Every finding on record at Landmark of Collins

Based on observation, staff interview, and facility policy review, the facility failed to remove expired food items from the refrigerator by the manufacturer's expiration date, maintain the refrigerator in a clean condition free from spills, and store food according to manufacturer's instructions for one (1) of four (4) survey days.Findings include:A review of the facility's policy, Food Storage Labeling revised August 2024, revealed, .The facility will ensure the safety and quality of food by following good storage procedures.Procedure.7. Recommended Food Storage Chart.c. Steps to use the chart.iii. Use the calendar to select the recommended date to discard.d. discard foods that are found to have exceeded their storage time.8. Rotation a. First In, First Out method is used to rotate food in all storage areas i. Identify the food item's use by date or expiration date .On 09/15/2025 at 10:18 AM, during the initial tour of the dietary department with the Dietary Manager (DM), a gallon of whole milk in cooler #3 was observed with a manufacturer's expiration date of 09/14/2025. The floor of the refrigerator was unclean and contained dried milk residue. The DM stated dietary aides are responsible for checking expiration dates and cleaning spills as they occur. A bottle of low-sodium soy sauce was also observed stored on a shelf above the sink despite manufacturer instructions indicating it must be refrigerated after opening. The DM acknowledged the finding and stated she was unaware soy sauce required refrigeration after opening.On 09/18/2025 at 1:36 PM, during an interview, the Administrator stated that it was his expectation that the dietary department ensure proper food storage and monitoring of expiration dates.

Based on observation and staff interview, the facility failed to handle residents' clean clothing in a manner that prevented the possible spread of infection for one (1) of four (4) days of survey.Findings include:On 9/15/25 at 2:50 PM, during an observation and interview with Laundry Worker (LW) #1, she was delivering clean clothes to residents' rooms while holding the clothes close to her body, so that the clothes touched her uniform during four (4) delivery stops. LW #1 stated she had been trained not to allow residents' clothing to touch her clothing, as this could spread germs and infection. She reported that staff were in-serviced monthly on infection control practices.On 9/18/25 at 9:33 AM, during an interview with the Infection Prevention (IP) Nurse, she acknowledged that LW #1 failed to handle the clean laundry in a manner that would prevent infection. The IP Nurse stated she provided monthly in-service training on infection control and expected staff to follow guidelines to keep clean clothing away from their uniforms.On 9/18/25 at 9:37 AM, during an interview with the Administrator, he acknowledged that he was made aware that a laundry worker had allowed residents' clean clothing to touch her uniform during transport. He stated that his expectation was for clothes to be washed and covered during delivery to prevent contamination.

Based on observation, staff interview, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety as evidenced by food items not dated and spoiled foods for two (2) of three (3) kitchen observations. Findings include: A review of the facility's policy, Food Service Operational Standards for Purchasing, Cooking and Storage, revised ,d+[DATE], revealed, .The facility stores .food under sanitary conditions to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety Procedure .3. Storage .f. Follow First In first Out (FIFO) . On [DATE] at 9:08 AM, an observation and interview with the Dietary Manager (DM) revealed the following: Refrigerator #1: One (1) unopened plastic bag of purple cabbage, one (1) unopened plastic bag of carrots strips, and six (6) unopened plastic wrapped heads of iceberg lettuce with no use-by or discard date. On [DATE] at 8:00 AM, an observation of a shelf located outside the pantry door, contained a plastic bin with 17 overly ripe onions with visible white and gray biological growth, and were soft to touch. The DM acknowledged the undated produce food items and the spoiled onions. The DM reported these incidences were unacceptable for the kitchen and explained it was her responsibility to inventory foods to ensure that outdated foods items were discarded. On [DATE] at 10:32 AM, an interview with the Cook revealed it was the responsibility of the DM to inventory food for expired foods. On [DATE] at 11:35 AM, an interview with the Administrator revealed he acknowledged he was aware of the food items not labeled and spoiled items in the kitchen. The Administrator reported it was the responsibility of the DM to inventory food for quality and to label foods.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide palatable meals for three (3) of 14 sampled residents reviewed. (Resident # 4, Resident #14, and Resident # 50) Findings include: A review of the facility's policy, Food Service, revised 8/00 revealed Purpose: To meet the nutritional needs of each resident. To provide a well-balanced, flavorful and varied food service program . Resident #4 On 04/30/24 at 12:14 PM, in an observation and interview, Resident #4 was eating lunch in the dining room. Resident #4 had refused to eat the spaghetti with meat sauce, corn bread and ice cream and had her sister to bring her lunch from home. The resident said the food was bland with no taste most of the time because the facility did not season the food. She stated she had complained to the nursing staff and the Dietary Manager (DM) several times. A record review of the Face Sheet revealed the facility admitted Resident #4 on 3/19/24 with current medical diagnoses including Dysphagia and Anorexia. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/26/24 revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 10, which indicated her cognition was moderately impaired. Resident #14 On 4/30/24 at 09:35 AM, during an interview, Resident #14 explained the food at the facility was not good because the food had no taste and was not seasoned. At 12:00 PM on 04/30/24, during an observation and interview, Resident #14 was eating lunch and was visited by family. Resident #14 explained the spaghetti was not good today and had no seasoning in the sauce. Her daughter brought her a chicken sandwich. Resident #14 further explained the alternative meal of ham, rice, and broccoli was not any better. The family member reported that she brought lunch to the resident several times a week because she complained the food was not seasoned. A record review of the Face Sheet revealed the facility admitted Resident #14 on 2/21/22 with current medical diagnoses including Type 2 Diabetes Mellitus. A record review of the Annual MDS with an ARD of 2/14/24 revealed Resident #14 had a BIMS score of 15, which indicated she was cognitively intact. Resident #50 On 4/30/24 at 10:17 AM, during an interview, Resident #50 complained the food tasted bad because it was not seasoned. At 11:30 AM on 4/20/24, in an observation and interview, Resident #50 was eating in the dining room. He had salad, spaghetti, and pink applesauce served on his meal tray and he reported the spaghetti was bland without any taste, but he had to eat it because the alternate meal of ham, rice, and broccoli was worse. At 12:25 PM on 4/30/24, during an interview with Certified Nurse Aide (CNA) #1, she explained the residents have complained in the past about the food not tasting good because it was not seasoned. She explained Resident #50 had complained about not liking the taste of the food, but he had snacks in his room and would eat the snacks more than the meals. At 12:35 PM on 4/30/24, in an observation, Resident #50's completed his meal and had eaten the spaghetti and bread. Meal trays were observed after residents finished eating and there were plates with half or more of the spaghetti noted to be uneaten on the plates. At 12:50 PM on 5/02/24, during an interview with Resident #50, he explained the lima beans had no seasoning and he could not eat them. Record review of the Face Sheet revealed the facility admitted Resident #50 on 5/05/23 and he had current medical diagnoses including Type 2 Diabetes Mellitus. Record review of the annual MDS with an ARD of 4/23/24 revealed Resident #50 had a BIMS score of 14, which indicated he was cognitively intact. On 04/30/24 at 11:45 AM, during an observation in the dining room, after lunch, there were plates with over half of the spaghetti left on the plate and a few plates with dark green mushy broccoli that were not eaten by the residents. During an interview on 4/30/24 at 12:17 PM, the Director of Nursing (DON) confirmed the residents have complained the food was bland with no seasoning. The DON stated the DM was new and had been at the facility for one (1) month. During an interview on 4/30/24 at 1:00 PM, the DM confirmed the residents had been complaining that the food was bland and had no taste. The DM stated that several residents are on a No added salt (NAS) diet and it was hard to season the food with all the restrictions. The DM said if the residents do not like what is on the menu or the alternate menu, the facility provided sandwiches, such as peanut butter and jelly and pimento and cheese. During an interview on 4/30/24 at 2:00 PM, the Administrator confirmed the residents had complained the food was bland and had no taste and explained the DM had been in her position for one (1) month. The Administrator stated he frequently ate the facility's food, but he was not picky about what he ate. He expected the kitchen staff to provide palatable meals for the residents. On 5/02/24 12:38 PM, a lunch meal tray was sampled which consisted of fried chicken, cheesy corn casserole, lima beans, and banana pudding. The lima beans and fried chicken were not seasoned. During an interview on 5/2/24 at 3:00 PM, the facility's Registered Dietician (RD) confirmed the residents have complained that the food was bland and had no taste and did not have enough seasoning. The dietician explained that she had advised the DM that residents could have seasoned food even if they were on a no added salt (NAS) diet. The RD explained that she had conducted a satisfaction survey last month and found the residents did not like the taste of the food and over half of the residents were having food bought in by family members. The RD stated that she had talked with the DM and that something was going to have to be done so the residents would eat the food. 41680 43283

Based on observation, staff interview, record review, and facility policy review the facility failed to prevent the possibility of the spread of infection, as evidenced by failure to clean a glucometer device according to manufacturer's guidelines for one (1) of two (2) observations. (Resident #32) Findings include: Review of facility's policy, Blood Glucose Quality Control, revised 01/24, revealed, .Maintenance of Blood Glucose Monitoring Systems Always clean the meter after each use. Gently wipe and clean surface of the meter with a disinfectant wipe . Record review of the General Guidelines for Use for the Super Sani-Cloth Germicidal Disposable Wipe, dated 2021, revealed, .4. Allow treated surface to remain wet for two (2) minutes. Let air dry . On 5/1/24 at 10:47 AM, during an observation, Licensed Practical Nurse (LPN) #3 used a glucometer to perform an accucheck on Resident #32. After LPN #3 performed the accucheck, she returned to the medication cart, applied clean gloves, and obtained a Super Sani-cloth disposable wipe from the container. LPN #3 cleaned the glucometer for a few seconds and placed it on a barrier to dry. The surface of the glucometer did not remain wet for two minutes. On 5/1/24 at 11:01 AM, in an interview, LPN #3 confirmed she had cleaned the glucometer for about ten (10) seconds with the disposable wipe and placed it on a barrier to dry and stated that was the way she had been trained. LPN #3 said the disinfectant wipes were used to kill bacteria on the glucometer and confirmed she did not clean it long enough to kill the bacteria, which could cause other residents to acquire an infection. On 5/1/24 at 11:53 AM, in an interview with Director of Nursing (DON), she stated the nurse should clean the glucometer and let it dry for two (2) minutes. She said the facility must be interpreting the directions for use incorrectly and confirmed she had not trained the staff to ensure the glucometer remained wet for two minutes when cleaning after use. On 5/1/24 at 2:45 PM, in an interview, LPN #1/Infection Preventionist (IP) stated that cleaning the glucometer for 10 seconds would not kill any potential bacteria on the device and LPN #3 should have cleaned it longer. The IP said that if a glucometer device was not cleaned properly, bacteria could be transferred to other residents. Record review of the Physician Orders for the month of May 2024 revealed Resident #32 had a Physician's Order, dated 5/1/18, for Accuchecks before meals and at night . Record review of the Face Sheet revealed the facility admitted Resident #32 on 10/5/16 with current diagnoses including Type 2 Diabetes Mellitus.

