Every finding on record at Laurelwood Community Living Center

Based on interview, record review, and facility policy review, the facility failed to prevent the misappropriation of resident property when staff left a controlled substance unattended, resulting in (30) Hydrocodone/Acetaminophen 10-325 milligram tablets prescribed for Resident #1 being unaccounted for and lost for one (1) of four (4) residents reviewed for abuse. (Resident #1).Findings include:A review of the facility's Abuse and Neglect Policy and Procedure (undated) revealed, .Policy: To provide a safe environment for all residents free of abuse.II. Types of Abuse.7. Misappropriation of Resident Property means 'the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent'. Examples.Missing prescription medications or diversion of a resident medications, including.limited to controlled substances .A review of the facility's Medication-Controlled Substances Policy and Procedure (undated) revealed .Procedure: 1.Only authorized licensed nursing and pharmacy personnel have access to controlled medications. 2. All controlled substances, CII-V are stored and maintained in a locked cabinet or compartment.4. Accurate accountability of the inventory of all controlled drugs is always maintained.A record review of the facility's investigation dated 03/18/26 revealed on 03/13/26 at approximately 9:40 PM, a pharmacy courier delivered thirty (30) Hydrocodone/Acetaminophen 10-325 milligram tablets for Resident #1 to the facility with a packing slip and narcotic accountability record, which were received and signed for by Licensed Practical Nurse (LPN) #2. The investigation revealed the medication was not signed onto the narcotic accountability record and could not be located.A record review of the admission Record revealed the facility admitted Resident #1 on 03/03/26 with diagnoses including Fracture of Left Femur.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/09/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of (15), which indicated the resident was cognitively intact.A record review of the Order Summary Report revealed a physician's order dated 03/03/26 for Hydrocodone-Acetaminophen 10-325 milligram tablets.A record review of the Employee Corrective Coaching Form dated 03/14/26 for LPN #1 and LPN #2 revealed both staff received a written warning for leaving medications, including controlled substances, unattended at the nurses' station.A record review of the Packing Slip Proof of Delivery revealed Hydrocodone-Acetaminophen 10-325 milligram tablets for Resident #1 were delivered on 03/13/26 at 9:47 PM and electronically signed as received by LPN #2.A record review of the Drug Record Book revealed Hydrocodone-Acetaminophen 10-325 milligram tablets were ordered on 03/12/26 and documented as received on 03/13/26.A record review of the Controlled Drugs-Count Record for March 2026 revealed Licensed Practical Nurse (LPN) #1 signed responsibility for the medication cart and controlled substances for the 7:00 AM to 3:00 PM shift on 03/13/26 and relinquished responsibility at the beginning of the 11:00 PM to 7:00 AM shift on 03/13/26.A record review of the Package Count for the South Hall narcotic box from 02/05/26 through 03/24/26 revealed no documentation of receipt of Hydrocodone/Acetaminophen 10-325 milligram tablets for Resident #1.On 03/25/26 at 12:29 PM, during an interview with Licensed Practical Nurse (LPN) #1, she reported receiving the blister pack of (30) Hydrocodone/Acetaminophen 10-325 milligram tablets for Resident #1 from LPN #2 and placing the medication on the nurses' station while she left the area. LPN #1 reported the medication was left unattended and later could not be located. She acknowledged the medication should have been secured immediately.On 03/25/26 at 3:07 PM, during an interview with Licensed Practical Nurse (LPN) #2, she reported signing for the delivery of the Hydrocodone/Acetaminophen 10-325 milligram tablets for Resident #1 and transferring the medication to LPN #1. She reported both nurses were in the medication room while the medication remained unattended at the nurses' station.On 03/25/26 at 4:30 PM, during an interview with the Director of Nursing (DON), she reported being notified on 03/14/26 at approximately 7:00 AM that the medication was missing. The DON reported an investigation was initiated and confirmed the medication could not be located. She reported the investigation revealed the medication had been left unattended at the nurses' station.On 03/25/26 at 4:45 PM, during an interview with the Administrator, she reported staff failed to ensure controlled medications were secured and accessible only to authorized personnel. The Administrator confirmed the facility was unable to determine the location of the missing medication.On 03/25/26 at 5:00 PM, during an interview with Resident #1, the resident reported being informed the Hydrocodone/Acetaminophen tablets delivered on 03/13/26 had been lost and was replaced by the facility.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were stored and handled in accordance with accepted professional standards when staff failed to immediately secure controlled medications upon receipt for Resident #1 and failed to store medications according to manufacturer's instructions for Resident #3, for two (2) of four (4) sampled residents.Findings include:A review of the facility policy, Medications Storage Policy and Procedure (undated), revealed, Medications and biologicals will be maintained in a secured locations only accessible to designated staff.3. Schedule II controlled medications will be maintained within a separately locked permanently affixed compartment. Record of receipt and disposition of controlled medications will be maintained.Resident #1A record review of the admission Record revealed the facility admitted Resident #1 on 03/03/26 with diagnoses including Fracture of Left Femur.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/09/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of (15), which indicated the resident was cognitively intact.A record review of the Order Summary Report revealed a physician's order dated 03/03/26 for Hydrocodone-Acetaminophen 10-325 milligram tablets.A record review of the facility investigation dated 3/18/26 revealed on 3/13/26 at approximately 9:40 PM pharmacy courier delivered (30) Hydrocodone/Acetaminophen 10/325 milligram tablets for Resident #1, which were received and signed for by Licensed Practical Nurse (LPN) #2; however, the medications were not documented as secured in the narcotic count system and were later unable to be located.During an interview on 3/25/26 at 12:29 PM, LPN #1 explained she received Resident #1's Hydrocodone/Acetaminophen from LPN #2 and left the medication unattended at the nurses' station while she went to complete other tasks instead of immediately securing it in the locked medication cart.During an interview on 3/25/26 at 3:07 PM, LPN #2 explained he received Resident #1's-controlled medication from the pharmacy courier and provided it to LPN #1 and confirmed the medication had not been immediately secured in the locked medication cart following delivery.Resident #3A record review of the admission Record revealed the facility admitted Resident #3 on 3/23/26 with diagnoses including heart disease.A record review of the BIMS Interview dated 3/23/26 revealed Resident 3 had a BIMS score of (10), which indicated his cognition was moderately impaired.A record review of the Order Summary Report revealed Resident #3 had a Physician's Order, dated 3/23/26, for Lorazepam (Ativan) oral concentrate.A record review of the Individual Patient's Narcotics Record for Resident #3 revealed two (2) containers of Lorazepam were signed into the narcotic record on 3/23/26.A record review of the Lorazepam Oral Concentrate: Package Inert/Prescribing Info (Information), reviewed 2/5/26, revealed, .How is Lorazepam Oral Concentrate supplied.PROTECT FROM LIGHT Store at Cold Temperature-Refrigerate.36 (degrees)-46 (degrees) F (Fahrenheit).On 3/25/26 at 3:00 PM, during an observation, LPN #3 and LPN #2 completed a controlled drug count on South Hall. Two (2) bottles of Lorazepam Oral 2 milligrams per milliliter (2 mg/ml) for Resident #3 were observed stored in the locked medication cart despite manufacturer labeling indicating, Store at Cold Temperature-Refrigerate 36-46 degrees F.On 3/25/26 at 3:00 PM, during an interview, LPN #3 confirmed the manufacturer's instructions on the Lorazepam label but stated she was unsure why the medication had not been refrigerated.On 3/25/26 at 3:07 PM, during an interview, LPN #2 explained he was aware the Lorazepam for Resident #3 required refrigeration and acknowledged it had been stored in the medication cart instead of the designated medication refrigerator.On 3/25/26 at 4:30 PM, during an interview, the Director of Nursing (DON) explained the expectation was for nursing staff to immediately secure controlled medications in the locked medication cart upon receipt and document the medications to maintain accountability and prevent unauthorized access. She confirmed the facility had a locked refrigerator located in the medication room for medications requiring refrigeration and expected staff to follow manufacturer storage instructions.

