Code Blue, and instructed in Healthcare Provider CPR and AED. Instruction will be provided by Staff Education and Training Services. Definitions. CPR and AED are emergency procedures that seek to restore and maintain the patient/resident/victims's respiration and circulation after his/her heart beat and breathing have stopped. The goal is to provide oxygen and blood to the heart, brain and other vital organs. Procedure. When a patient/resident is found to be unresponsive, assess the patient/resident and call for assistance from another staff member before attempting to open the airway and restore breathing or circulation. Initiate a Code Blue by verbally designating someone at the scene to call extension 2911, get the AED device, notify the physician, get the Code Blue form and get the patient's/resident's chart. Begin CPR, unless the patient's/resident's advance directive prohibits this measure. The staff answering the call for the AED will immediately retrieve the device and transport it to the location where it is needed. A staff member will call 2911 and report the Code Blue and specify the building number/location of the emergency to the Operator. After hours, weekends and holidays the Operator will: notify the MOD (medical doctor of duty), notify the MSH police for patient transportation, notify the nursing supervisor, notify the evening/night Administrator and notify the (local hospital) of impending arrival." Review of the facility policy "Standard of Care", dated [DATE], revealed "The purpose of this policy is to identify the Lippincott Manual of Nursing Procedures as the designated nursing reference manual for clinical practice on all nursing units at MSH. This policy applies to all clinical nurses and unlicensed nursing staff in all facilities of MSH. Standards of Care attachment A refer to the Lippincott Manual of Nursing Procedures (Volume 5) for procedural steps for the following: CPR, page ,[DATE]. "Allegation of Compliance (AOC)" "On [DATE] at approximately 11:43 p.m., CNA Supervisor #1 was conducting rounds, when she found Resident #1 coughing. CNA #1 let the head of the bed up and reported to LPN #1 Resident #1 looked sick in the face. CNA #1 and LPN #1 returned to Resident #1 room and Resident #1 was non-responsive. CNA #1 and LPN #1 started CPR. LPN #1 notified MOD (Medical Officer of the Day) #1 via Telephone call that code blue was in progress. The MOD (Medical Officer of the Day) #1 is the attending physician on campus on call after hours. On [DATE] at approximately 12:06 a.m., MOD #1 arrived on Building and CPR was continued. On [DATE] at 12:10 a.m., Resident #1 was pronounced dead by MOD #1. On [DATE] at approximately 12:30 a.m., a verbal debriefing was conducted by RN Supervisor #1 on Code Blue Procedure (Cardiac Respiratory Arrest) with CNA #1, CNA #2, CNA #3, CNA #4, LPN #1 and Agency LPN #1; specifically calling 2911. Calling 2911 will activate the emergency plan listed below: During regular business hours (Monday-Friday, 8 a.m.-5 p.m.), the Operator will: 1. notify Medical Officer on Duty at (local hospital), 2. notify the Transportation Department for patient/resident transportation and 3. notify (local hospital) clinic of impending arrival. After hours, weekends and holidays the Operator will: 1. notify the MOD, 2. notify (facility name) Police (for patient transportation), 3. notify the Nursing Supervisor, 4. notify the Evening/Night Administrator and 5. notify the (facility name) Surgical Unit of impending arrival. (3) The MOD, Nursing Supervisor and Evening/Night Administrator will respond to the site of the Code Blue. (4.) (facility name) police will report to the site with the patient transportation vehicle when a resident is found unresponsive. On [DATE] at 7:00 a.m., in-servicing began by Head Nurse #1 for all (facility name) staff (Nursing Staff, CNA Staff, Housekeeping Staff, Laundry Staff, Pantry Staff, Agency Nurses, Coordinator of Unit Operation (CUO), Staffing Coordinator, Recreation Staff, Social Services Staff and Psychology Staff) on (facility name) policy ,[DATE] Patient/Resident Foreign Body Airway Obstruction/Code Blue/CPR/AED. (Facility name) POL ,[DATE] Patient/Resident Foreign Body Airway Obstruction/Code Blue/CPR/AED. The purpose of this policy is to establish guidelines for initiating measures to remove foreign-body airway obstructions, initiating a code blue (cardiac/respiratory arrest), initiating Cardiopulmonary Resuscitation (CPR) and using the Automated External Defibrillator (AED). No staff was allowed to work on the unit until he/she was in-serviced. No changes were made to the above policy as a result of this incident. On [DATE] at 8:00 a.m., NHA (nursing home administrator) #1 and Nurse Administrator #1 discussed incident at the (facility) administrator weekly meeting. In the meeting it was discussed that there was a code blue situation on [DATE] on Building (#) in which 2911 was not called. Recommendation made was that all staff needed to be in-serviced on Code Blue Policy. In attendance were NHA #2, NHA #3, NHA #4 and NHA #5. On [DATE] at 8:00 a.m., incident was turned over to Safety and Investigative Services (SAIS) for review and recommendation. On [DATE] at 9:30 a.m., incident was discussed with (facility name) Stand-up Team (NHA #1, DON #1, Head Nurse #1, MDS nurse #1, RN #1, CUO #1, Recreation Staff #1 and #2 and Social Service Staff #1.) In the meeting it was discussed that was a code blue situation on [DATE] on Building (#) in which 2911 was not called. Recommendation