Based on observation, interviews, record review and facility policy review the facility failed to honor the resident's right for choices as evidenced by serving a meal that included a known dislike for one (1) of (14) sampled residents. (Resident #4) Findings Include: Review of the facility's policy, Dietary Services, revised 11/17, revealed, . Food likes, dislikes and eating habits are assessed by the Nursing and Dietary Departments. This information is recorded in the resident's Medical Record . During an observation and interview on 4/30/24 at 12:14 PM, Resident #4 was served spaghetti with meat sauce on her meal tray. Resident #4 stated that had told the staff and the Dietary Manager (DM) several times that she did not eat noodles or rice. The resident's meal consisted of spaghetti with meat sauce, lettuce and tomato salad, cornbread, and ice cream with tea and water. The resident ate her salad and did not eat any other items on the meal tray. Resident #4's sister brought her lunch from home. Record review of the Lunch meal tray ticket for Resident #4, dated 4/30/24, revealed, .Dislikes Buttered Biscuits .eggs .PASTA/NOODLE .Rice . On 4/30/24 at 12:17 PM, the Director of Nursing (DON) confirmed Resident #4 received spaghetti with meat sauce on her meal tray. She also confirmed the dietary slip indicated Resident #4 had a dislike for noodles and rice. In an interview on 4/30/24 at 1:00 PM, with the Dietary Manager (DM), she confirmed Resident #4 received spaghetti with meat sauce and the alternate was rice, ham, and broccoli. The DM also confirmed Resident #4 did not eat noodles or rice. The DM stated that she could have fixed mashed potatoes to go with the ham and broccoli, however, it was not brought to her attention at that time that the resident did not eat noodles or rice and she did not look at the resident's dietary slip. The DM also stated that if the residents do not like what is on the menu or the alternate, the facility provided peanut butter and jelly sandwiches or pimento cheese sandwiches. During an interview on 4/30/24 at 2:00 PM, with the Administrator, he stated that he expected the kitchen staff to monitor the likes and dislikes of the residents so they will not be getting food that they do not like. During an interview on 5/2/24 at 3:00 PM with the Dietician, she stated she was unaware the kitchen staff were providing residents with foods that were on the meal tray card as a dislike and she expected the kitchen staff to follow the dietary slips and honoring the residents likes and dislikes. A record review of the Face Sheet revealed the facility admitted Resident #4 on 3/19/24 with current diagnoses including Dysphagia and Anorexia. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/26/24 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated her cognition was moderately impaired.

Based on staff interview, record review, and facility policy review the facility failed to ensure physicians orders for laboratory tests were followed for one (1) of five (5) residents reviewed for unnecessary medications. (Resident # 9) Findings Include: Review of the facility's policy, Physician Orders, revised 9/23, revealed, It is the policy of this facility that all physician's orders will be implemented timely and carried out in a professional manner . Record review of the Physician's Orders, for the month of April 2024 revealed Resident #9 had Physician's Orders, dated 11/6/20 for a Vitamin D level yearly in November, Thyroid Stimulating Hormone (TSH) yearly in November, and a Basic Metabolic Panel (BMP) every six (6) months in November and May. Resident #9 also had a Physician's Order, dated 9/22/22 for a Complete Blood Count (CBC) every 6 months in November and May. Record review of a Departmental Note, dated 11/21/23 at 5:13 AM, for Resident #9 revealed, resident refused to allow his labs to be drawn this morning . Record review of a Departmental Note, dated 12/12/23 at 11:40 AM, for Resident #9 revealed, Attempted x (times) 2 to obtain resident's blood for labs .Failed x 2 attempts .Resident stated that he did not want to be stuck again. MD notified . Review of the medical record for Resident #9 revealed there were no laboratory results for a Vitamin D Level, TSH level, BMP, or CBC for November 2023. On 5/1/24 at 3:53 PM, in an interview with Licensed Practical Nurse #1 (LPN)/ Infection Preventionist, she stated Resident #9 refused labs on 11/21/23. She explained that she had attempted two (2) times to draw labs on 12/12/23 and was not able to obtain the labs. She stated that she contacted the physician but did not document his response and stated she should have made a note of his response. She was unable to recall what the physician had told her when she called him about the resident's refusal. She explained that when a lab order was not completed, it remained active, and the labs should have been obtained. The physician reviewed all labs, determined if any medication adjustments are required, and signed off on the labs as having been reviewed. On 5/1/24 at 4:08 PM, in an interview with Director of Nursing (DON), she confirmed the bloodwork for Resident #9 should have been completed and she was unaware the labs were not drawn. She stated the TSH level was used to determine the toxicity level of Synthroid medication in the resident and the physician reviews the labs to adjust medications. She stated when the labs are not drawn, it could affect the resident's health. On 5/1/24 at 4:36 PM, in an interview with the physician, he stated Resident #9 often refused care and had refused labs several times. He stated he was unsure if he had been contacted in November or December about his refusals, but staff had told him several times and his response should have been documented. Record review of the Face Sheet revealed the facility admitted Resident #9 on 11/6/20 and he had current diagnoses including Hypothyroidism, Hyperlipidemia, Iron Deficiency Anemia, Heart Failure, and Vitamin D Deficiency. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/19/24 revealed Resident # 9 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated he had moderate cognitive impairment.

Based on interviews, record review, and facility policy review, the facility failed to ensure the comprehensive care plan was reviewed timely for one (1) resident, Resident #39, and revised for two (2) residents, Resident #39 and Resident #103, out of four (4) residents sampled for falls. Findings Include: Review of the facility's policy, Care Plan Process with a revision date of 08/17 revealed, .The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care .Re-evaluates the resident's status at prescribed intervals (i.e. quarterly, annually, or if a significant change in status occurs) .Interventions are actions that should promote meeting the established goal . Review of the facility's policy Fall Prevention and Management Program with the latest revision date of 09/18 revealed, .will be used to develop interventions after each fall and for care plan revisions .Management .The resident's care plan is updated to reflect the new intervention(s). Resident #103 A record review of Resident #103's Face Sheet revealed the facility admitted him on 11/26/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/2/21 revealed Resident #103 had a Brief Interview of Mental Status (BIMS) score of nine (9), which indicated he had moderate cognitive impairment. A record review of Departmental Notes for Resident #103, dated 12/2/2021 at 7:27 AM, revealed, Resident noted on floor on his bottom by CNA (Certified Nursing Assistant) . A record review of Resident #103's Baseline Care Plan And Summary reflected actual falls dated 11/30/21 and 12/7/21, along with the interventions. There was no fall with an intervention for the fall that occurred on 12/2/2021. A record review of the medical record revealed there was no comprehensive care plan developed related to falls for Resident #103. On 6/8/22 at 1:50 PM, in an interview with the DON, she stated the care plan should have been updated on 12/2/21 to include Resident #103's fall. The care plan is used by staff to give care to the residents. Resident #34 Record review of the Face Sheet revealed Resident #34 was admitted by the facility on 10/2/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 4/25/22 revealed Resident #34 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated she is cognitively intact. Record review of Resident #34's Incident Log dated from 12/6/21 through 6/6/22 revealed she had falls that occurred on 12/15/21, 2/4/22, 3/26/22, 3/29/22, 4/10/22, 5/10/22. Record review of Resident #34's care plan revealed a Problem/Need listed as Resident is at risk for falls with dates of actual falls listed as 11/12/19, 3/6/21, and 2/4/22. There were no actual fall dates listed for the falls that occurred on 12/15/21, 3/26/22, 3/29/22, 4/10/22, and 5/10/22. The Goal & Target date was listed as Resident will be free of injury and complications through the next review 8-25-21 and Resident will have no falls through next review 8/25/21, which indicated Resident #34's status had not been re-evaluated with the results of the latest MDS assessment dated [DATE]. Care plan approaches related to the falls corresponded with the date of the actual falls on 3/6/21 and 2/4/22. There were no approaches listed for the actual falls that occurred on 12/15/21, 3/26/22, 3/29/22, 4/10/22, and 5/10/22. On 06/07/22 at 11:17 AM, in an interview with Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1, RN #1 confirmed Resident #34's care plan was not reviewed timely and that typically the care plan is reviewed with each assessment. The care plans are located in each resident's chart and updates are handwritten until the next comprehensive MDS assessment, in which the entire care plan is reprinted and placed on the chart. She confirmed the care plan should be revised with each fall to include the date the fall occurred and the corresponding intervention. On 06/08/22 at 10:09 AM, in an interview with the Director of Nursing (DON), she stated that it is her expectation that the care plan be reviewed with each MDS, which is at least quarterly. She stated falls are reviewed daily in morning meeting and interventions are discussed. The care plan should be updated at that time with the intervention. The interventions discussed in the morning meetings for Resident #34 did not make it to the resident's care plan in the chart. She acknowledged that the care plan is used by the staff to know how they are to provide care to the residents.

Based on observation, interviews, record review and facility policy review, the facility failed to discard expired food items, ensure daily temperature logs for the freezer were completed, and failed to label and date refrigerated items for one (1) of four (4) kitchen observations. Findings Include: A record review of the facility's policy Food Storage Labeling, with a revision date of ,d+[DATE], revealed, Policy: The facility will ensure the safety and quality of food by following good storage and labeling procedures Procedure: 1. Labeling . a. All temperature controlled foods and ready to eat foods that are prepared in the facility and held for longer than twenty-four hours will be labeled. Information included on the label: Name of the Food Date of storage .3. Rotation .b. Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufactured use-by date or expiration date . 4. Monitoring storage temperatures .b. Temperatures in food storage units are monitored daily. C. Documentation of time and temperature is recorded on a Temperature Monitoring Log . On [DATE] at 10:22 AM, during an initial kitchen tour and interview with the Head Cook (Dietary #1), the State Agency (SA) observed that the temperature logs for the Milk Box and Ice Cream Box freezers had missing documentation. The SA observed an 8-ounce container in the refrigerator that contained a white liquid substance and was not labeled with the name of the food or the date of storage. The SA observed a 32-ounce container of [NAME] Culinary egg shade food color with an open date of [DATE] and an expiration date of ,d+[DATE]. The SA observed an undated clear container with potato salad and coleslaw that had no label containing the name of the food or the date of storage. Dietary #1 commented that she had informed the staff that it is important to check all refrigerators, and freezers for labeled food items and to complete the documentation of the temperature logs daily. She confirmed the food should have been labeled and the temperatures logs should have been completed because this information lets the staff know that the food is good to serve to the residents. Dietary #1 explained that all expired foods should be thrown away so that staff will not use them. She further acknowledged that although the egg shade color had not been used for a long time, it should not have been in the kitchen. On [DATE] at 2:45 PM, in an interview with the Administrator, he confirmed that Dietary #1 is in charge of the kitchen while the Dietary Manager is on leave. He acknowledged that staff should be checking for expired food, logging temperatures daily, and labeling and dating foods in the refrigerator so that the residents will not be served expired food. He said that dietary staff should check and record temperatures on the refrigerators and freezers to make sure that the food does not spoil. A record review of the Daily Freezer/Refrigerator Temperature Log for the Month/Year of ,d+[DATE] with a Location/Unit Description listed as Milkbox Dietary revealed there was no temperature recorded for [DATE]. A record review of the Daily Freezer/Refrigerator Temperature Log for the Month/Year of ,d+[DATE] with a Location/Unit Description listed as Ice Cream Box Dietary revealed there was no temperature recorded for [DATE]. A record review of the facility's In-Service Attendance revealed Dietary #1 received training on the Topic of Storage Temperatures on [DATE].