Based on interviews and record review, the facility failed to ensure adequate supervision and take appropriate actions to prevent an avoidable accident when staff continued transporting a resident after the resident removed his seatbelt and staff failed to stop the transport and request assistance, resulting in the resident falling from his wheelchair inside the facility van, for one (1) of five (5) sampled residents, Resident #1.Findings include:A record review of the admission Record revealed the facility admitted Resident #1 on 2/4/2025 with diagnoses including Encephalopathy. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/9/25 revealed Resident #1 had a Brief Interview for Mental Status Summary score of 8, which indicated his cognition was moderately impaired. A record review of the facility's fall report, dated 10/13/25 at 11:45 AM, revealed Resident #1 had an incident Location of Facility Vehicle with a Predisposing Situation Factors including During Transfer.On 12/15/2025 at 9:27 AM, during an interview with the Complainant, she reported that two (2) months ago, Resident #1 was dropped from his seat while on the van following a doctor's appointmentOn 12/15/2025 at 11:23 AM, during an interview with Resident #5 who was also on the facility van on 10/13/25, stated that Resident #1 was upset because he wanted to go home with his sister who had been at the doctor's appointment with him. Resident #1 was cursing CNA #1 and was repeatedly taking his seat belt off. CNA #1 had to stop and refasten the seat belt.On 12/15/2025 at 11:30 AM, during an interview with the Certified Nurse Aide (CNA) #1, he revealed he was the driver of the facility's van on 10/13/2025 when Resident #1 fell from wheelchair. CNA #1 reported that on 10/13/25, he was driving Resident's #1 and another resident from a doctor's appointment at a local clinic. The Driver affirmed that he followed protocol and bolted the chair wheels in place and put the seat belt on the passengers. The Driver reported that Resident #1 kept saying he wanted to go home with his sister, who had joined him at his appointment. The Driver stated that Resident #1unfastened his seatbelt and he would pull over and refasten the belt and encourage Resident #1 to stay fastened in his seat for his safety. The Driver affirmed that the resident took his seatbelt off a second time and fell to the floor of the van. The Driver reported that he pulled the van over, assessed the resident, talked to him and got him back in his chair. The Driver acknowledged that he and his passengers were within 2 miles of the facility, so he continued to drive and when he reached the facility the nurse was waiting and he reported the incident. On 12/15/2025 at 1:50 PM, an interview with the Director of Nursing (DON) revealed she acknowledged the resident's fall on the van on 10/13/2025. The DON stated the Driver told her that the resident unfastened his belt twice, falling on the second time. The DON stated the resident was assessed by the RN supervisor upon his return to the facility and was found to have an abrasion over his left eye. The DON noted that the resident was sent to the hospital as a standard precaution and was returned the same day. The DON affirmed that the resident's behavior problem of repeatedly unfastening his belt was at the root of the incident. The DON further acknowledged that the saftest action for the driver to take at the initial unfastening of the seatbelt would have been to pull over, notify the facility to be directed on which way to go. The DON stated she and another nurse or CNA would have met the van to provide assistance. The DON stated that it was reported to her that the van was less within 2-3 miles of the facility. The DON stated she expects residents to be transported safely. On 12/15/2025 at 2:15 PM, an interview with the Administrator revealed she felt the Driver did not do anything wrong by refastening the Resident #1's seatbelt. The Administrator acknowledged that Resident #1 was displaying behavior problems by removing his seatbelt and his behavior problem was the root cause of the incident

Based on interviews, record review, and the facility policy review, the facility failed to implement comprehensive person-centered care plan interventions for a resident with constipation and no documented bowel movements for consecutive days, which resulted in a Resident being hospitalized on [DATE] for evaluation that included findings consistent with fecal impaction for one (1) of 14 sampled residents. Resident#25 Cross Reference F580, F684 Findings include: A review of the facility's policy Care Plans, Comprehensive Person-Centered, reviewed 10/2022 revealed, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 7. The comprehensive, person-centered care plan: . e. reflects currently recognized standards of practice for problem areas and conditions . 10. When possible, interventions address the underlying source (s) of the problem area (s), not just symptoms or triggers. 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change . A record review of the Care Plan Report revealed Resident #25 had a comprehensive care plan with a Focus of (Proper Name of Resident #25) is at risk for constipation r/t (related to) polypharmacy. The Goal that was initiated on 10/4/2023 revealed, (Proper Name of Resident) will have a normal bowel movement at least every 3 (three) days . Interventions included Follow orders for bowel management, Glycolax powder .as needed for constipation, and Observe for/document/report to MD (medical doctor) PRN (as needed) s/sx (signs and symptoms) of complications related to constipation .fecal compaction . A record review of Resident #25's Admission Record revealed the facility originally admitted the resident on 03/01/2022 and she had a diagnosis of Constipation. Diagnoses added with an onset date of 2/5/2025 included Hemorrhage of Anus and Rectum and Fecal Impaction. A record review of Resident #25's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/03/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated she was cognitively intact. Further review revealed Resident #25 is dependent on staff for toileting hygiene and frequently incontinent of bowel and bladder. A record review of the facility's Documentation Survey Report for January 2025 revealed Resident #1 experienced multiple days without a documented bowel movement. Specifically, there was no documented bowel movement on January 1, 2, 3, and 5, and again on January 14, 15, 16, 17, 18, and 19, which was six (6) consecutive days. There was also no bowel movement documented on January 23, 24, and 28. A record review of an acute hospital Summary of Care Document confirmed that Resident #1 was hospitalized from 01/30/2025 through 02/04/2025 with multiple medical issues, including a diagnosed fecal impaction. A record review of the Resident's Medication Administration Record (MAR) for January 2025 revealed Resident #25 continued to receive Lomotil three (3) times daily despite the documented days of no BM. Additionally, MiralAX (type of laxative) was ordered PRN (as needed) and was not administered. In a phone interview, on 04/07/25 at 02:38 PM, Resident #25's daughter explained that her mother had been hospitalized in January because she did not have a bowel movement (BM) for a week. She had to be transferred to an acute hospital in another state and was there for almost a week because her bowels were impacted. In an interview on 04/08/25 at 04:00 PM, the Director of Nursing (DON) confirmed Resident#25 was hospitalized with a fecal impaction several months ago. She explained the resident had a history of diarrhea and constipation and when she experienced diarrhea, medications were administered. She confirmed Resident#25 was receiving Lomotil (antidiarrheal medication) three (3) times a day prior to the hospitalization . The CNAs are to notify the nurse if a resident goes three (3) consecutive days without a BM and the nurse should give medications and notify the physician if there are no changes. She reported she was not aware Resident #25 was not having BMs, and explained the physician did see the resident prior to the hospital admission in January. She also advised the physician after she was informed by the hospital that the resident had a fecal impaction in January. In a follow up interview with the DON on 04/09/2025 at 10:45 AM, she acknowledged there was no documentation of nursing interventions, constipation medications administered, or provider notification regarding the gaps in bowel movements prior to the hospitalization for Resident #25. In a phone interview with the physician on 04/10/25 at 12:45 PM, he confirmed Resident#25 was on Lomotil for diarrhea and reported he was aware the resident was admitted to the hospital several months ago for a fecal impaction. However, he was not informed that the resident had no BMs or documentation of no BM for six (6) consecutive days prior to being sent to the hospital. He stated that the facility has standing orders to follow if a resident has no BM. He confirmed that if he had been notified that Resident #25 had no BMs for consecutive days, he would have implemented orders for constipation. In an interview on 04/10/25 at 1:30 PM, LPN #3/Care Plan Nurse explained the facility has working care plans and are updated daily. She described the purpose of the care plan as providing the staff with a guideline to care for each individual resident. She expects staff to follow the care plans to provide care for the residents. In an interview on 04/10/25 at 1:40 PM, the DON explained she expects the staff to follow care plans to provide the highest quality of care for each resident, to follow standing orders related to no bowel movements, and to notify her and the physician of any changes in any resident. She reported there was miscommunication with the staff and the physician. In an interview on 04/10/25 at 1:50 PM, the Administrator explained the facility wants to provide each resident care as planned and to notify the DON and the physician of any changes.