made was that all staff needed to be in-serviced on Code Blue Policy. On [DATE] at 2:41 p.m., NHA #1 received initial report from SAIS investigator #1 stating that neglect was not substantiated. However, LPN #1 failed policies-(facility name) ,[DATE] Patient/Resident Foreign-Body Airway Obstruction/Code Blue/CPR/AED and NSG ,[DATE] Standard of Care. Neglect was unsubstantiated due to immediate care was being give. However, failure to follow Policy (facility name) Policy ,[DATE] and NSG Policy ,[DATE] were substantiated against LPN #1. LPN #1 did not initiate/delegate Code Blue be initiated; LPN #1 did not open Resident #1 airway or suction resident; LPN #1 left the resident after he sent CNA #1 to get the Ambu-bag to go the AED and decided to call the doctor while LPN #1 was at the nurses' station. NSG ,[DATE] Standards of Care. The purpose of this policy is to identify the Lippincott Manual of Nursing Procedures as the designated nursing reference manual for clinical practice on all nursing units at (facility name). On [DATE], LPN #1 was placed on administrative leave at 11:00 p.m. by Evening Administrator #1 pending the outcome of the investigation. On [DATE] at 8:00 a.m., in-servicing began for (facility name) RNs, LPNs, agency nurses and CNA staff on policy NSG ,[DATE] Standards of Care by RN Supervisor #1 and #2, Head Nurse #1, RN #1 and #2. NSG ,[DATE] Standards of Care. The purpose of this policy is to identify the Lippincott Manual of Nursing Procedures as the designated nursing reference manual for clinical practice on all nursing units at (facility name). Specific items covered were CPR (Ambu-bag and AED), vital signs, suction and oxygen. No staff was allowed to work on the unit until he/she was in-serviced. No changes were made to the above policy as a result of this incident. On [DATE] at 9:00 a.m., a Quality Assurance (QA) meeting was held to discuss the incident and actions taken thus far, in attendance were NHA #1, DON #1, Building Physician/Medical Director #1, (facility) Office Manager #1, Head Nurse #1, (facility) Director #1 and Licensure and Certification Director #1. Additional recommendations were discussed and approved by Building Physician/Medical Director #1. These additional recommendations included implementation of mock codes conducted by RN #1, RN #2, Head Nurse #1, RN Supervisors #1, #2 and #3 for all (facility) staff (Nursing Staff, CNA Staff, Housekeeping Staff, Laundry Staff, Pantry Staff, Coordinator of Unit Operation (CUO), Staffing Coordinator, Recreation Staff, Social Services Staff and Psychology), QA monitoring tool (Questionnaire for staff on Code Blue policy and procedures) and the recommendation for review by (facility) Nurse Executive #1. A recommendation from the Nurse Executive #1 was to report LPN #1 to the Mississippi Board of Nursing for failing to provide adequate care for Resident #1. On [DATE], LPN #1 and CNA #1 were re-trained on Code Blue and CPR procedures by (facility) Staff Education Director #1. A follow-up QA meeting was held on [DATE] at 9:00 a.m. All actions indicate facility compliance with QA monitoring. The 66 (facility) residents of full code status were assessed by Head Nurse #1, RN #1 and #2 and none were found to be a to risk. On [DATE] at 11:40 p.m., NHA #1 reported incident to Licensure and Certification. On [DATE] at 2:05 p.m., NHA #1 reported incident to the Mississippi Attorney General's Office. On [DATE] at 1:00 p.m., (facility) Nurse Administrator #1, DON #1 met with (facility) Nurse Executive #1 to review incident and whether to report to Mississippi Board of Nursing per letter from (facility) Nurse Executive #1. On [DATE] (facility) Nurse Executive #1 reported actions of LPN #1 to Mississippi Board of Nursing by mail. On [DATE] at 1:00 a.m., Resident #1's Responsible Party #1 was notified by MOD #1 of death of Resident #1. On [DATE] at 8:30 a.m., Building Physician/Medical Director #1 was notified by DON #1 of Resident #1. On [DATE] at 4:00 p.m., QA monitoring tool was implemented by (facility) RN Supervisor #1 and #2, head Nurse #1, RN #1 and #2. The monitoring tool checks the knowledge of random staff with question regarding Code Blue compliance. On [DATE] at 7:00 a.m., in-services began for all (facility) staff (Nursing Staff, CNA Staff, Housekeeping Staff, Laundry Staff, Pantry Staff, Coordinator of unit Operation (CUO), Staffing Coordinator, Recreation Staff, Social Services Staff and Psychology Staff) on (facility) POL J,[DATE] Injury, Abuse, Neglect, or Exploitation of Residents by NHA #1 and DON #1. (facility) POL J,[DATE] Injury, Abuse, Neglect, Mistreatment or Exploitation of Residents. The purpose of this policy is to affirm that (facility) residents have a right to be free from abuse, neglect, sexual battery, mistreatment exploitation and misappropriation of property and to outline procedures for complying with Centers for Medicare Medicaid Services (CMS) and the Mississippi Vulnerable Adults Act of 1986 as annotated. No staff was allowed to work on the unit until he/she was in-serviced. No changes were made to the above policy as a result of this incident. On [DATE] at 8:00 a.m., Staff Education Instructor #1 conducted CPR refresher training for LPN #1 and CNA #1. On [DATE] at 11:30 p.m., mock code blue exercises were initiated by RN Supervisor #1 on C shift. The mock code blue exercises intent was to test staff knowledge and practices during a code blue situation. The results of the exercises were positive due to the fact staff responded timely