Based on observations, interviews, record review, and facility policy review, the facility failed to prevent the development of an avoidable pressure ulcer on a resident with an immobilization brace for one (1) of three (3) facility acquired pressure ulcers reviewed. Resident #30 Findings Include: Review of the facility's policy, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .C. monitoring of skin integrity. The skin will be observed daily during care by the nursing assistants. If any skin concerns are noted, they are to be reported immediately to the designated nurse verbally and via the kiosk in electronic facilities . On 06/06/22 at 11:33 AM, the State Agency (SA) observed wound care for Resident #30 performed by the Director of Nursing (DON). The SA observed two wounds to the resident's right heel. Record review of Resident #30's Departmental Notes dated 3/21/22 at 2:44 PM revealed, Pressure Ulcer//Right Heel// .New DTI (Deep Tissue Injury), which appears to be from the brace resident must wear on her leg. The metal part was under the heel and medial side where the DTI was located. Record review of the facility's Pressure Ulcer Evaluation for Unavoidable/Avoidable Status dated 3/21/22 revealed Resident #30 was evaluated for clinical conditions and pressure ulcer risk factors with formal and clinical assessments on 3/18/22. Risk factors for development and or delayed healing of pressure ulcers were indicated as cast or non-removable device. Record review of the Wound Assessment Report dated 3/18/22, revealed an Assessment Occasion as New Wound. The stage and the type of pressure area was indicated as Unstageable and Suspected Deep Tissue Injury. The location of the pressure injury was the right heel and measurements were recorded as 5.50 CM X 2.80 CM. The wound report Notes revealed, New DTI appears to be from the brace resident has to wear on her leg. The metal part was under the heel and on the medial side where the DTI is located. During an interview on 06/06/22 at 12:15 PM, with Resident #30, she said she fell at home, fractured her knee, and came to the facility to receive therapy. She did not know her foot was pressing against the medal on the brace and had caused a wound. On 06/06/22 at 11:34 AM, the SA conducted a telephone interview with Registered Nurse (RN) #2, a former employee who was the wound care nurse. She said she was told by another nurse that Resident #30's right heel was boggy which possibly meant the resident's heel had underlying tissue damage. RN #2 said she monitored the area for a few days and notified the doctor, but she was unable to recall the exact date this occurred. RN #2 commented that the resident's immobilizer brace kept sliding down her leg causing the metal bar in the brace to apply pressure to her right heel. RN #2 confirmed the Certified Nursing Assistants (CNAs) could not remove the brace per doctor's order and only the nurse that provided care to the surgical site could remove the device. RN #2 believed Resident #30 developed the pressure injury on her heel from the metal bar on the brace. She stated that as the wound care nurse, she should have requested a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an Interview on 06/07/22 at 11:00 AM, with Licensed Practical Nurse (LPN) # 2, revealed she assisted RN #2 during wound care by holding Resident #30's right foot. LPN #2 said she was holding the residents' foot and noted the resident's right heel was red and boggy. LPN #2 said she reported her findings related to the heel to RN #2 and was told that RN #2 was going to monitor the heel for a while. LPN #2 said that approximately one week later, Resident #30's right heel continued to be boggy and had developed a purple discoloration. LPN #2 advised RN #2 that something needed to be done to prevent the resident from having skin breakdown. By the third week, Resident #30's right heel had opened, and wound care orders were received. LPN #2 said she was responsible for the weekly body audits, but she did not document there were any skin issues because she had already told RN #2 and the DON about the condition of Resident #30's heel. During an Interview on 6/07/22 at 1:00 PM, with the Medical Doctor (MD), he confirmed he was notified that Resident #30 had developed a deep tissue injury on her right heel. He was unaware that the resident's heel was pressing against the metal bar of the brace as it would slide down. He had thought the facility had padded all the pressure points on the resident's leg and heel to prevent pressure ulcers and friction, and he thought the facility was assessing the pressure areas daily. An interview on 6/7/22 at 1:30 PM, with the Physical Therapy Assistant (PTA) revealed he was asked on 3/28/22 by RN #2 to look at Resident #30's brace to see why it kept sliding down. The PTA said he adjusted the brace which kept the brace in place until it was removed. Record review of the facility's Timeline for (Proper Name of Resident #30) Wounds given to the SA by the DON revealed, 3/7/22 External Fixator with pins was removed and immobilizer was placed. 3/14/22 clarification from ortho (Orthopedics) on removal/placement of brace due to pain voiced by resident. Ortho states only loosen for wound care. 3/18/22 Deep tissue injury to right heel developed . During an Interview on 6/7/22 at 2:30 PM with the DON, she confirmed the resident acquired both the unstageable pressure ulcer and the Stage 2 pressure ulcer to the right heel because it had been one (1) wound that developed into two (2) separate wounds. The wound occurred from the metal bar on the brace. She acknowledged there is no documentation showing the facility was monitoring the pressure points daily for pressure injury development underneath the brace. She confirmed it was the wound care nurse's responsibility to make sure the resident's pressure points were checked daily to prevent skin breakdown. Record review of the Face Sheet revealed the facility admitted Resident #30 on 11/10/21, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/3/22 revealed Resident #30 had a Brief Interview of Mental Status (BIMS) score of 15 that indicated she was cognitively intact. Review of Section M revealed Resident #30 is at risk of developing pressure ulcer injury and had more than one (1) unhealed pressure injuries. Review of RN #2's, Licensed Nurses Orientation Checklist, revealed on 12/8/21 information was covered related to Policies/Procedures, schedules, documentation on the Skin Program/Wound Care which included body audits, treatments/orders

Based on staff interviews, record review, and facility policy review, the facility failed to complete an investigation for a resident who had a fall. Resident #103. Findings Include: A record review of the facility's policy Fall Prevention and Management Program, revealed, .Management .Should falling occur .the underlying cause will be investigated . A record review of Departmental Notes for Resident #103, dated 12/2/2021 at 7:27 AM, revealed, Resident noted on floor on his bottom by CNA (Certified Nursing Assistant) . A record review of the facility's Incident Log with dates of incidents listed from 12/1/21 through 6/6/22 revealed there was no fall listed for Resident #103 on 12/2/2021. On 6/8/22 at 1:05 PM, in an interview with the Director of Nursing (DON), she stated she had not been made aware that Resident #103 had a fall on 12/2/21. She verified the nurse who authored the Departmental Note for Resident #103 was an agency nurse and she is no longer working at the facility. The nurse, Licensed Practical Nurse (LPN) #3, did not communicate to the DON that the resident had fallen. On 6/8/22 at 1:50 PM, in an interview with the DON, she stated that the protocol used when a fall occurs is that the nurse will complete an incident report and place the information in a box at the nurses station. The DON will retrieve the incident information from the box, follow up on the incident, and forward the information to the Administrator. The staff will discuss incidents and accidents in the weekly High Risk Management Committee Meetings, and Resident #103's fall was never discussed in the meetings. She confirmed LPN #3 had received training on the protocol for incidents and accidents. A record review of the High Risk Management Committee Meetings dated 12/1/21 and 12/8/21 revealed Resident #103's fall was not discussed at the weekly meetings. A record review of Resident #103's Face Sheet revealed the facility admitted him on 11/26/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/2/21 revealed Resident #103 had a Brief Interview of Mental Status (BIMS) score of nine (9), which indicated he had moderate cognitive impairment. A record review of the Contract Caregiver Staff Orientation Checklist, revealed LPN #3 signed the checklist on 9/21 which included Accident and Incident Reporting.

Based on staff interviews and record reviews, the facility failed to complete the comprehensive Minimum Data Set (MDS) for one (1) of 38 residents reviewed for comprehensive assessments, with the potential to affect 57 residents. Resident #3 A record review of the facility's policy MDS Process, with a latest revision date of 12/20, revealed, The Assessment Nurse/ Nurse Case Manager will set the Assessment Reference Date on an allowable date with input from the interdisciplinary team and communicate scheduled assessments to the interdisciplinary team. The RAI (Resident Assessment Instrument) manual is the source document to be used for further MDS coding guidelines, time schedules and requirements . A record review of Centers for Medicare and Medicaid (CMS) RAI Version 3.0 Manual, dated October 2019, revealed, .The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) . A record review of the Face Sheet revealed the facility admitted Resident #3 on 03/20/2014. A record review of Resident #3's last comprehensive annual MDS assessment revealed a date of 05/24/2021, which is greater than 366 days. On 06/08/22 at 9:30 AM, during an interview with Registered Nurse (RN) #1, she confirmed Resident #3's last annual assessment was completed on 05/24/2021. On 06/08/22 at 9:45 AM, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed Resident #3's last annual MDS assessment had an Assessment Reference Date (ARD) of 05/24/2021 and she verified it had been over 366 days since an annual MDS assessment had been completed. On 06/08/22 at 10:30 AM, during an interview with the Director of Nursing (DON), she explained Resident #3 had an annual assessment that was open (not completed). She had not been made aware previously that the annual assessment was open and had been missed. She was trying to complete the MDS assessments that were due for April and May 2022 and she must have missed Resident #3's assessment. She confirmed that she was aware that some MDS assessments were behind because two (2) MDS nurses had quit in April 2022. The facility used the RAI manual for guidance in completing MDS assessments.