Based on interviews, record review, and the facility policy review, the facility failed to identify or respond to a clinically relevant pattern of constipation, which resulted in a resident being hospitalized on [DATE] for evaluation that included findings consistent with fecal impaction for one (1) of 14 sampled residents. Resident #25 Cross Reference F580, F656 Findings include: A record review of the statement provided via the Administrator on facility letterhead dated 4/10/25 revealed, . (Proper Name of Facility) does not have a policy for constipation or bowel movements. During a phone interview, on 04/07/25 at 02:38 PM, Resident #25's daughter explained that her mother had been hospitalized in January because she did not have a bowel movement (BM) for a week. She had to be transferred to an acute hospital in another state and was there for almost a week because her bowels were impacted. During an interview on 04/08/25 at 03:20 PM, Licensed Practical Nurse (LPN) #1 explained that the CNAs advise if there is a problem with a resident's BMs and the nurses receive an alert on the computer if a resident goes three (3) consecutive days without a BM. She further explained that the facility has standing orders for medications to give if a resident needs it for no BM or constipation. Usually, the nurse will administer oral medications related to constipation and if there are no results, they will use a suppository and rarely use an enema. If the medications are not effective, then the physician is notified. During an interview on 04/08/25 at 04:00 PM, the Director of Nursing (DON) confirmed Resident #25 was hospitalized with a fecal impaction several months ago. She explained the resident had a history of diarrhea and constipation and when she experienced diarrhea, medications were administered. She confirmed Resident#25 was receiving Lomotil (antidiarrheal medication) three (3) times a day prior to the hospitalization . The CNAs are to notify the nurse if a resident goes three (3) consecutive days without a BM and the nurse should give medications and notify the physician if there are no changes. She reported she was not aware Resident #25 was not having BMs, and explained the physician did see the resident prior to the hospital admission in January. She also advised the physician after she was informed by the hospital that the resident had a fecal impaction in January. During a follow up interview with the DON on 04/09/2025 at 10:45 AM, she confirmed there was no documentation of nursing interventions, constipation medications administered, or provider notification regarding the gaps in bowel movements prior to the hospitalization for Resident #25. During a phone interview with the physician on 04/10/25 at 12:45 PM, he explained Resident #25 had irritable bowels, with alternating patterns of diarrhea and constipation. He confirmed Resident#25 was on Lomotil for diarrhea and reported he was aware the resident was admitted to the hospital several months ago for a fecal impaction. However, he was not informed that the resident had no BMs or documentation of no BM for six (6) consecutive days prior to being sent to the hospital. He stated that the facility has standing orders to follow if a resident has no BM. He confirmed that if he had been notified that Resident #25 had no BMs for consecutive days, he would have implemented orders for constipation. A record review of Resident #25's Admission Record revealed the facility originally admitted the resident on 03/01/2022 and she had a diagnosis of Constipation. Diagnoses added with an onset date of 2/5/2025 included Hemorrhage Of Anus And Rectum and Fecal Impaction. A record review of Resident #25's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/03/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated she was cognitively intact. Section GG revealed Resident #25 was dependent on staff for toileting hygiene and Section H revealed she was frequently incontinent of bowel and bladder. A record review of the facility's Documentation Survey Report for January 2025 revealed Resident #1 experienced multiple days without a documented bowel movement. Specifically, there was no documented bowel movement on January 1, 2, 3, and 5, and again on January 14, 15, 16, 17, 18, and 19, which was six (6) consecutive days. There were also no bowel movement documented on January 23, 24, and 28. A record review of the medical record revealed there was no documentation of nursing interventions, assessments, or physician notification to address Resident #25's ongoing constipation or lack of consecutive days with no BM during the month of January 2025. A record review of an acute hospital Summary of Care Document confirmed that Resident #1 was hospitalized from 01/30/2025 through 02/04/2025 with multiple medical issues, including a diagnosed fecal impaction. A record review of the Resident's Medication Administration Record (MAR) for January 2025 revealed Resident #25 continued to receive Lomotil three (3) times daily despite the documented days of no BM. Additionally, MiralAX (type of laxative) was ordered PRN (as needed) and was not administered. A record review of the Resident's Physician's Progress Notes dated 01/30/25 revealed, pt (patient) with decreased LOC (Level of Consciousness), pt noncompliant with therapy, pt with no dysuria, . good BS (bowel sounds) . A record review of the Resident's Physician's Progress Notes dated 02/06/25 revealed, pt with GI (Gastrointestinal) bleed .

Based on interviews, record review, and the facility policy review, the facility failed to notify the physician of a resident with no documented bowel movement for six (6) consecutive days, which resulted in the resident being hospitalized on [DATE] for evaluation that included findings consistent with fecal impaction for one (1) of 14 sampled residents. Resident #25 Cross Reference F684, F656 Findings include: A record review of the facility's policy Notification of Changes in a Resident's Conditions or Status, undated, revealed, . It is the policy of this facility to .consult with his or her physician .changes in the resident's condition and/or status .Procedure 1. Nursing services shall be responsible for notifying the resident's attending physician when .d. There is a need to alter the resident's treatment significantly . A record review of the statement provided via the Administrator on facility letterhead dated 4/10/25 revealed the facility did not have a policy regarding constipation or bowel movements. On 04/07/25 at 02:38 PM, during a phone interview with a family member, she explained Resident #25 had been hospitalized in January because she did not have a bowel movement (BM) for a week. On 04/08/25 at 03:20 PM, during an interview with Licensed Practical Nurse (LPN) #1, she explained the Certified Nurse Aides (CNAs) are to notify them if a resident does not have a BM for three (3) consecutive days and the electronic health record (EHR) will trigger an alert for anyone with 3 days of no BM. She reported that the facility has standing physician's orders for medications to give if needed for residents with no BM. She confirmed that the physician is not always notified of no bowel movements unless the medications are not effective. On 04/08/25 at 04:00 PM, during an interview with the Director of Nursing (DON), she confirmed Resident#25 was hospitalized with a fecal impaction several months ago. She explained the resident had a history of diarrhea and constipation and when she experienced diarrhea, medications were administered to stop it. The CNAs are to notify the nurse if there are no BMs in 3 consecutive days and then the nurse is to give the resident medications and notify the physician if there are no changes. She confirmed she was not aware the resident was not having BMs, and explained the physician did see the resident prior to the hospital admission in January. On 04/09/2025 at 10:45 AM, during a follow up interview with the DON, she acknowledged there was no documentation of nursing interventions, constipation medications administered, or provider notification regarding the gaps in bowel movements prior to the hospitalization for Resident #25. On 04/10/25 at 12:45 PM, during a phone interview with Resident #25's Physician, he explained he is familiar with the resident and explained the resident has had irritable bowels, with alternating patterns of diarrhea and constipation. He confirmed Resident #25 was on Lomotil for diarrhea and reported he was aware the resident was admitted to the hospital several months ago for a fecal impaction. However, he was not informed that the resident had no BMs or documentation of no BM for 6 consecutive days prior to being sent to the hospital. The facility has standing orders to follow if a resident has no BM. He confirmed that if he had been notified that Resident #25 had no BMs for consecutive days, he would have implemented orders for constipation. A record review of Resident #25's Admission Record revealed the facility originally admitted the resident on 03/01/2022 and she had a diagnosis of Constipation. Diagnoses added with an onset date of 2/5/2025 included Hemorrhage Of Anus And Rectum and Fecal Impaction. A record review of Resident #25's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/03/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated she was cognitively intact. Resident dependent on staff for toileting hygiene and frequently incontinent of bowel and bladder. A record review of the facility's Documentation Survey Report for January 2025 revealed Resident #1 experienced multiple days without a documented bowel movement. Specifically, there was no documented bowel movement on January 1, 2, 3, and 5, and again on January 14, 15, 16, 17, 18, and 19, which was six (6) consecutive days. There was also no bowel movement documented on January 23, 24, and 28. A record review of the medical record revealed there was no documentation of nursing interventions, assessments, or physician notification to address Resident #25's ongoing constipation or lack of consecutive days with no BM during the month of January 2025. A record review of an acute hospital Summary of Care Document confirmed that Resident #1 was hospitalized from 01/30/2025 through 02/04/2025 with multiple medical issues, including a diagnosed fecal impaction. A record review of the Resident's Medication Administration Record (MAR) for January 2025 revealed Resident #25 continued to receive Lomotil (antidiarrheal medication) three (3) times daily despite the documented days of no BM. Additionally, no medications were administered for constipation, including Miralax (type of laxative medication) that was ordered to be administered PRN (as needed).

Based on observation, staff interviews, record review, and facility policy review, the facility failed to maintain a sanitary and pest-free environment in the kitchen by not ensuring effective pest control measures were implemented and sustained for two (2) of three (3) kitchen observations. Findings included: A review of the facility's policy, Sanitization (undated), revealed, .The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation 1. All kitchens, kitchen areas shall be . protected from rodents, roaches, flies, and other insects. A review of the facility's Pest Control Policy, dated 4/10/23, revealed, .Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .6. Maintenance services assist, when appropriate and necessary, in providing pest control services. On 4/7/25 at 10:02 AM, during the initial kitchen tour with the Dietary Manager, the dry goods storage area was observed. A cardboard box containing individually packaged cereal had small, black, rice-sized objects and shredded cardboard inside. The Dietary Manager confirmed the rice-sized objects appeared to be rat droppings. A glue trap with what appeared to be peanut butter smeared on top was observed on the floor of the pantry area. The Dietary Manager stated he was unaware of when the kitchen was last treated for rodents. He reported concern that rodents may be entering through a small gap beneath the kitchen's back door, which leads directly outside. On 4/9/25 at 8:50 AM, during a phone interview with the Registered Dietitian (RD), she explained she performs monthly kitchen tours at the end of each month. She stated she had not observed pest or rodent activity during those walk throughs. She stated her expectations were for dietary staff to maintain an effective pest control plan and adhere to sanitation standards. On 4/9/25 at 10:00 AM, during an interview with the Maintenance Supervisor, he stated he was unaware of rodent activity in the kitchen but acknowledged that rodents may have entered through a gap under the back door. He explained the rear kitchen area had a two-door system-a screen door and a solid, sealed door. He reported that staff had previously left the solid door open to allow air circulation when the air conditioning system was not functioning. He stated the air system was scheduled to be repaired that day. On 4/9/25 at 11:04 AM, during an observation of the assembly line plating, a live roach was observed crawling across a resident's meal tray. The tray was immediately removed after confirmation by the Dietary Manager, Dietary Aide, Head Cook, and Maintenance Supervisor. On 4/10/25 at 9:10 AM, during observation of the low-temperature dishwasher, a live roach was observed crawling on top of the machine. On 4/10/25 at 1:10 PM, during an interview with the Administrator, she was informed of the pest-related concerns identified during two (2) of three (3) kitchen inspections. She stated she had been unaware of pest issues in the kitchen and acknowledged that high staff turnover had affected kitchen oversight. She emphasized that her expectations were for food to be prepared safely, the kitchen to be maintained in a clean and organized condition, and for pest infestations to be minimized. A record review of the facility's pest control logs revealed treatments for rodents and pests had occurred since December 2024. A review of the facility's pest control logs revealed the pest control company were targeting mice and roaches with roaches and rodent activity noted on visits during the monthly visits for the months of January, February, and March 2025.