Based on resident interview, staff interview, record review, and facility policy review, the facility failed investigate a witnessed incident of verbal abuse in a timely manner and prevent the potential of further abuse occurring, for one (1) of four (4) residents reviewed, Resident #1. On 01/25/2020 at approximately 1:00 PM, Resident #1 and Certified Nursing Assistant (CNA) #1 were witnessed having a verbal altercation. CNA #1 was overheard telling Resident #1 she was sick and tired of her peeing on herself and everywhere in the facility. The incident was witnessed by Registered Nurse (RN) #1 and CNA #2, and overheard through the call system by Licensed Practical Nurse (LPN) #1 and LPN #2. CNA #1 was allowed to continue providing direct care to residents from 01/25/2020 to 01/27/2020 and was not sent home or made to leave the building after the witnessed incident of verbal abuse towards Resident #1 on 01/25/2020. Resident #1 was not assessed for any potential harm following the incident with CNA #1. The Administrator did not initiate an investigation of the witnessed verbal abuse until 01/28/2020, after she was informed by the State Ombudsman (SO) of her concerns regarding the incident between Resident #1 and CNA #1. The facility's failure to investigate and protect Resident #1 from abuse and allow a staff member to continue work in the facility, following a witnessed incident of verbal abuse, placed Resident #1 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 01/25/2020 when the verbal abuse occurred. The facility's Administrator was notified of the IJ and SQC on 02/12/2020 at 9:40 AM and provided with the IJ template. An acceptable, credible Removal Plan was provided by the facility on 02/12/2020, in which the facility alleged all corrective actions were completed, and the IJ was removed on 02/12/2020. The SA validated the Removal Plan and determined that the IJ was removed on 02/12/2020, prior to exit. Therefore, the scope and severity for the IJ and SQC at 42 CFR(s): 483.12 (c)(2)-(4) F610, Investigate/Prevent/Correct Alleged Violation was lowered to a D while the facility develops and implements a plan of correction (POC) and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Incident Investigation and Reporting policy, revised 05/2018, revealed, the facility would take all necessary steps to prevent recurrence and/or further potential abuse, any employee of the facility involved in incidents of abuse, would be suspended pending investigation until such time as the facility investigation is complete. During and after the investigation, the residents will be protected from harm through frequent supervision by staff. The final result of the investigation is to be reported to the Corporate Compliance Officer, Regional Supervisor, and appropriate officials in accordance with state law, within 72 hours after the event per fax and certified mail, or per specific state guidelines. Review of a complaint report submitted to the State Crimes Submission website by the facility's Administrator, dated 01/28/2020, revealed, the State Ombudsman reported concerns of verbal abuse, to the facility's Administrator, which involved a staff member and Resident #1. Review of the facility's investigation report, received by the State Agency (SA), revealed the report was faxed to the SA on 02/03/2020 at 5:36 PM, which was six (6) working days after the incident occurred. Review of the facility's Employee Warning Report for CNA #1, dated 01/26/2020, revealed, Registered Nurse (RN) #1 documented Date of Violation 01/25/2020, Time 1:00 PM, Yelling and arguing with resident in her room about toileting. The report was signed by RN #1 and dated 01/26/2020. The report was signed by the facility's Administrator, but undated. A review of the facility's CNA schedule for January 2020, revealed CNA #1 was scheduled to work on 01/25/2020 through 01/27/2020. Record review of Resident #1's medical record revealed there was no documentation of an assessment completed on 01/25/2020 following the witnessed incident of verbal abuse. On 02/10/2020 at 2:00 PM, during an interview with the Director of Nursing (DON), she revealed that she was notified on Sunday, 01/26/2020 regarding an incident between Resident #1 and CNA #1. The DON stated she told the nurse to write up the incident, slide it under her door, and that she would investigate the incident on Monday, 01/27/2020. The DON confirmed CNA #1 worked at the facility from 01/25/2020 to 01/27/2020 and was not reassigned or sent home as a result of the incident on 01/25/2020. During an interview with the facility's Administrator (ADM), on 02/10/2020 at 2:30 PM, she stated the Ombudsman reported the incident of verbal abuse between Resident #1 and CNA #1 to her on Monday, 01/27/2020. (The Ombudsman was present at the facility on Tuesday, 01/28/2020). The ADM stated she did not know anything about the alleged verbal abuse, until the Ombudsman told her of concerns she had regarding an incident that had occurred between Resident #1 and CNA #1. The ADM confirmed CNA #1 was not reassigned to another hall or asked to leave the building on the day of the incident (01/25/2020). The ADM confirmed CNA #1 continued to work at the facility until 01/27/2020. The ADM revealed it was the facility's policy to send any staff home that was involved in an investigation or alleged to be accused of abuse. During an interview via telephone, on 02/10/2020 at 4:00 PM, RN #1 she was in another resident's room when she heard CNA #1 and Resident #1 yelling and screaming extremely loud at each other on 01/25/2020. RN #1 stated CNA #1 told Resident #1 that she was tired of her peeing everywhere and that she had peed on another resident's foot and down the hall. RN#1 revealed CNA #1 spoke to Resident #1 in a harsh tone. RN #1 stated she told CNA #1 to come out of Resident #1's room and go take a break, and not to go back into the resident's room until she cooled off. RN #1 stated she did not assess Resident #1, and assumed LPN #1 had assessed her since she was assigned to the hall where Resident #1 resided. RN #1 revealed she called the DON on Sunday, 01/26/2020, and was told to write up the incident and push it under her office door. RN #1 stated the DON told her she would handle the situation when she returned to work on Monday 01/27/2020. Review of the facility's Licensed Staff job description, dated 09/19/2019 and signed by RN #1, revealed her responsibilities included to assure accurate and timely documentation of any unusual observation, incident or happening. The Job Summary included: Make rounds, evaluate the physical, emotional and social needs of the residents and provide intervention as indicated. Review of the facility's personnel records for RN #1, revealed on 09/19/2019, she signed to acknowledge reading and receiving policies and procedures on Resident Rights, Reporting Requirements of the Vulnerable Adult Act and the Mississippi Vulnerable Adult Act. During an interview via telephone, on 02/10/2020 at 4:45 PM, LPN #1 revealed that she was kind of the leader on weekends and that all reports are sent to her to resolve. LPN #1 stated on the day of the incident (01/25/2020), she and LPN #2 were sitting at the nurse's desk charting and heard an argument over the intercom call system. LPN #1 revealed she and LPN #2 went down the hall and saw RN #1 standing outside of Resident #1's room talking to CNA #1. LPN #1 stated she assumed RN #1 had handled the situation between Resident #1 and CNA #1. LPN #1 revealed she never assessed any residents. On 02/11/2020 at 2:00 PM, during an interview, the facility's Social Service Designee (SSD) revealed she had never been asked to evaluate Resident #1 or had spoken to Resident #1 about any incidents that had occurred between her and any staff members. The SSD stated during the Stand-Up meeting on 01/27/2020, the DON announced she had been given some information about an incident between a resident and a CNA, but the DON did not reveal any details about the incident. The SSD confirmed the Ombudsman was at the facility on 01/28/2020. The SSD further revealed they had a Quality Assurance (QA) on 01/28/2020, but there was no discussion about an incident occurring between Resident #1 and any CNA. During an interview, on 02/11/2020 at 3:26 PM, the State Ombudsman (SO) revealed she had visited the facility on Tuesday, 01/28/2020. The SO revealed she told the ADM, Resident #1 had voiced being upset about an incident that occurred between her and CNA #1 on 01/25/2020. The SO stated Resident #1 told her she had been fussed at because of wetting herself and that the statements were hurtful and embarrassed her. An interview on 02/12/2020 at 11:30 AM, with CNA #1, revealed that on 01/25/2020 at approximately 1:00 PM, she was involved in an argument with Resident #1. CNA #1 revealed that she and Resident #1 both cussed each other and that the argument got loud. CNA #1 revealed RN #1 heard the loud argument, intervened and asked her to go on break to cool off, and not to go back in Resident #1's room until she was calm. CNA #1 confirmed she worked her entire shifts on 01/25/2020, 01/26/2020, and 01/27/2020 and was never reassigned nor asked to leave the building on any of those days. CNA #1 revealed that no one ever asked her about the incident between her and Resident #1 until Monday, 01/27/2020. CNA #1 stated the DON asked her to write a statement about what happened on 1/25/2020, between her and Resident #1. CNA #1 revealed the DON did not talk to her about the incident, but only asked her to write a statement. CNA #1 revealed the ADM called her on 01/30/2020 and told her there was an investigation into the incident and for her not to return to work until the investigation was over. The facility submitted an acceptable Removal Plan on 02/12/2020, for the IJ and SQC. Review and validation of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit on 02/12/2020. 1. On January 25, 2020, while making rounds at approximately 1:00 PM, Registered Nurse #1 overheard Certified Nursing Assistant #1 yelling at Resident #1 from the inside of the resident's room. Registered Nurse #1 stated she instructed Certified Nursing Assistant #1 to take a break and removed her from the resident immediately. Registered Nurse #1 stated she notified Director of Nursing #1 on January 26, 2020 of the occurrence at approximately 2:00 PM. Director of Nursing #1 instructed Registered Nurse #1 to complete a disciplinary action with Certified Nursing Assistant #1. 2. On January 28, 2020, Ombudsman #1 reported to the Facility Administrator #1 of an allegation of verbal abuse reported by Resident #1. Resident #1 reported to Ombudsman #1 that Certified Nursing Assistant #1 yelled at her while providing incontinent care during the day shift hours of Saturday, January 25, 2020. 3. A written warning was completed by Director of Nursing #1 and reviewed with Certified Nursing Assistant #1 on January 27, 2020 regarding unsatisfactory behavior towards a resident on January 25, 2020. 4. The Facility Administrator #1 suspended Certified Nursing Assistant #1 on January 28, 2020 pending investigation. Certified Nursing Assistant #1 was terminated on February 3, 2020 by the Facility Administrator #1. As of February 11, 2020, Resident #1 remains in good spirits with no psychosocial changes noted. 5. Director of Nursing #1 assessed Resident #1 on January 28, 2020 at approximately 2:15 PM. Resident#1 was in good spirits with no indications of fear or withdrawn behavior. Resident #1 attended group activities on January 26th, January 27th, and January 28th, 2020. 6. The Facility Administrator #1 notified the local authorities on January 28, 2020 at approximately 4:45 PM. The Facility Administrator #1 notified the Mississippi State Department of Health and the Mississippi Attorney General's office on January 28, 2020 at approximately 4:55 PM. 7. A Quality Assurance meeting was held on February 11, 2020 at approximately 4:00 PM to discuss Verbal Abuse and investigations. The facility Quality Assurance Committee members which consisted of Facility Administrator #1, Director of Nursing #1, Infection Control Prevention Officer #1, Medical Director #1, Social Services Director #1, Assessment Nurse #1, Treatment Nurse #1 and Staff Development Nurse #1, Activity Director #1, Housekeeping Supervisor #1. Topics discussed include: (a) Resident Rights, (b) Accident/Incident Reporting, (c) Incident Investigation and Reporting, (d) Abuse/Neglect, e) Dignity/Respect. The Facility Action Plan was reviewed and approved by the Quality Assurance Committee Members. The SA validated the facility's Removal Plan and determined that the facility took the appropriate measures to correct the IJ. The validation was confirmed through staff interviews, Residents interviews, Responsible Party interview, Ombudsman interview, and record review on 2/12/2020 prior to exit from the facility. 1. The SA validated Resident #1 was not free from verbal abuse and the facility failed to remove the perpetrator from the building following a witnessed account of verbal abuse that was witnessed by RN #1 and CNA #2 toward Resident #1 by CNA #1 on 01/25/2020 at approximately 1:00 PM. The facility failed to provide for the safety of Resident #1 and all 53 residents of the facility. 2. The SA validated through interview and record review that CNA #1 was allowed to work in direct resident care with residents in the facility for eight (8) hour shifts on Saturday 01/25/2020; Sunday 01/26/2020; and Monday 01/27/2020. The facility did not perform assessments of the residents in the facility and of Resident #1 and did not provide for their safety by completing assessments and removing the perpetrator from the building. The facility did not report the verbal abuse within two (2) hours of the witnessed verbal abuse toward Resident #1. 3. The SA validated through interview and record review with RN #1 that she reported that verbal abuse via telephone to the DON and completed a written report of the incident and pushed it under the office door of the DON. The SA validated through interviews and record reviews that the facility conducted In-Service Training on Abuse, Neglect, and Reporting of Incidents prior to exit on 2/12/2020. 4. The SA validated on 02/12/2020 through interviews with staff that a Quality Assurance (QA) Committee Meeting was held on 02/11/2020 at approximately 4:00 PM to discuss the incident of verbal abuse that was witnessed toward Resident #1 on 01/25/2020. All QA members required were in attendance. 5. The SA validated on 02/20/2020 through interviews with the Staff Development Nurse (RN#3) that she was conducting the in-service training and returning to the facility after hours and on weekends to conduct in-service training Abuse, Neglect, and Reporting of incidents as well as safety of all Residents. The RN#3 confirmed through interview that no staff member will be allowed to return to work before in-services / trainings were completed. 6. The SA validated on 02/12/2020 through staff and resident interviews and record review that all 53 residents residing in the facility had been assessed by facility staff for abuse, and neglect, and verbal abuse and safety. As well as psychosocial wellbeing and physical wellbeing. 7. The SA validated on 02/12/2020 through interviews and record reviews that the corrective actions were put into place by the facility on February 11, 2020. The IJ was removed on 2/12/2020 prior to exit.

Based on resident interview, staff interview, record review, and facility policy review, the facility failed to report an allegation of staff to resident abuse within the two (2) hours required time frame, for one (1) of four (4) residents reviewed, Resident #1. On 01/25/2020, at approximately 1:00 PM, Resident #1 and Certified Nursing Assistant (CNA) #1 were involved in a verbal altercation in the resident's room. The incident began when Resident #1 called for assistance to get changed after having an incontinent episode. CNA #1 and CNA #2 responded to the resident's room, and an argument took place at that time. CNA #1 was witnessed yelling and cursing at Resident #1. CNA #1 used the language Damn it and I'm tired of you peeing everywhere and told Resident #1 that she had peed all down the halls and had peed on another resident's feet. The incident was witnessed by Registered Nurse (RN) #1 and CNA #2, and also overheard through the call system by Licensed Practical Nurse (LPN) #1 and LPN #2. CNA #1 was allowed to continue providing direct care of residents from 01/25/2020 to 01/27/2020. The incident was not reported on 01/25/2020, to the appropriate state agencies within the required two (2) hour time frame. The facility did not report the incident of verbal abuse to the State Agency until 02/04/2020 at 3:53 PM, which was approximately nine (9) days later. The facility's failure to notify the appropriate authorities, including the Responsible Party (RP) of Resident #1 and to immediately remove the perpetrator of a witnessed incident of verbal abuse, and ensure proper measures had been addressed, placed Resident #1 and all residents of the facility at risk for the likelihood of serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 01/25/2020, when the staff witnessed verbal abuse of Resident #1. The facility's Administrator (ADM) was notified of the IJ and SQC on 02/12/2020 at 9:40 AM and provided with the IJ template. An acceptable credible Removal Plan was provided by the facility on 02/12/2020, in which the facility alleged all corrective actions were completed, and the IJ was removed on 02/12/2020. The State Agency (SA) validated the Removal Plan and determined the IJ was removed on 02/12/2020 prior to exit. Therefore, the scope and severity for the IJ and SQC at CFR(s): 483.12 (c)(1)(4), Reporting of Alleged Violations, F609, was lowered to a D while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Incident Investigation and Reporting policy, revised 05/2018, revealed: The facility administrator shall ensure that any incident involving an allegation or suspicion of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported not later than 2 hours after allegation is made to local law enforcement and the state agency, if the events that cause the allegation involve abuse or result in serious bodily injury to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities in accordance with state law. The policy also revealed, the facility would take all necessary steps to prevent recurrence and/or further potential abuse, any employee of the facility involved in incidents of abuse, would be suspended pending investigation until such time as the facility investigation is complete. During and after the investigation, the residents will be protected from harm through frequent supervision by staff. The final result of the investigation is to be reported to the Corporate Compliance Officer, Regional Supervisor and appropriate officials in accordance with state law, within 72 hours after the event per fax and certified mail, or per specific state guidelines. Review of the records provided by the facility, revealed an Employee Warning Report for CNA #1, dated 01/26/2020 and completed by RN #1, regarding an incident which occurred on 01/25/2020 at 1:00 PM. The report documented Yelling and arguing with resident in her room about toileting. The report was signed by the Administrator and undated. Review of a complaint report, submitted via the State Crimes Submission website, revealed the facility's Administrator reported the incident of verbal abuse on 01/28/2020. The Administrator revealed in the report that the State Ombudsman had reported concerns of verbal abuse to her, which involved a staff member and Resident #1. A review of the State Agency (SA) records, revealed the facility faxed the investigation report to the SA on 02/03/2020, which was nine (9) days after the witnessed verbal abuse that had occurred on 01/25/2020 between Resident #1 and CNA #1. During an interview, on 02/10/2020 at 2:30 PM, the Administrator (ADM) revealed she had been at the facility for [AGE] years and this was her first case of reported verbal abuse. The ADM stated that she had no knowledge of the alleged verbal altercation involving Resident #1, until the Ombudsman visited on Monday, 01/27/2020 (The Ombudsman visited on Tuesday, 01/28/2020). The ADM confirmed CNA #1 provided direct resident care on Saturday, 01/25/2020; Sunday, 01/25/2020; and Monday, 01/27/2020, and she was not removed from the building after the witnessed verbal abuse of Resident #1 on 01/25/2020. During an interview, on 02/10/2020 at 2:00 PM, the Director of Nursing (DON) revealed she received a telephone voice message on 01/26/2020 that indicated a resident and a CNA got into it with each other. The DON stated after getting the message, she called the facility and told the nurse to write up the incident, slide it under her door, and that she would investigate the incident on Monday, 01/27/2020. The DON confirmed CNA #1 continued to work in the facility from 01/25/2020 to 01/27/2020 and was not reassigned or sent home as a result of the incident on 01/25/2020. During an interview, on 02/10/2020 at 2:45 PM, Resident #1 revealed she had attitudes from a few of the CNAs on an ongoing basis. She stated the CNAs fussed at her about wetting and overfilling her diaper with urine. Resident #1 revealed on 01/25/2020, she had just had enough of being fussed at. Resident #1 stated CNA #1 came into her room, started yelling and cussing at her, saying she had left urine up and down the hall, and that she could help herself. Resident #1 stated CNA #1 was belittling her. Resident #1 revealed she raised her hands in the air and told CNA #1 to stop it and told her that she didn't want to hear another word she had to say. Resident #1 stated CNA#1 got louder, then she got louder, and they were both yelling at each other. Resident #1 stated CNA #2 was in the room when she and CNA #1 were yelling and cussing each other. Resident #1 stated CNA #2 went and got the nurse, and the nurse called CNA #1 out into the hall. Resident #1 stated CNA #1 was still in the building working with residents, a few days after the incident, and that made her feel a little uneasy and a little fearful. Resident #1 stated the Ombudsman came to see her a few days after the incident, and she told the Ombudsman about the incident. Resident #1 stated she hated that it took telling the Ombudsman in order to get the yelling and fussing to stop, but she was glad it finally got the residents some help. Resident #1 revealed the whole thing was upsetting to her for days afterwards, but she was okay now. During a telephone interview, on 02/10/2020 at 4:00 PM, RN #1 revealed that on 01/25/2020, she was doing treatments in the room next door to Resident #1. RN #1 stated she heard CNA #1 yelling and screaming loudly, in a threatening and very bad tone. RN #1 stated she overheard CNA #1 saying she was tired of Resident #1 peeing everywhere and that the resident had peed down the hall and on another resident's foot. RN #1 stated she did not like the way CNA #1 was yelling at Resident #1. RN #1 confirmed she went to Resident #1's room and told CNA #1 to leave Resident #1's room, take a break, and not to go back in Resident #1's room until she cooled off. RN #1 stated she called the DON on Sunday, 01/26/2020 and reported the incident she witnessed between Resident #1 and CNA #1. RN #1 further stated the DON told her to write the incident up, push it under her office door, and she would take care of the matter when she returned to work on Monday, 01/27/2020. RN #1 stated they (nurses) were asked to have a meeting with the CNAs, but the CNAs refused to meet with the nurses. RN #1 confirmed that she did not remove CNA #1 from the building or reassign her after the witnessed verbal abuse of Resident #1. RN #1 stated she did not evaluate or check on Resident #1 after the witnessed verbal abuse occurred. During a telephone interview, on 02/11/2020 at 3:26 PM, the State Ombudsman (SO) revealed she reported the alleged verbal abuse of Resident #1 directly to the ADM on Tuesday, 01/28/2020 at approximately 3:00 PM. The SO stated Resident #1 reported to her an argument between her and CNA #1 that had occurred on Saturday, 01/25/2020. The SO revealed the ADM told her, during her exit meeting on Tuesday, 01/28/2020, that she had no knowledge of any incidents of verbal abuse and that was the first report she had received. On 02/11/2020 at 2:00 PM, during an interview, the Social Services Designee (SSD) revealed the DON and the ADM announced in a Stand-Up meeting on 01/27/2020, that there had been an incident involving Resident #1 and that they would be getting interviews. The SSD stated they did not give any details of what had occurred with Resident #1. The SSD confirmed the State Ombudsman (SO) was at the facility on 01/28/2020 and talked with the ADM, which delayed a scheduled meeting. The SSD stated she had not been given any directives to evaluate Resident #1 and had not been given any information concerning the investigation of the incident which occurred on 01/25/2020 between Resident #1 and CNA #1. An interview with the Responsible Party (RP), on 02/12/2020 at 10:50 AM, revealed no one from the facility had contacted him about the witnessed verbal abuse of Resident #1 by CNA #1 that occurred on 01/25/2020 at 1:00 PM. The RP stated the facility notified him about the incident (which occurred on 01/25/2020), at approximately 10:00 AM on 02/12/2020. The RP stated the facility told him that Resident #1 had been involved in an argument with a staff member and that the matter had been resolved. The facility submitted an Acceptable Removal Plan on 2/12/2020, for the IJ and SQC. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit: 1. On January 25, 2020, while making rounds at approximately 1:00 PM, Registered Nurse #1 overheard Certified Nursing Assistant #1 yelling at Resident #1 from the inside of the resident's room. Registered Nurse #1 stated she instructed Certified Nursing Assistant #1 to take a break and removed her from the resident immediately. Registered Nurse #1 stated she notified Director of Nursing #1 on January 26, 2020 of the occurrence at approximately 2:00 PM. Director of Nursing #1 instructed Registered Nurse #1 to complete a disciplinary action with Certified Nursing Assistant #1. 2. On January 28, 2020, Ombudsman #1 reported to the Facility Administrator #1 of an allegation of verbal abuse reported by Resident #1. Resident #1 reported to Ombudsman #1 that Certified Nursing Assistant #1 yelled at her while providing incontinent care during the day shift hours of Saturday, January 25, 2020. 3. A written warning was completed by Director of Nursing #1 and reviewed with Certified Nursing Assistant #1 on January 27, 2020 regarding unsatisfactory behavior towards a resident on January 25, 2020. 4. The Facility Administrator #1 suspended Certified Nursing Assistant #1 on January 28, 2020 pending investigation. Certified Nursing Assistant #1 was terminated on February 3, 2020 by the Facility Administrator #1. As of February 11, 2020, Resident #1 remains in good spirits with no psychosocial changes noted. 5. Director of Nursing #1 assessed Resident #1 on January 28, 2020 at approximately 2:15 PM. Resident#1 was in good spirits with no indications of fear or withdrawn behavior. Resident #1 attended group activities on January 26th, January 27th, and January 28th, 2020. 6. The Facility Administrator #1 notified the local authorities on January 28, 2020 at approximately 4:45 PM. The Facility Administrator #1 notified the Mississippi State Department of Health and the Mississippi Attorney General's office on January 28, 2020 at approximately 4:55 PM. 7. A Quality Assurance meeting was held on February 11, 2020 at approximately 4:00 PM to discuss Verbal Abuse and investigations. The facility Quality Assurance Committee members which consisted of Facility Administrator #1, Director of Nursing #1, Infection Control Prevention Officer #1, Medical Director #1, Social Services Director #1, Assessment Nurse #1, Treatment Nurse #1 and Staff Development Nurse #1, Activity Director #1, Housekeeping Supervisor #1. Topics discussed include: (a) Resident Rights, (b) Accident/Incident Reporting, (c) Incident Investigation and Reporting, (d) Abuse/Neglect, e) Dignity/Respect. The Facility Action Plan was reviewed and approved by the Quality Assurance Committee Members. The SA validated the facility's Removal Plan and determined that the facility took the appropriate measures to correct the IJ. The validation was confirmed through staff interviews, Residents interviews, Responsible Party interview, Ombudsman interview, and record review on 2/12/2020 prior to exit from the facility. 1. The SA validated Resident #1 was not free from verbal abuse and the facility failed to remove the perpetrator from the building following a witnessed account of verbal abuse that was witnessed by RN #1 and CNA #2 toward Resident #1 by CNA #1 on 01/25/2020 at approximately 1:00 PM. The facility failed to provide for the safety of Resident #1 and all 53 residents of the facility. 2. The SA validated through interview and record review that CNA #1 was allowed to work in direct resident care with residents in the facility for eight (8) hour shifts on Saturday 01/25/2020; Sunday 01/26/2020; and Monday 01/27/2020. The facility did not perform assessments of the residents in the facility and of Resident #1 and did not provide for their safety by completing assessments and removing the perpetrator from the building. The facility did not report the verbal abuse within two (2) hours of the witnessed verbal abuse toward Resident #1. 3. The SA validated through interview and record review with RN #1 that she reported that verbal abuse via telephone to the DON and completed a written report of the incident and pushed it under the office door of the DON. The SA validated through interviews and record reviews that the facility conducted In-Service Training on Abuse, Neglect, and Reporting of Incidents prior to exit on 2/12/2020. 4. The SA validated on 02/12/2020 through interviews with staff that a Quality Assurance (QA) Committee Meeting was held on 02/11/2020 at approximately 4:00 PM to discuss the incident of verbal abuse that was witnessed toward Resident #1 on 01/25/2020. All QA members required were in attendance. 5. The SA validated on 02/20/2020 through interviews with the Staff Development Nurse (RN#3) that she was conducting the in-service training and returning to the facility after hours and on weekends to conduct in-service training Abuse, Neglect, and Reporting of incidents as well as safety of all Residents. The RN#3 confirmed through interview that no staff member will be allowed to return to work before in-services / trainings were completed. 6. The SA validated on 02/12/2020 through staff and resident interviews and record review that all 53 residents residing in the facility had been assessed by facility staff for abuse, and neglect, and verbal abuse and safety. As well as psychosocial wellbeing and physical wellbeing. 7. The SA validated on 02/12/2020 through interviews and record reviews that the corrective actions were put into place by the facility on February 11, 2020. The IJ was removed on 2/12/2020 prior to exit.