Based on observation, interview, and policy review, the facility failed to ensure medications were secured when a wound care treatment cart was left unlocked and unattended in a hallway for one (1) of four (4) days of the survey. Findings included: A review of the facility's policy titled Medication Administration Guidelines, revised August 25, 2014, revealed, .Procedure .2. Administration .m. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by . On 4/9/25 at 2:14 PM, during an observation on the North Hall, a wound care treatment cart was unlocked. The cart was left unattended by Registered Nurse (RN) #1, who had entered a resident's room to perform wound care. RN #1 remained in the room with the door closed until 2:34 PM. When she exited the room, she confirmed the treatment cart had been left unlocked and unattended. On 4/9/25 at 2:38 PM, during a follow up interview with RN #1, she confirmed the cart had been left unlocked and unattended for approximately 20 minutes. She stated that the cart should have been locked to prevent resident access. RN #1 opened the cart and demonstrated the contents, which included bactericidal isopropyl alcohol-based sanitizer wipes, Santyl ointment (used for tissue removal and debridement), normal saline, betadine, and nail clippers. She explained that these items could pose risks to residents, including gastrointestinal distress or requiring emergency care, if consumed. On 4/10/25 at 12:10 PM, during an interview with the Director of Nursing (DON), she confirmed that it was her expectation for staff to keep carts locked and not leave them unattended. She stated the risks of leaving wound carts unsecured included possible resident poisoning from substances such as betadine or Santyl, and unauthorized access by staff without proper training, which could result in theft or misuse of supplies. She confirmed that RN #1 should have locked the cart while it was unattended per facility policy.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure appropriate incontinence care was provided, as evidenced by the failure to cleanse the skin during a brief change for one (1) of two (2) residents observed for incontinence care (Resident #13). Findings included: A review of the facility's policy titled, Perineal Care, revised 8/25/2014, revealed, .Procedure .5. Clean perineal area well with soap and warm water taking care to clean from front to back using a clean washcloth or clean area of the cloth for each stroke. 6. Rinse perineal area, moving from front to back using a clean area of the washcloth or towelette or use another clean washcloth or towelette for each stroke. (Note: Not all products require rinsing. Follow product instructions). 7. Dry perineal area moving from front to back. Use a blotting motion with towel. 8. Turn resident on side. 9. Clean, rinse (as applicable) and dry buttocks and perianal area without contaminating perineal area. 10. Remove wet incontinent pad or protective linen. Change gloves and perform hand hygiene . On 4/8/25 at 2:20 PM, during an observation of incontinence care, and interview with Certified Nurse Aide (CNA) #1, she explained that Resident #13 was dependent on staff for activities of daily living (ADLs) and was incontinent of bowel and bladder. Resident #13 was lying in bed, and his brief was soiled with urine. Disposable wipes were noted on the bedside table. CNA #1 removed the soiled brief and applied a clean one without cleansing or rinsing the perineal area or buttocks. The CNA repositioned the resident and covered him with a blanket. On 4/8/25 at 2:50 PM, during a follow-up interview with CNA #1, she confirmed she changed Resident #13's soiled brief and did not provide perineal care. She stated she was nervous during the observation and forgot, but she knew the appropriate procedure. She acknowledged that failing to cleanse the resident could contribute to urinary tract infections and skin breakdown. On 4/9/25 at 4:00 PM, during an interview with the Director of Nursing (DON), she stated her expectation is for staff to always provide proper incontinence care to prevent infections or skin breakdown. A record review of the Admission Record revealed the facility admitted Resident #13 on 3/10/25 with diagnoses including Metabolic Encephalopathy. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/16/25 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated his cognition was severely impaired. Further review revealed he was frequently incontinent of bowel and bladder and dependent on staff for toileting hygiene.