Based on resident interview, staff interview, record review, and facility policy review, the facility failed to ensure a resident was free from verbal abuse for one (1) of four (4) residents reviewed for abuse, Resident #1. On 01/25/2020, Resident #1 and Certified Nursing Assistant (CNA) #1 were involved in a verbal altercation, where CNA #1 yelled, screamed, and belittled Resident #1 in a loud voice. CNA #1 was overheard telling Resident #1 she was sick and tired of her peeing on herself and everywhere in the facility. The incident was witnessed by Registered Nurse (RN) #1 and CNA #2, and overheard through the call system by Licensed Practical Nurse (LPN) #1 and LPN #2. RN #1 intervened and told CNA #1 to go take a break and not to go back into Resident #1's room until she cooled off. Resident #1 was not assessed for harm after the witnessed incident of verbal abuse on 01/25/2020. CNA #1 was not sent home after the incident with Resident #1 and was allowed to continue providing direct care of residents from 01/25/2020 to 01/27/2020. The facility's failure to protect Resident #1 from verbal abuse and allow the staff member to work in the facility following a witnessed incident of verbal abuse, placed Resident #1 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 01/25/2020 when the verbal abuse occurred. The facility's Administrator was notified of the IJ and SQC on 02/12/2020 at 9:40 AM and provided with the IJ template. An acceptable, credible Removal Plan was provided by the facility on 02/12/2020, in which the facility alleged all corrective actions were completed, and the IJ was removed on 02/12/2020. The SA validated the Removal Plan and determined that the IJ was removed on 02/12/2020, prior to exit. Therefore, the scope and severity for the IJ and SQC at 42 CFR(s): 483.12 (a)(1) F600, Freedom from Abuse and Neglect, and Exploitation, was lowered to a D while the facility develops and implements a plan of correction (POC) and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Incident Investigation and Reporting policy, with a revision date of 05/2018, revealed: Each resident has the right to be free from any type of abuse including verbal, sexual, mental, physical abuse, neglect, misappropriation of resident property and exploitation. The policy also revealed, Verbal Abuse is defined as the use of oral, written, or gestured language that willingly includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. A review of the facility's Dignity and Respect policy, revised 11/2017, revealed: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each residents individuality. The facility shall protect and promote the rights of the resident. Facility staff shall display respect when speaking with, caring for and talking about residents, as constant affirmation of their individuality and dignity as human beings. Review of a complaint, submitted to the State Crimes Submission website by the facility's Administrator, dated 01/28/2020, revealed, the State Ombudsman reported concerns of verbal abuse, to the facility's Administrator, which involved a staff member and Resident #1. The report documented Resident #1 stated she felt belittled by remarks made regarding her incontinent episodes. Review of the facility's Employee Warning Report for CNA #1, dated 01/26/2020, revealed, Registered Nurse (RN) #1 documented Date of Violation 01/25/2020, Time 1:00 PM, Yelling and arguing with resident in her room about toileting. The report was signed by RN #1 and dated 01/26/2020. The report was signed by the facility's Administrator, but undated. Record review of Resident #1's medical record revealed there was no documentation of an assessment completed on 01/25/2020 following the witnessed incident of verbal abuse. There was no documentation between the dates of 01/25/2020 and 02/11/2020 of Resident #1's Responsible Party being notified of the incident which occurred on 01/25/2020. During an interview, on 02/10/2020 at 2:00 PM, the Director of Nursing (DON) revealed she was notified on Sunday, 01/26/2020 regarding the incident between Resident #1 and CNA #1. The DON stated she told the nurse to write up the incident, slide it under her door, and that she would investigate the incident on Monday, 01/27/2020. The DON stated staff did not use the terminology abuse when the incident was reported to her. The DON confirmed CNA #1 continued to work in the facility from 01/25/2020 to 01/27/2020 and was not reassigned or sent home as a result of the incident on 01/25/2020. During an interview, on 02/10/2020 at 2:30 PM, the facility Administrator (ADM) stated the Ombudsman reported the incident of verbal abuse, which occurred on 01/25/2020, to her on Monday, 01/27/2020. The ADM stated she did not know anything about the alleged verbal abuse, until the Ombudsman told her of concerns she had regarding an incident that had occurred between Resident #1 and CNA #1. The ADM stated CNA #1 was not reassigned to another hall or asked to leave the building on the day of the incident (01/25/2020) and continued to work at the facility until 01/27/2020. The ADM confirmed it was the facility's policy to send any staff home that was involved in an investigation or alleged to be accused of abuse. The ADM revealed there was no documentation of Resident #1 being assessed following the incident on 01/25/2020. During an interview, on 02/10/2020 at 2:45 PM, Resident #1 stated CNA #1 came to her room on 01/25/2020 and started yelling and cussing at her, saying she had left urine up and down the hall, and that she could help herself. Resident #1 stated CNA #1 was belittling her. Resident #1 revealed she raised her hands and told CNA #1 she didn't want to hear another word she had to say. Resident #1 stated CNA#1 got louder. Resident #1 stated CNA #2 was in the room and witnessed the argument. Resident #1 stated CNA #2 went and got the nurse, and the nurse called CNA #1 out into the hall. Resident #1 stated CNA #1 continued working in the building working with residents, a few days after the incident. Resident #1 revealed she felt uneasy and a little fearful with CNA #1 still working. Resident #1 stated the Ombudsman came to see her a few days after the incident, and she told the Ombudsman about what happened between her and CNA #1. Resident #1 stated she hated that it took telling the Ombudsman in order to get the yelling and fussing to stop. Resident #1 stated the whole thing was upsetting to her for days afterwards, but she was okay now. During an interview via telephone, on 02/10/2020 at 4:00 PM, RN #1 revealed she was the treatment nurse on the day of the incident (01/25/2020) between Resident #1 and CNA #1. RN #1 revealed she was in another resident's room when she heard CNA #1 and Resident #1 yelling and screaming extremely loud at each other. RN #1 revealed CNA #1 told Resident #1 that she was tired of her peeing everywhere and that she had peed on another resident's foot and down the hall. RN#1 stated CNA #1 spoke to Resident #1 in a harsh tone. RN #1 stated she told CNA #1 to come out of Resident #1's room and go take a break, and not to go back into the resident's room until she cooled off. RN #1 revealed she did not assess Resident #1, and assumed LPN #1 had assessed her since she was assigned to the hall where Resident #1 resided. RN #1 stated she called the DON on Sunday, 01/26/2020, and was told to write the incident up and push it under her office door. RN #1 revealed the DON told her she would handle the situation when she returned to work on Monday 01/27/2020. During an interview via telephone, on 02/10/2020 at 4:45 PM, LPN #1 revealed she was the charge nurse on weekends. LPN #1 stated on the day of the incident (01/25/2020), she and LPN #2 were sitting at the nurse's desk charting and heard an argument over the intercom call system. LPN #1 revealed she and LPN #2 went down the hall and saw RN #1 standing outside of Resident #1's room talking to CNA #1. LPN #1 stated she assumed RN #1 had handled the situation. LPN #1 stated she did not assess Resident #1 or any residents and did not reassign CNA #1 to a different area after the incident occurred. On 02/11/2020 at 2:00 PM, during an interview with the facility's Social Service Designee (SSD), she revealed that she had never been asked to talk with Resident #1 and she had never evaluated or spoken to Resident #1 about any incidents that had occurred between Resident #1 and any staff members. SSD stated that on Monday morning 01/27/2020 at the Stand Up meeting, the DON announced she had been given some information about an incident between a resident and a CNA. The SSD revealed no details were shared about the incident, only that they would be conducting an investigation. The SSD confirmed the Ombudsman was at the facility on 01/28/2020. The SSD revealed they had a Quality Assurance (QA) on 01/28/2020 and there was no discussion about an incident occurring between Resident #1 and any CNA. The SSD stated she had heard through the grapevine that a CNA had cussed out Resident #1 in her room for wetting herself. During an interview, on 02/11/2020 at 3:26 PM, the State Ombudsman (SO) confirmed she visited the facility on Tuesday, 01/28/2020, and had an exit meeting at approximately 3:00 PM with the facility's ADM. The SO stated she reported to the ADM, that Resident #1 voiced being upset about an incident that had occurred between her and CNA #1 on 01/25/2020. The SO stated Resident #1 told her that she was fussed at because of wetting herself and it was hurtful and embarrassed her. An interview on 02/12/2020 at 11:30 AM, with CNA #1, revealed that on 01/25/2020 at approximately 1:00 PM, she was involved in an argument with Resident #1. CNA #1 confirmed that they both cussed each other and that the argument got loud between the both of them. CNA #1 confirmed RN #1 heard the loud argument, and asked her to step away, go on break to cool off, and not to go back in Resident #1's room until she was calm. CNA #1 confirmed that CNA #2 was in the room and witnessed the argument between her and Resident #1. CNA #1 confirmed LPN #2 had come down the hall and also heard the argument. CNA #1 revealed LPN #2 stood in the hallway outside the room of Resident #1 and talked with her. CNA #1 stated LPN #2 was always very helpful to her and that she was a good supervisor. CNA #1 further stated she assumed LPN #2 had written the incident up and had given it to the DON. CNA #1 confirmed she worked her entire shifts on 01/25/2020, 01/26/2020, and 01/27/2020. CNA #1 confirmed she was never reassigned nor asked to leave the building on 01/25/2020, 01/26/2020, and 01/27/2020. CNA #1 stated that no one ever asked her about the argument between herself and Resident #1 until approximately 11:30 AM on 01/27/2020, when the DON asked her to write a statement as to what happened between her and Resident #1 on 1/25/2020. CNA #1 stated the DON did not talk to her about the incident, but just asked her to write a statement. CNA #1 was scheduled off on 01/28/2020 and 01/29/2020. CNA #1 revealed the ADM called her on 01/30/2020 and told her there was an investigation and not to return to work until the investigation was over. On 02/12/2020 at 2:00 PM, during an interview, CNA #2 confirmed she was in the room with CNA #1 and Resident #1, on 01/25/2020, when they got into it an argument. CNA #2 revealed Resident #1 had turned on her call light to request assistance to be changed. CNA #2 stated CNA #1 saw puddles of pee in the hall and dining room and told Resident #1 she should have called and asked for help before peeing everywhere. CNA #2 revealed Resident #1 put her hands up and told CNA #1 she was tired of her mouth and didn't want to hear another word. CNA #2 stated CNA #1 began cursing at Resident #1. CNA #2 stated she couldn't remember all the curse words that were used, but for sure Damn it being used a few times. CNA #2 confirmed RN #1 heard the argument and told CNA #1 to go on break. A record review of CNA #1's personnel records, revealed CNA #1 was hired by the facility on 07/31/2018. CNA #1 was in-serviced and trained on Abuse and Neglect, the Elder Justice Act, Vulnerable Adult Act, and Accident/ Incident Reporting on 09/03/2019. Record review of the facility's document titled Termination Report for CNA#1, revealed it was signed by the ADM and dated 02/05/2020. The termination date was effective as of 02/03/2020 for violation of policy and misconduct. The report did not contain a signature or date for CNA #1. A review of the facility's Admission Record for Resident #1, revealed, an admission date of [DATE]. Admission [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Date (ARD) of 11/25/2019, revealed she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognitive skills for daily decision making. The facility submitted an acceptable Removal Plan on 02/12/2020, for the IJ and SQC. Review and validation of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit on 02/12/2020. 1. On January 25, 2020, while making rounds at approximately 1:00 PM, Registered Nurse #1 overheard Certified Nursing Assistant #1 yelling at Resident #1 from the inside of the resident's room. Registered Nurse #1 stated she instructed Certified Nursing Assistant #1 to take a break and removed her from the resident immediately. Registered Nurse #1 stated she notified Director of Nursing #1 on January 26, 2020 of the occurrence at approximately 2:00 PM. Director of Nursing #1 instructed Registered Nurse #1 to complete a disciplinary action with Certified Nursing Assistant #1. 2. On January 28, 2020, Ombudsman #1 reported to the Facility Administrator #1 of an allegation of verbal abuse reported by Resident #1. Resident #1 reported to Ombudsman #1 that Certified Nursing Assistant #1 yelled at her while providing incontinent care during the day shift hours of Saturday, January 25, 2020. 3. A written warning was completed by Director of Nursing #1 and reviewed with Certified Nursing Assistant #1 on January 27, 2020 regarding unsatisfactory behavior towards a resident on January 25, 2020. 4. The Facility Administrator #1 suspended Certified Nursing Assistant #1 on January 28, 2020 pending investigation. Certified Nursing Assistant #1 was terminated on February 3, 2020 by the Facility Administrator #1. As of February 11, 2020, Resident #1 remains in good spirits with no psychosocial changes noted. 5. Director of Nursing #1 assessed Resident #1 on January 28, 2020 at approximately 2:15 PM. Resident#1 was in good spirits with no indications of fear or withdrawn behavior. Resident #1 attended group activities on January 26th, January 27th, and January 28th, 2020. 6. The Facility Administrator #1 notified the local authorities on January 28, 2020 at approximately 4:45 PM. The Facility Administrator #1 notified the Mississippi State Department of Health and the Mississippi Attorney General's office on January 28, 2020 at approximately 4:55 PM. 7. A Quality Assurance meeting was held on February 11, 2020 at approximately 4:00 PM to discuss Verbal Abuse and investigations. The facility Quality Assurance Committee members which consisted of Facility Administrator #1, Director of Nursing #1, Infection Control Prevention Officer #1, Medical Director #1, Social Services Director #1, Assessment Nurse #1, Treatment Nurse #1 and Staff Development Nurse #1, Activity Director #1, Housekeeping Supervisor #1. Topics discussed include: (a) Resident Rights, (b) Accident/Incident Reporting, (c) Incident Investigation and Reporting, (d) Abuse/Neglect, e) Dignity/Respect. The Facility Action Plan was reviewed and approved by the Quality Assurance Committee Members. The SA validated the facility's Removal Plan and determined that the facility took the appropriate measures to correct the IJ. The validation was confirmed through staff interviews, Residents interviews, Responsible Party interview, Ombudsman interview, and record review on 2/12/2020 prior to exit from the facility. 1. The SA validated Resident #1 was not free from verbal abuse and the facility failed to remove the perpetrator from the building following a witnessed account of verbal abuse that was witnessed by RN #1 and CNA #2 toward Resident #1 by CNA #1 on 01/25/2020 at approximately 1:00 PM. The facility failed to provide for the safety of Resident #1 and all 53 residents of the facility. 2. The SA validated through interview and record review that CNA #1 was allowed to work in direct resident care with residents in the facility for eight (8) hour shifts on Saturday 01/25/2020; Sunday 01/26/2020; and Monday 01/27/2020. The facility did not perform assessments of the residents in the facility and of Resident #1 and did not provide for their safety by completing assessments and removing the perpetrator from the building. The facility did not report the verbal abuse within two (2) hours of the witnessed verbal abuse toward Resident #1. 3. The SA validated through interview and record review with RN #1 that she reported that verbal abuse via telephone to the DON and completed a written report of the incident and pushed it under the office door of the DON. The SA validated through interviews and record reviews that the facility conducted In-Service Training on Abuse, Neglect, and Reporting of Incidents prior to exit on 2/12/2020. 4. The SA validated on 02/12/2020 through interviews with staff that a Quality Assurance (QA) Committee Meeting was held on 02/11/2020 at approximately 4:00 PM to discuss the incident of verbal abuse that was witnessed toward Resident #1 on 01/25/2020. All QA members required were in attendance. 5. The SA validated on 02/20/2020 through interviews with the Staff Development Nurse (RN#3) that she was conducting the in-service training and returning to the facility after hours and on weekends to conduct in-service training Abuse, Neglect, and Reporting of incidents as well as safety of all Residents. The RN#3 confirmed through interview that no staff member will be allowed to return to work before in-services / trainings were completed. 6. The SA validated on 02/12/2020 through staff and resident interviews and record review that all 53 residents residing in the facility had been assessed by facility staff for abuse, and neglect, and verbal abuse and safety. As well as psychosocial wellbeing and physical wellbeing. 7. The SA validated on 02/12/2020 through interviews and record reviews that the corrective actions were put into place by the facility on February 11, 2020. The IJ was removed on 2/12/2020 prior to exit.

Based on record review, staff interview and facility policy review, the facility failed to provide in writing the bed hold policy to the resident and/or the Resident Representative at the time of transfer to an acute care hospital for two (2) of four (4) resident's hospitalization s reviewed. Residents #3 and #38. Findings include: Review of the facility's policy titled, Notice of Hospital Transfer/Therapeutic Leave, with the latest revision date of 2/2017, revealed: 2. When a resident is transferred to the hospital, or goes out on therapeutic leave, a copy of the completed form (notice) is sent with the resident, specifying the duration of the bed-hold according to the state plan, and the facility's policy regarding bed-hold periods. In case of emergency transfer, notice at the time of transfer means that the family or resident representative are provided with written notification within 24 hours of the transfer. The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident to the hospital. The staff member completing the transfer paperwork should complete the location, time, and date section of the form. A copy of the competed form should also be forwarded to the Accounts Manager. Resident #3 Review of the Face Sheet revealed Resident #3 was admitted by the facility on 1/10/18. Review of Resident #3's Departmental Notes, dated 7/9/18 at 7:09 AM, revealed the resident was sent out to the emergency room (ER) due to vomiting green emesis. Further review of the Department Notes revealed, on 7/11/19 at 11:49 AM, Resident #3 returned to the facility. Review of Resident #3's Departmental Notes, dated 7/1/19 at 3:21 PM, revealed the resident was transferred to (Name of Hospital's Initials) for observation, and vomiting dark brown emesis. Further review of the Departmental Notes revealed Resident #3 returned to the facility on [DATE] at 1:27 PM. The facility had no evidence Resident #3 or the Resident Representative was notified in writing of the bed hold policy/agreement. Resident #38 Review of the Face Sheet revealed Resident #38 was admitted by the facility, on 11/26/18. Review of Resident #36's Departmental Note, dated 6/15/19 at 4:51 PM, revealed the resident was transferred to (Name of Hospital) ER due to change in status and further evaluation. The facility had no evidence Resident #36 or the Resident Representative was notified in writing of the bed hold policy/agreement. On 8/14/19 at 2:37 PM, an interview with the Accounts Manager revealed when she was asked about the residents being notified of the bed hold policy she replied, the originals are signed on admission and not dated . When the resident goes out to the ER the form is completed by the nurse. The nurses fills out the location, time and date and a copy is sent to the Resident and or family representative. We are not keeping a copy when it is sent out. On 8/14/19 at 3:45 PM, an interview with the Administrator revealed the facility does not keep written documentation that the resident and or representative are notified at the time of transfer of the bed hold policy.

Based on observation, record review, facility policy review, and staff interview, the facility failed to prevent the possible spread of infection for one (1) of 52 Resident rooms observed. Resident #17's room [ROOM NUMBER]-A. Findings include: Review of the facility's policy titled, General Infection Prevention and Control Nursing Policies, dated 6/2014, revealed it is the policy of this facility that all nursing activities will be performed in a manner to minimize the potential for infection in resident, staff, and visitors. During the initial tour of the facility, on 8/13/2019 at 9:20 AM, an observation revealed the door to Resident Room # 206-A was closed. After knocking, announcing, and gaining permission to enter, it was observed that after entering there was a soiled brief and soiled blue pad lying on the floor in the middle of Resident #17's room. It was observed that Certified Nursing Assistant (CNA) #1 was present in the room assisting Resident #17 to get dressed. Review of the facility's orientation document titled, Infection Control Orientation Checklist, dated for 1/2019, revealed the person signing this checklist was acknowledging that they had received and understood the explanation of the infection process, Occupational Safety and Health Administration (OSHA) standards for blood borne diseases, epidemiology, and transmission/ prevention of infection. The checklist was signed by Certified Nursing Assistant (CNA) #1 on 7/30/2019. Review of the facility's document titled, Inservice Training, dated 4/24/2019, revealed an in-service was provided for the CNA staff. The document revealed the content of the in-service included gloves, diapers (briefs), wipes, trash cans, trash bags, and dirty/soiled linens. The document stated that you must take trash bags into the room, and one of the bags was to be used to discard dirty linen. The document stated the in-service was provided by Registered Nurse (RN) #1/ Staff Development Nurse/ Infection Control Nurse. During an interview, on 8/13/2019 at 9:26 AM, Registered Nurse (RN) #1, Staff Development Nurse/ Infection Control Nurse, stated that CNA #1 should not have laid the soiled brief and pad on the floor. RN #1 stated doing that is considered is an infection control concern. During an interview, on 8/13/2019 at 9:30 AM, with Certified Nursing Assistant (CNA) #1, it was confirmed that she had put the soiled brief and pad on the floor. CNA #1 stated she did that because she did not have any bags to put it in. CNA stated, they are no supposed to put dirty briefs or any linen on the floor. CNA #1 stated there are garbage bags available, but she just didn't bring one with her to the room. During an interview, on 8/15/2019 at 8:16 AM, the Director of Nursing (DON), confirmed that soiled linen should not be placed on the floor. The DON stated that the staff is trained to put soiled linen in a trash bag and take it to a designated area. The DON stated, soiled linen should never be placed on the floor.