Based on observation, interview, record review, and facility policy review, the facility failed to thaw food at the correct temperature, failed to clean the equipment according to the cleaning schedule, and failed to ensure the three compartment sinks' chemical sanitation was working appropriately to prevent possible foodborne illnesses for two (2) of four (4) dietary observations. This has a potential to affect all residents receiving meals prepared by the facility's dietary department. Findings Include: Review of the facility's policy titled, Meat Cookery and Storage, from [NAME] Corporate Dietitians (Copyright (C)2020), revealed, the Food and Nutrition Services Department should ensure that meat shall be prepared in a manner to preserve quality, maximize nutrient retention and to obtain maximum yield of product .Procedure: Meat which needs defrosting should be pulled three days prior to service and defrosted in a dry, cool area at 41 degrees F (Fahrenheit) or less. Larger meats, such as whole turkey may require additional thawing time. Date meat when pulled for defrosting . Review of the facility's in-service dated 9/22/23 revealed the dietary staff was in-serviced on Cooling Monitor for Hazardous Foods. Review of the facility's in-service dated 9/25/23 revealed the dietary staff was in-serviced on the proper way to store food. The in-service included a document titled, Food Storage, from [NAME] Corporate Dietitians, (Copyright (C)2019), which revealed, Improper storage of Time/Temperature Controlled for Safety (TCS) foods can affect your budget or even worse, get a resident sick . b. Fresh raw poultry should be kept in a refrigerator that maintains 40 degrees F (Fahrenheit) or below and used with 1-2 days. c. Improper storage of food is the main reason for foodborne illness . Review of the facility's policy titled, Cleaning Schedules from [NAME] Corporate Dietitians (Copyright (C)2018), revealed The Food and Nutrition Services staff shall maintain sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinical qualified nutrition professionals . Community satellite kitchens will be able to be held to the same sanitary standards as the main kitchen, utilizing a comprehensive cleaning schedule specific to each kitchen . Procedure: 1. The Director of Food and Nutrition Services or other qualified nutrition professionals shall record all cleaning sanitation tasks for the Food and Nutrition Services Department. 2. A cleaning schedule shall be posted with task designated to specific positions in the department. 3. All tasks shall be addressed as to frequency of cleaning . 6. On the Position cleaning schedules the Director of food and Nutrition Services or other clinically qualified nutrition professional fills in the Position, the item to be clean, Frequency, i.e. daily, day of week, or week 1, 2, 3, 4. 7. Under the days of the week or the weeks, the Director of Food and Nutrition Services or other clinically qualified nutrition professional can check off assignments completed, or the employee can initial . A record review of the facility's, Daily and Weekly Cleaning Schedule, revealed schedules dated 9/31/23-10/8/23, 10/9/23-10/13/23 and 10/18/23-10/22/23 staff initials were present indicating the grill/ovens, range/catch pan, steam table/tray lines, and pots and pans sink had been cleaned each day. A record review of the facility's document titled, Sanitizer Use Concentrations for Food Service and Food Production Facilities, from [NAME] Corporate Dietitians (Copyright (C)2020), revealed, . a. A chlorine solution shall have a minimum temperature and contact time based on the concentration and pH (acidity or basicity) of the solution as listed in the following chart: Concentration Range 25 ppm (parts per million) with a 10 second contact time, 50 ppm with a seven (7) second contact time, and 100 ppm with a 10 second contact time . d. A hot water sanitize shall have a minimum temperature and contact time based on equipment specifications as listed in the following chart: . a. Equipment Specifications .3-compartment (three-compartment) sink integral heating device immersed in rack or basket . Minimum Temperature .171 degrees F .Minimum Contact Time 30 (thirty) seconds. Review of the facility's, in-service, dated 6/27/23, revealed the dietary staff received an inservice that included Review of Sanitation. An initial tour of the kitchen on 10/16/23 at 11:40 AM, with the Dietary Manager (DM), revealed six (6) bags of chicken in zip lock bags were soaking in water in the three-compartment sink, thick grease and grime was noted on the side of the stove, a thick grease substance around the edge of the steam table lids and a thick calcium build up was in the steam table compartment pans. The Dietary Manager (DM) said the lids are cleaned every shift but food spill on them because they are stored underneath the steam table where food is served. The DM revealed that the chicken had been soaking in the water since 10:30 AM. During an interview on 10/16/23 at 11:45 AM, with Dietary Worker/Cook #2, she explained the chicken is thawing in the sink for Wednesday's lunch. During an interview on 10/17/23 at 12:08 PM, with the DM confirmed the chicken was soaking in the water. The DM said that Dietary Aide #3 put the chicken in the water to thaw, as he was trying to prep for Wednesday. An observation on 10/17/23 at 12:15 PM, revealed Dietary Worker/Cook #5 washing pots in the three-compartment sink. The Dietary Worker washed the pots and pan in soapy water and rinsed them with clear water, then placed with the clean pots and pans. The pots and pans were not sanitized. During an interview with Dietary/Cook #5 on 10/17/23 at 12:31 PM, she confirmed she washed the pots and pans and rinsed them off without sanitizing them. The Dietary Worker revealed the sanitizer did not work. She explained when they turn on the sanitizer, the water runs from the back of the dispenser to the floor. Dietary Worker #5 said the sanitizer has been broken for a week and a half to two weeks and states that it has been reported to the DM. During an interview on 10/17/23 at 1:00 PM, with the Registered Dietitian (RD), she revealed she works at the facility on Mondays and Tuesdays. The RD revealed that she was unaware that there was a problem with the sink and sanitizer on the three-compartment sink. The RD revealed she thought the staff was cleaning the stove at least monthly and confirmed the facility should have been cleaning and sanitizing the steamed table lids and steam table compartments daily to prevent cross contamination, food borne illnesses. The RD confirmed the chicken should not have been soaked in water to thaw, as the chicken should have been thawed in the refrigerator or with running water over it to prevent the chicken from causing foodborne illnesses which could cause the residents to get sick. The RD explained that by not sanitizing the pots and pans appropriately, it could also cause foodborne illnesses. In an interview on 10/17/23 at 1:30 PM, with the DM he stated that Dietary Worker #3 put the chicken in the water to thaw because he was trying to help the cooks to have the chicken ready for Wednesday. The DM confirmed the chicken should have been left in the refrigerator to thaw or it should have had cold running over the chicken to prevent the chicken from getting too warm and possibly cause a food borne illness to the residents and staff. The DM stated that the monthly cleaning schedule for the stove is done by the night cook. He revealed he doesn't remember when the last time the cook cleaned the stove, but he thinks it was between two and three months ago. The manager confirmed the stove had thick greasy grime and build up all over it and needed to be cleaned to prevent fires and cross contamination. The DM also confirmed he was notified Friday of last week (10/13/23) at 9:00 AM, that the sanitation on the three-compartment sink was not working appropriately. The DM stated that the water was running down onto the floor whenever the sanitation was turned on. The DM also explained that the staff was told to turn it on only to allow the sanitation in the water during the time needed and to make sure it was turned off afterwards to prevent it from leaking onto the floor. The DM stated that he was told at that time that the leaking had occurred a week and half prior to his knowledge. The DM revealed that he had called the local dishwashing company and notified them of the leaking. The DM also confirmed the steam table lids had grease build up and grime around the edge of the lids. The DM stated that the lids are cleaned daily but because they are housed under the steam table it causes food and other things to drop on the lids. The DM further confirmed the compartments on the steam table had extra calcium and grime buildup. During an interview on 10/17/23 at 1:45 PM, the Administrator revealed she did not know that the sink was broken and running water continuously. The Administrator also said she did not know that the sanitation system on the three-compartment sink was not working until today. The Administrator confirmed that by not sanitizing the pots and pans, it could cause foodborne illnesses in the facility. The Administrator also stated that she did not know the staff were soaking the chicken in water to thaw. The Administrator stated that she expects the kitchen to follow the approved dietary guidelines to prevent foodborne illnesses. The Administrator also revealed that she had not been in the kitchen for a while and did not know that the stove had not been cleaned. The Administrator stated that the DM is responsible for the cleaning schedule and making sure it is followed by the dietary staff. During an interview on 10/17/23 at 2:00 PM, with the Maintenance Director he revealed he was unaware that the sink was continuously running and would not stop, nor was he unaware that sanitation was not working appropriately in the three-compartment sink was The Maintenance Director stated that he does not deal with the three-compartment sink, as the local dishwashing company does not want anyone else to perform maintenance on their equipment. The Maintenance Director stated that the facility is responsible for putting equipment issues in the maintenance log and he signs off on them when they are finished. The Maintenance Director revealed that he would fix the sink today as soon as possible. During an interview on 10/17/23 at 2:30 PM, with Dietary Worker/Cook #4, he revealed he cooks at night. The cook confirmed it has been between five (5) and six (6) months since he cleaned the stove. He also confirmed the compartments and lids on the steam table should have been cleaned. He revealed that when he washed the pots and pans, he ran the sanitizer in the sink and then turned it off, to stop the water from running onto the floor. Dietary Worker #4 confirmed the sanitation system has been broken for two weeks and it had been reported to the Dietary Manager. During an interview on 10/18/23 at 9:10 AM, with Dietary Worker #3, he confirmed he put the chicken in the water to thaw, as he was trying to help the cooks get prepared for Wednesday. Dietary Worker #3 revealed he did not know that thawing chicken submerged in water could cause a foodborne illness.

Based on interviews, record review, and facility policy review, the facility failed to ensure Resident Council complaints were resolved in a timely manner regarding transportation to outings. This affected nine (9) of (12) Resident council members who participate in the Resident Council meetings. Residents #4, #11, #17, #18, #20, #27, #28, #30 and #31 Findings Include: Review of the facility's policy titled, Grievances and Complaints, dated 2/14/23, revealed, Social services will act as the grievance officer for the facility and oversee the grievance process. Grievance forms should be kept outside of the office, where residents, and staff members can access them at any time. All grievances will be reported to Social Services and Social Services will follow the following procedure to investigate and work to resolve the grievance . STEP 1 Upon receipt of a grievance, Social Services will complete a written report within five working days of the filed grievance and determine what corrective action, if any should be taken . STEP 2 Social services must notify the person who filed the grievance, within 10 working days of the filed grievance, in the form of a report. Copies of this report will be available to the person at any time. STEP 3 If filer is not satisfied with the results of the investigation, the filer may file a report with the local ombudsman . Review of the facility's policy titled, Facility Assessment, reviewed 1/2023. revealed, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment 3. The facility assessment includes a detailed review of the resident's population. This part of the assessment includes: . d. (3) activities . Review of the facility's policy titled, Life Connection Program, reviewed 3/2023 revealed, Policy Statement: Life connections programs are designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. Policy Interpretation and Implementation: 1. The life connections program is provided to support the well-being of residents and to encourage both independence and community interactions . Review of the facility's, Admission Agreement dated 1/20/09, revealed, .GRIEVANCES and/or CONCERNS (Resident) . Policy Statement: It is the policy of this facility to support each resident's right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear or discrimination or reprisal. After receiving a concern/grievance, the facility will actively seek a resolution and keep the residents appropriately appraised of its progress toward a resolution. As necessary, the facility will take action to prevent further occurrences during the investigation . Review of the facility's Resident Rights, revised and implemented on November 28,2016, revealed, . (3) The resident has all right to interact with members of the community and participate in community activities both inside and outside of the facility . (5) The resident has a right to organize and participate in residents groups in the facility . (iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility . (8) The resident has the right to participate in other activities, including social, religious, and community activities that do not interfere with other residents in the facility . (j) . (2) The resident has the right to, and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph . During a Resident Council meeting on 10/16/23 at 03:30 PM, with the Resident Council members, Residents #4, #11, #17, #18, #20, #27, #28, #30 and #31 complained that the facility van has not been available for over a year, as it is need of repair. The residents said in the past, they enjoyed going shopping, fishing, and taking part in community events. The residents said when the van was working, they were able to participate in different functions outside of the facility. However, since the van stopped working, they feel isolated. The residents also said they feel like inmates, as they are unable to leave the facility. The Activity Director has been shopping for them, but they prefer to look around the stores and choose for themselves. They were told this was their home, but they can't go out of the building to functions because they don't have transportation. During an interview on 10/18/23 at 2:47 PM, with the Activity Director, she confirmed the residents have complained several times in the Resident Council meetings about the van being broken. The Activity Director said the residents want to go shopping for themselves. She explains to them every month the new shopping policy to remind them not to give money to staff to buy things. The Director revealed there are only two (2) people in the facility that can shop for the residents, her, and the Business Office Manager (BOM). The Director also said the residents complain about being stuck at the facility and not having transportation to go out to other events. The Activity Director said she talked to the Administrator about the residents' concerns about not going to outside events. The Administrator told her that is working with the corporate office to resolve the issue, but she doesn't know how long it would take. During an interview on 10/18/23 at 3:00 PM, with the Social Worker revealed she was not told about the grievance of the van. The Social Worker stated she is aware the van has not been running for a long time, but neither the Activity Director, nor the residents have complained to her. During an interview on 10/19/23 at 10:54 AM, the Administrator confirmed the van has not worked for over a year. The Administrator said she doesn't know the exact day the van stopped running. She stated she is working with the corporate office on a resolution. The Administrator commented the corporate office has not decided whether they're going to get the motor fixed in the van or buy another van. For now, the Administrator said the facility uses the local transportation company to make sure the residents can get to their doctor appointments. The Administrator confirmed that the facility has not rented a van or used transportation services for outside activity events for the residents. The Administrator revealed she doesn't know how long it will take for the corporate office to make a decision regarding the van. Resident #4 A record Review of Resident #4's Admission Record revealed the facility admitted the resident on 8/16/22, with diagnoses that included Lack of Coordination, Depression, and Malignant Neoplasm of Breast. A record review of the Comprehensive Minimum Data Set (MDS) with Assessment Reference Date (ARD) 8/2/23 revealed a Brief Interview of Mental Status (BIMS) score of 14, which indicated resident was cognitively Intact. Resident #11 A record Review of Resident #11's Admission Record revealed the facility admitted the resident on 7/26/22, with diagnoses that included Hypertension, Anxiety and Diabetes Mellitus. A record review of Resident #11's Quarterly MDS with an ARD of 10/3/23, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #17 A record Review of Resident #17's Admission Record revealed the facility admitted the resident on 6/1/23, with diagnoses that included Heart Failure, Kidney Disease and Osteoarthritis. A record review of Resident #17's Quarterly MDS, with an ARD of 8/23/23, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #18 A record Review of Resident #18's Admission Record revealed the facility admitted the resident on 5/25/22, which included diagnoses of Hypertension, Heart Failure and Diabetes Mellitus. A record review of Resident #18's Quarterly MDS, with an ARD of 8/2/23, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #20 A record Review of Resident #20's Admission Record revealed the facility admitted the resident on 10/21/20, with diagnoses that included Heart Disease, Hypertension and Lack of coordination. A record review of Resident #20's Quarterly MDS, with an ARD of 9/11/23, revealed a BIMS score of 14, which indicated the resident was cognitively intact. Resident #27 A record Review of Resident #27's Admission Record revealed the facility admitted the resident on 4/9/23, with diagnoses of Hypertension, Anxiety Disorder and Diabetes Mellitus. A record review of Resident 27's Quarterly MDS, with an ARD of 8/14/23, revealed a BIMS score of 14, which indicated the resident was cognitively intact. Resident #28 A record Review of Resident #28's Admission Record revealed the facility admitted the resident on 10/13/20, with diagnoses of Hypertension, Heart Failure and Anxiety Disorder. A record review of Resident #28's Annual MDS, with an ARD of 8/11/23, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #30 A record Review of Resident #30's Admission Record revealed the facility admitted the resident on 8/28/23, with diagnoses of Hypertension, Renal Disease and Anxiety. A record review of Resident #30's Quarterly MDS, with an ARD of 9/22/23, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #31 A record Review of Resident #31's Admission Record revealed the facility admitted the resident on 2/15/23, with diagnoses of Hypertensive Urgency, Rheumatoid Arthritis and Anxiety Disorder. A record review of Resident' #31's Quarterly MDS, with an ARD of 9/13/23, revealed a BIMS score of 11, which indicated the resident had moderate cognitive impairment.

Based on interview, record review and facility policy review the facility failed to ensure the residents were able to obtain funds from their trust accounts on weekends for nine (9) of (12) Resident council members interviewed. (Residents #4, #11, #17, #18, #20, #27, #28, #30 and #31) Findings Include: Review of the facility's policy titled, Resident Trust Fund Policy & Agreement, dated 10/7/07, revealed, .WHEREAS the resident acknowledges that he/she has been informed and understands that he/she has the right to manage his/her own financial affairs . The Facility will give the Resident due receipt for such monetary sums . During an interview on 10/16/23 at 3:30 PM, with the Resident Council members, Residents #4, 11, #17, #18, #20, #27, #28, #30 and #31 complained that they were not able to get their money from their trust fund on weekends. The residents said if they want money for the weekend, they must get it on Friday. The residents revealed that has been a problem for them, because if they wanted to order a pizza or food from Door Dash on weekends, they've unable to do so, as they do not have access to their money. Review of the facility's, Resident Fund Management Service undated, revealed Residents #4, #11, #17, #18, #20, #27, #28, # 30 and #31 have money in the Facility Trust Fund. During an interview on 10/18/23 at 2:47 PM, with the Activity Director revealed she did not know the residents were unable to get their money on weekends. In an interview on 10/18/23 at 2:50 PM, the Business Office Manager (BOM) revealed she works Monday through Friday. She stated she leaves $50.00 with the Director of Nursing (DON) in an envelope on Fridays to be put on the medication cart, so the charge nurse can have money to give to residents that request it over the weekend. During an interview on 10/18/23 at 3:10 PM, with Registered Nurse (RN) #1, she revealed she works every other weekend. RN #1 said if the resident wants a snack, she purchases it out of the vending machine with her money. The RN stated the facility does not leave money on weekends for the residents. RN #1 confirmed that residents must request money from their account by Friday evening, or they won't be able to get money until Monday. During an interview on 10/18/23 at 3:14 PM, with Licensed Practical Nurse (LPN) #1, she confirmed she works every other weekend on the medication cart. LPN #1 said she has never seen an envelope with money on the medication cart. The nurse said the residents must get their money from the business office by Friday evening. During an interview on 10/19/23 at 9:05 AM, with the Director of Nursing (DON), she said when she first started working at the facility, the BOM would leave money in a black box on weekends on the medication cart. The DON said she has not seen the black box lately. She revealed she doesn't know where it's kept but knows it's not on the medication cart. The DON said she doesn't know if the BOM is leaving the money with the kitchen and doesn't know if the residents are able to get money on weekends now or not. During an interview on 10/19/23 at 10:08 AM, with LPN #3, revealed she occasionally works on weekends. The nurse stated the business office does not give her an envelope with money for the residents to have over the weekend. On 10/19/23 at 10:54 AM, during an interview with the Administrator, she stated the BOM should be leaving an envelope on the medication cart with $50.00 on Friday for the residents to use on the weekend. The Administrator revealed she did not know the money was not being left for the Residents to use of the weekends. During an interview on 10/19/23 at 11:00 AM, with the Dietary Manager, she revealed the dietary department never receives resident funds for the weekend or any other time. Resident #4 A record Review of Resident #4's Admission Record revealed the facility admitted the resident on 8/16/22, with diagnoses that included Lack of Coordination, Depression, and Malignant Neoplasm of Breast. A record review of the Comprehensive Minimum Data Set (MDS) with Assessment Reference Date (ARD) 8/2/23 revealed a Brief Interview of Mental Status (BIMS) score of 14, which indicated resident was cognitively Intact. Resident #11 A record Review of Resident #11's Admission Record revealed the facility admitted the resident on 7/26/22, with diagnoses that included Hypertension, Anxiety and Diabetes Mellitus. A record review of Resident #11's Quarterly MDS with an ARD of 10/3/23, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #17 A record Review of Resident #17's Admission Record revealed the facility admitted the resident on 6/1/23, with diagnoses that included Heart Failure, Kidney Disease and Osteoarthritis. A record review of Resident #17's Quarterly MDS, with an ARD of 8/23/23, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #18 A record Review of Resident #18's Admission Record revealed the facility admitted the resident on 5/25/22, which included diagnoses of Hypertension, Heart Failure and Diabetes Mellitus. A record review of Resident #18's Quarterly MDS, with an ARD of 8/2/23, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #20 A record Review of Resident #20's Admission Record revealed the facility admitted the resident on 10/21/20, with diagnoses that included Heart Disease, Hypertension and Lack of coordination. A record review of Resident #20's Quarterly MDS, with an ARD of 9/11/23, revealed a BIMS score of 14, which indicated the resident was cognitively intact. Resident #27 A record Review of Resident #27's Admission Record revealed the facility admitted the resident on 4/9/23, with diagnoses of Hypertension, Anxiety Disorder and Diabetes Mellitus. A record review of Resident 27's Quarterly MDS, with an ARD of 8/14/23, revealed a BIMS score of 14, which indicated the resident was cognitively intact. Resident #28 A record Review of Resident #28's Admission Record revealed the facility admitted the resident on 10/13/20, with diagnoses of Hypertension, Heart Failure and Anxiety Disorder. A record review of Resident #28's Annual MDS, with an ARD of 8/11/23, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #30 A record Review of Resident #30's Admission Record revealed the facility admitted the resident on 8/28/23, with diagnoses of Hypertension, Renal Disease and Anxiety. A record review of Resident #30's Quarterly MDS, with an ARD of 9/22/23, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #31 A record Review of Resident #31's Admission Record revealed the facility admitted the resident on 2/15/23, with diagnoses of Hypertensive Urgency, Rheumatoid Arthritis and Anxiety Disorder. A record review of Resident' #31's Quarterly MDS, with an ARD of 9/13/23, revealed a BIMS score of 11, which indicated the resident had moderate cognitive impairment.