Base on observation, staff interview, record review, facility policy review, the facility failed to ensure the dishwasher is maintained in a safe operating condition for one (1) of three (3) kitchen tours. Findings Include: A review of the facility policy titled, Machine Warewashing, revealed all dishes and utensils will be washed and sanitized after each use. The dish machine operator documents the machine temperature and concentration of the sanitizing solution for ware washing for each meal on a temperature log. See DT 377 (LA)- Daily Department Temperature & Chemical Monitoring Log and/or DT-351- Temperature Monitoring Log. Chlorine test papers are used to test the proper chlorine concentration of the rinse water for each meal. A review of the facilities Dish Washing Temperature Log, dated 7/18/2018, revealed the dish washing machine chlorine strip test was 50 parts per million. Observation on 07/18/18 at 9:00 AM, During a second day tour of the kitchen, with the Dietary Manager, revealed Dietary Aide #1 was unable to get a reading on the chlorine/sanitation strip. Dietary Aide #1 tried several times to get a reading of the sanitation strip. The dietary Manager confirmed the facility was unable to get a reading of the sanitation strip. The Dietary Manager also confirmed the breakfast dishes was washed without the sanitation solution. Interview on 07/18/18 at 09:15 AM, with Dietary Aide #1, revealed the machine is checked every two (2) weeks. The Dietary Manager corrected the employee and stated the dish washing machine is checked daily. The Dietary Aide repeated that she checked the strip every two (2) weeks. The Dietary Aide also confirmed the breakfast dishes were just washed without the sanitation solution. Interview on 07/18/18 at 9:38 AM, with the Dietary Manager, revealed she checked the dishwasher at 6:10 AM on 7/18/18, and the wash temperature was 140, the rinse was 145, and chlorite was 50 parts per million. The Dietary Manager said that she couldn't understand why the strips did not show a reading. The Dietary Manager called Auto Chlor to come out and check the dish washing machine. The Dietary Manager also confirmed the facility failed to prevent the possible spread of food borne illness by washing the breakfast dishes without the sanitation chlorine/sanitation solution. Interview on 07/18/18 at 10:15 AM, with the Maintenance Director, revealed she checked the dishwasher. The strips did not register the first time it was checked. The second time the Dietary manager checked the strip, she noticed the sanitation solution was not coming out of the tubing. The Maintenance Director primed the tubing which caused the solution to come out.

Based on staff interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for one (1) of 15 MDS Assessments reviewed; Resident # 48. Findings include: A review of the facility's policy entitled, MDS Charting Documentation Guidelines, revealed in order to have an accurate assessment of the resident, information must be gathered on the resident while in the observation period for the MDS. The MDS Manual dated (MONTH) (YEAR), Chapter two (2) reads: Nursing homes are responsible for ensuring that all participants in the MDS process have the requisite knowledge to complete an accurate assessment. Record review revealed Resident #48's physician orders [REDACTED]. The most recent Minimum Date Set (MDS) Significant Change in Status Assessment, with an ARD of 4/19/18, revealed section O0100-K was not coded for Hospice services. On 7/20/18 at 11:20 AM, interview with the Director of Nurses (DON) revealed, They (referring to the MDS nurses) just forgot to code it on the MDS. On 7/20/18 at 11:40 AM, interview with the DON revealed the facility used the Resident Assessment Instrument (RAI) Manual and the Case Mix guidelines for the completion of a Significant Change in Status Assessment. On 7/20/18 at 12:55 PM, interview with Registered Nurse #1 (RN) confirmed the MDS was coded wrong for Resident #48's Hospice services. She stated that she used the Resident Assessment Manual (RAI) as a guideline for completing the MDS assessments. A review of the facility's Face Sheet revealed the facility admitted Resident #48 on 3/26/18, with a [DIAGNOSES REDACTED].

Based on staff interview, record review, and facility policy review, the facility failed to complete a Significant Change in Status Assessment in a timely manner for a resident admitted to Hospice services, for one (1) of three (3) Hospice resident assessments reviewed; Resident # 48. Findings include: A review of the facility's policy entitled, Minimum Data Set (MDS) Process, with an original date of 12/00, and latest revision date of 03/16, revealed: The Resident Assessment Instrument (RAI) Manual is the source document to be used for coding schedules and requirements. The MDS Manual dated (MONTH) (YEAR) revealed: A Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a Hospice program. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the Hospice election. Record review revealed, Resident # 48 was discharged from Hospice services on 6/3/18, and a Significant Change in Status Assessment with an ARD of 6/22/18, was completed. On 7/20/18 at 11:20 AM, interview with the Director of Nurses (DON) confirmed the Significant Change in Status Assessment should be completed within 14 days. On 7/20/18 at 11:40 AM, interview with the DON revealed the facility followed the Resident Assessment Instrument (RAI) Manual and the Case Mix guidelines for the timeframe of completing a Significant Change in Status Assessment. On 7/20/18 at 12:55 PM, interview with Registered Nurse (RN) #1 revealed, a Significant Change in Status Assessment should be completed within 14 days, and the facility used the RAI Manual as a guideline for completing the MDS. A review of the facility's Face Sheet revealed, Resident # 48 was admitted on [DATE], with a [DIAGNOSES REDACTED].

CI MS #9230 Based on observation, staff and resident interview, facility document and resident record review, the facility failed to prevent injury with use of a side rail for one (1) of four (4) residents in the sample (Resident #1). An additional two (2) of four (4) residents in the sample were at risk due to equipment problems, leaving space between the mattress and the side rail large enough for a limb or the head of the resident to slip into and become entrapped (Residents #3 and #4). Findings Include: Resident #1 Resident #1, date of birth 7/12/30, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medications included Antibiotic Therapy daily due to recurrent Bronchitis, Aricept, Lasix, Nexium, Lexapro, Abilify and Claritin daily and Ativan 1 mg twice a day for Agitation. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] reflected an inability in communication, and memory loss with cognitive impairment. Care Plans with an onset dated 5/24/07 included problems with impaired decision making and difficulty understanding others, chronic-recurrent bronchitis, joint contractures, and high risk for falls. Intervention for risk of falls included side rails up X2. A nurse's note dated 3/30/11 at 7:35 a.m. reflected that a Certified Nurse's Assistant (CNA) informed her that Resident #1 was found with the resident's head between the mattress and the side rail in the bed. The note reflected an assessment of the resident by the nurse who noted a 3 centimeter laceration to the left eyebrow, the physician was notified and the resident was sent to the emergency room at the hospital for evaluation. Review of Resident #1's Incident report dated 3/30/11 revealed that CNA #1 reported to nurses that the resident's head was between the mattress and side rail on the left, upper corner of the side of the bed. An injury was noted as a laceration above the left eye, hematoma left side of eye, edema left cheek and redness. The report reflected the resident was sent to the ER and received sutures to the left supraorbital area. On 4/26/11, review of the facility's Restraint policy and procedure, originally dated 12/00 with the latest revision 3/11, reflected the need for screening for the use of approved restraints and for the use of side rail covers or bolsters to prevent the resident's body from going under or through side rails if side rails are used. Interview with the Administrator at 11 a.m. on 4/26/11 revealed that the Resident #1 did sustain a cut that required sutures. The Administrator stated that the resident had contractures but could move, and that the side rails had side rail protectors on the bed, but now have wedge cushions to prevent recurrence of the problem. Interview with CNA #2 at 2:45 p.m. on 4/26/11 revealed that Resident #1 can move in bed and "scoots all around". Observation of Resident #1 at 10:40 a.m. on 4/26/11 revealed a very fair skinned resident dressed in a short sleeved top and shorts. There were no bruises noted to the arms, hands, head, face or legs. The Resident #1 was in a wheelchair with a lap buddy in place, leaning heavily on the tray. When CNA #3 was asked to sit the resident up, she had difficulty positioning the resident upright due to contractures. Observation of the Resident #1's bed at 10:50 a.m. on 4/26/11 revealed that wedge bolsters were in place on each side of the bed to prevent further problems. The Director of Nursing (DON) accompanied the surveyor on a tour of the facility to check all 60 beds for side rail/mattress positioning at 11:15 a.m. on 4/26/11. Concerns were noted with potential for problems with spacing between the side rail and mattress for two (2) additional residents in the sample (Residents #3 and #4), and two (2) other residents outside the sample had very loose side rails. The remainder of the beds in the 60 bed facility had properly fitted side rails, or the absence of side rails. Resident #3 Resident #3 was noted in bed with the head of the bed elevated due to prevention of aspiration due to tube feeding. Side rails were up on both sides of the bed and there was a gap between the mattress and the side rail at the hip level, large enough for a resident to entrap a leg or arm despite the use of side rail pads. The resident was positioned near the center of the bed with a pillow to her back, filling the space on that side, but nothing filled the gap on the other side of the bed. The resident's left leg was in a contracted position. A CNA was interviewed at 2:45 p.m. on 4/26/11 and stated that Resident #3 is not able to move much. She stated that they have to turn and position the resident. While this resident may not have been at risk, another resident with the ability to move could be placed in this bed and be at risk due to the space between the mattress and side rail. Resident #3, date of birth 9/18/24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] reflected an altered level of consciousness, inability in communication, and memory loss with cognitive impairment. Review of the resident's record did not reflect that a problem had occurred with the space between the side rail and mattress. Resident #4 Resident #4's bed was checked at 11:45 a.m. on 4/26/11 and the side rail was very loose, with enough space between the mattress and the side rail to allow a limb or the head to fall into that space when the side rail was in use. The DON stated that this resident refuses to allow them to use side rail pads. Resident #4 was observed up in a wheelchair, ambulating in the hallway. When asked, the resident stated that she does not want side rails or padding on the rails, stating that she will not fall out of bed. She stated they keep trying to put those "blue thing" (side rail padding) on the bed and I don't want them. She was wearing a self-release seat belt in the wheelchair. Resident #4, date of birth 7/29/45, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An assessment dated [DATE] reflected a cognitive decision making score of 13 and no problems with communication. A care plan problem reflected a risk for falls with an intervention on 2/10/11 to apply a seatbelt to the wheelchair while up. There was no intervention for use of side rails. Review of the resident's record did not reflect an incident in relation to use of the side rails. At 11:55 a.m. a resident off the sample (Resident #1a) had very loose, shaky side rails and the foot board was loose. The DON stated that the resident does not use side rails. At noon, Resident #2a's side rail was found to be very loose and shaky with some space between the mattress and the side rail. The resident was somewhat obese and not at risk at this time. Side rails for the remainder of the residents in the 60 bed facility were found to fit properly.