Based on interview, record review, and facility policy review, the facility failed to provide the Resident, or the Resident Representative (RR), written notification of the bed hold policy at the time of transfer for one (1) of 15 sampled residents. Resident #39 Findings include: A review of the facility's policy, Bedhold Policy and Procedure, undated, revealed, Before the facility transfers a resident to the hospital .written information should be provided to the resident and family member or legal representative specifying the following information .The duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the facility; and .The policies regarding bed hold periods, which should be consistent . Resident #39 On 10/17/23 at 10:09 AM, during a phone interview with the RR, she stated that she did not receive written notification of the bed hold information regarding Resident #39's recent hospitalization . A review of the medical record revealed there was no written notification of the bed hold policy at the time of Resident #39's transfer from the facility on 7/25/23. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/23, revealed the resident was discharged to an acute care hospital on 7/25/23. A record review of the Admission Record revealed the facility initially admitted Resident #39 on 12/15/22 with a diagnosis of Dementia, and he was readmitted on [DATE] with a diagnosis of Urinary Tract Infection. A record review of the Quarterly MDS with an ARD of 6/23/23 revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated he had severe cognitive impairment. On 10/17/23 at 10:15 AM, an interview with the Admissions Coordinator (AC), revealed she reviewed the subject of the Bed hold with the Resident and/or RR at the time of admission. The AC revealed she explained to the RR that in the event of hospitalization , they may hold the Resident's bed for a daily charge. The AC reported the admissions packet, which included the bed hold form, was sent to the Business Office when completed. On 10/17/23 at 10:20 AM, an interview with the Business Office Manager (BOM), revealed she received the admissions packet, included the bed hold form from the AC and filed the form in her office. The BOM stated that at the time of a resident hospitalization , she called the RR to ask if they wanted to hold the Resident's bed and discussed payment at that time. She confirmed she did not provide written notification to the Resident or the RR at the time of the hospital transfer. On 10/17/23 11:58 AM, an interview with the Social Services Director (SSD) revealed that when a resident is transferred or discharged to the hospital, she mailed the RR a notification of transfer and that she did not provide written notification of bed hold at the time of resident transfer to the hospital. On 10/19/23 at 07:37 AM, during an interview with the Administrator, she acknowledged the failure of the facility to provide written notification to the Resident or RR of the bed hold policy at the time of each hospitalization . The Administrator reported that this was a learning experience for her staff.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a call light was within reach for one (1) of 15 sampled residents. Resident #26 Findings include: A review of the facility's policy, Call Light, Use of, revised 11/15/2019, revealed . It is the policy of this facility to have an adequately equipped communication system that allows residents to call for staff . Be sure all call lights are placed within reach . The facility will routinely inspect: Call lights are placed appropriately and within reach at bedside . On 10/16/23 at 11:46 AM, during an initial interview and observation with Resident #26, she explained that her call light had not been in reach many times and that occurred on all shifts. An observation revealed the call light was on the nightstand and out of reach of the resident. She stated that she has been told by staff not to yell out, but if there was an emergency, she would yell anyway. On 10/16/23 at 12:20 PM, during an observation, Certified Nurse Aide (CNA) #1 took a meal tray into Resident #26's room and placed the tray on the bedside table. CNA #1 did not place the call light within reach of the resident. At 12:45 PM on 10/16/23, during an observation, CNA #2 entered Resident #26's room and removed the meal tray. CNA #2 did not place the call light within the resident's reach. At 1:00 PM on 10/16/23, during an interview and observation with Resident #26, she confirmed that neither CNA #1 or CNA #2 placed her call light within her reach when her tray was delivered or removed from her room. At 1:10 PM on 10/16/23, during an observation and interview with CNA #2, she confirmed that the call light was not within reach for Resident #26. She explained that the call light should always be within reach and that the residents are observed every two hours during rounds. She said it was her responsibility to make sure the call light was within reach of the resident. At 11:40 AM on 10/19/23, during an interview with Director of Nursing (DON), she explained she expected all staff to respect resident's wishes and keep all call lights within reach at all times. Record review of the Admission Record revealed the facility admitted Resident #26 on 7/03/23 with a diagnosis of Chronic Kidney Disease. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/10/23 revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Section G revealed she required extensive assistance with bed mobility and transfers.

Based on interview, record review, and facility policy review, the facility failed to notify the Resident's Representative (RR) of a room change for one (1) of 15 sampled residents. Resident #39 Findings include: A review of the facility's policy, Room Changes Policy, revised April 9, 2021, revealed, The facility will promote resident's right to make choices and to receive written notice of a room change when being relocated .When a resident is changing rooms at the request of facility staff, the resident and/or resident representative should receive written notification that contains the reason for the room change, the effective date of the change, and the location to which the resident will be moved . On 10/17/23 at 10:06 AM, a phone interview with Resident #39's RR revealed the resident was changed to a new room during his stay. The RR stated she did not know of Resident # 39's room change until she came to the facility, and the resident was not in his room. The RR reported being scared and had to look for a staff member to help her find the resident. A record review of the resident's medical record revealed there was no notation of a room change for Resident #39 from December 31, 2022, to January 1, 2023. A record review of the facility's Census Reports for December 31, 2022, to January 01, 2023, revealed the resident was moved from room [ROOM NUMBER]A to room [ROOM NUMBER]A. A record review of the Admission Record revealed the facility initially admitted Resident #39 on 12/15/22 with diagnoses that included Type II Diabetes Mellitus and Dementia. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 6/23/23, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated he had severe cognitive impairment. On 10/17/23 at 02:51 PM, an interview with the Social Services Director (SSD) revealed Resident #39 was admitted to the facility on [DATE]. The SSD stated the Resident was moved from room [ROOM NUMBER]A to room [ROOM NUMBER]A on 1/1/23. The SSD confirmed there was no documentation that supported the facilities' effort to contact the RR regarding the room change. On 10/19/23 at 07:37 AM, in an interview with the Administrator, she acknowledged the facility failed to notify the Resident or RR of the room change. On 10/19/23 at 11:50 AM, in an interview with the Director of Nursing (DON), she confirmed there were no progress notes which documented the resident's room change from 10A to room [ROOM NUMBER]A on 1/1/23.

Based on observations, interviews, record review, and facility's policy review, the facility failed to ensure a resident who was dependent on staff assistance for showering received those services for one (1) of three (3) residents reviewed for Activities of Daily Living (ADL) assistance. Resident #10 Findings include: A record review of the facility's policy Bath, Shower/Tub, dated August 25, 2014, revealed . The purposes of this procedure are to promote cleanliness, provide comfort to the resident . The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath . 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. On 10/16/23 at 12:30 PM, during an interview and observation, Resident #10 was observed in her wheelchair, with toiletry supplies in her hand. It was noted that the resident's hair looked dirty and oily. The resident explained it has been a week ago Monday since she had her last shower. She stated she is to take a shower three (3) times a week on the evening shift. Resident #10 revealed she goes to the shower with a Certified Nursing Assistance (CNA), as she is afraid of falling and needs assistance. On 10/17/23 at 8:15 AM, observed and interviewed Resident #10 lying in bed. The resident was alert and oriented. The resident explained she did not receive a shower last night. Her hair continues to look dirty and oily. On 10/17/23 at 10:10 AM, during an interview with CNA #1, she explained she does not have Resident #10 today but reported she has worked with the resident. CNA #1 revealed that the resident gets showers on the evening shift and the assistance of one person is required. The CNA commented that Resident #10 has never refused any care on her, especially a shower. She stated that Resident #10 loves to take showers. On 10/17/23 at 10:25 AM, during an interview with CNA #2, she explained Resident #10 is given baths/showers on evening shifts and sometimes resident may get washed off in the mornings but gets showers on the evening shift. On 10/17/23 at 3:40 PM, during an interview with CNA #3, she explained Resident #10 is scheduled for evening showers and she seldom has had Resident #10 on her care load, but Resident #10 rarely refused showers on her. On 10/17/23 at 4:20 PM, during an interview with CNA #4, she explained the facility has a shower binder to help with who gets showers and when, but reported the showers are listed in the Kiosk under task for the CNAs to complete. The CNA revealed that Resident #10 always wants to go to the shower, seldom refuses, and she thought Resident #10 went to the shower last night. While reviewing the task record with the CNA, the record revealed the resident refused her shower, however, CNA #4 confirmed that she doesn't remember the refusal. The CNA then commented that she will try and give the resident a shower tonight. She explained the shower binder is only an extra source for quick review of the showers. CNA #4 confirmed that Resident #10's hair appears dirty and oily. On 10/17/23 at 4:30 PM, during an interview with Resident #10, she explained she does not remember staff asking her about a shower last night. She revealed she has seldom refused showers, except for last week when she had a doctor's appointment on Wednesday and was just too tired to go to the shower. On 10/17/23 at 4:45 PM, during an interview with Registered Nurse (RN) #1, she explained if a resident frequently refuses care, a care plan meeting should be arranged with the resident and family and should be care planned for refusal. The RN confirmed Resident #10's hair looked dirty and oily. On 10/18/23 at 7:30 AM, Resident #10 was observed sitting in the foyer area, the resident's hair continued to look dirty. The resident reported she still did not get a shower last night, and no one came and asked her. On 10/19/23 at 11:35 AM, during an interview with the Administrator, she explained she expects her staff to provide showers as scheduled consistently. At 11:40 AM on 10/19/23, during an interview with the Director of Nurses (DON), she explained she expects all staff to respect resident's wishes, give showers as scheduled and chart if the resident refused. Record review of Resident #10's Admission Record revealed the facility admitted the resident on 8/02/22 with the diagnoses of Malignant Neoplasm of Colon, Chest Pain, and Need for Assistance for Personal Care. Record review of Resident #10's Annual Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 7/20/23, revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Further review of the MDS revealed that showers are somewhat important to the resident and the resident had no rejection of care. The MDS also revealed that bathing did not occur during the timeframe of the MDS documentation. Record review of the Resident #10's Point Click Care Documentation Survey Report for July-2023 through October-2023 revealed an intervention/task for bathing M-W-F (Monday-Wednesday-Friday) 3-11. For the month of July 2023 Resident #10 missed seven (7) showers for the month. For the month of August 2023, Resident #10 missed three (3) showers for the month. For the month of September 2023, Resident #10 missed two (2) showers for the month. For the month of October 2023 Resident #10 missed two (2) showers and refused once.

Based on observation, staff interview, record review, and facility policy review, the facility failed to prevent the possible spread of infection during wound care for one (1) of two (2) residents reviewed with wounds. Resident #1 Findings Include: Review of the facility's policy, Infection Control Program, dated 7/16/22, revealed, .The facility will establish and maintain an Infection Control Program focused on preventing the transmission of infectious disease .Purpose .Decrease the risk of infection for residents .Insure compliance with federal and state infection control guidelines . Review of the facility's policy, Handwashing/Hand Hygiene, dated June 2010, revealed, .Policy Interpretation and Implementation .6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. IF hands are not visibly soiled, use an alcohol-based hand rub .for all of the following situations: .before handling clean or soiled dressings .after removing gloves . During an observation of wound care on 8/10/23 at 10:05 AM, for Resident #1 with Registered Nurse (RN) #1 revealed RN #1 gathered supplies for wound care that included a package of gauze, spray container of wound cleanser, container of betadine, package of Alginate, and container of hand sanitizer. All items were gathered in her arms and held against her chest and in contact with her clothing. RN #1 did not wash or sanitizer her hands before applying gloves and initiating wound care. RN #1 removed and discarded the soiled dressing, but did not wash or sanitize her hands before applying a clean pair of gloves. RN #1 returned unused supplies from Resident #1's room to the treatment cart. In an interview with RN #1, on 8/10/23 at 10:15 AM, she confirmed that not sanitizing her hands could have caused the wound to become infected. She confirmed that she should not have taken all the supplies into the resident's room and brought them back out and placed them in the treatment cart. During an interview with the Director of Nursing on 8/10/23 at 10:20 AM, she stated that she expected the nurses to sanitize their hands during wound care. Record review of the Order Summary Report with Active Orders As Of: 08/10/2023 revealed Resident #1 had a Physician's Order, dated 7/22/23, for Cleanse wound to midline abdomen with wound cleanser, pat dry, apply alginate, paint wound with betadine, cover with bordered gauze, change drsg (dressing) every other day and prn (as needed) . Record review of the Admission Record revealed the facility admitted Resident #1 on 8/19/20 with diagnoses that included Fistula of Stomach and Duodenum.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide treatment and services in accordance with professional standards for one (1) of two (2) residents reviewed with wounds. Resident #1 Findings Include: A review of the facility's Skin Care Process policy, dated 1/17/2018, revealed, .It is the policy of this facility to provide care and services that meet professional standards to treat the loss of skin integrity . On 8/10/23 at 10:05 AM, during an observation of wound care for Resident #1 with Registered Nurse (RN) #1, revealed RN #1 gathered supplies including a package of gauze, spray container of wound cleanser, container of betadine, package of Alginate, and container of hand sanitizer. All items were gathered in her arms and held against her chest and in contact with her clothing. RN #1 removed and discarded the soiled dressing. She retrieved several of the gauze from the packet, touching the container, and applied wound cleanser to the gauze. She cleaned the lower wound to the abdomen by blotting up and down on and around the wound, used the same gauze to clean the upper wound by blotting up and down on and around the wound, then used the same gauze to make one swipe from the top of the upper wound all the way down to the bottom of the lower wound. She did not discard and use clean gauze, or reposition the gauze to use a clean area while cleaning the wound. RN #1 then discarded the soiled gloves, applied hand sanitizer, and donned a clean pair of gloves. She reached into the container of Alginate and tore off a small piece. Her hands were in contact with the remaining Alginate in the container and she touched the container itself. She applied the Alginate to the sound, applied betadine, and covered the wound. RN #1 then gathered the package of gauze, wound cleanser, the packet of Alginate, betadine, and the hand sanitizer and exited the room. She took the supplies into the hallway and placed them back in the treatment cart. On 8/10/23 at 10:15 AM, in an interview with RN #1, she confirmed that she should not have taken all the supplies into the resident's room and brought them back out and placed them in the treatment cart. She said she thought she should have only taken what was needed into the room but had understood she was supposed to take in all the supplies. She also confirmed that cleaning the wound improperly could have caused the wound to become infected. On 8/10/23 at 10:20 AM, in an interview with the Director of Nursing, she stated that she expected the nurses to complete wound care without contaminating the supplies. She stated that the facility currently has an outside wound care service that comes into the facility weekly to measure, assess, and treat resident wounds. Record review of the Order Summary Report with Active Orders as of: 08/10/2023 revealed Resident #1 had a Physician's Order, dated 7/22/23, for Cleanse wound to midline abdomen with wound cleanser, pat dry, apply alginate, paint wound with betadine, cover with bordered gauze, change drsg (dressing) every other day and prn (as needed) . Record review of the Admission Record revealed the facility admitted Resident #1 on 8/19/20 with diagnoses that included Fistula of Stomach and Duodenum. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/17/23, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact.

Based on interviews, record review, and facility policy review, the facility failed to protect a resident from misappropriation of property for one (1) of four (4) sampled residents. Resident #1 Findings Include: Review of the facility's policy, Freedom from Abuse, Neglect and/or Exploitation Prevention Plan Education, dated 11/14/17 revealed, The resident has the right to be free from . misappropriation of residents property . ` Record review of the facility's investigation dated 8/5/22 and signed by the Administrator, revealed Resident #1 notified her nurse that she had asked Certified Nursing Assistant (CNA) #1 to take her Electronic Benefit Transfer (EBT) card and some cash to go shopping for her. She stated she paid CNA #1 $140 in cash and gave her EBT card to buy snacks for her and her roommate and to get her four (4) T-shirts/camisoles, two (2) bralettes, hairspray, shampoo and a grooming kit. CNA #1 had brought her all the items except the T-shirts and bralettes because she had left them in her truck. She did not work the next couple of days and did not have a phone so Resident #1 canceled her card not knowing what had happened. An interview with CNA #1 stated she did bring all items, change and receipts. CNA #1 was suspended pending investigation. In the investigation it was determined that although the resident has a BIMS of 15, she did receive the rest of her items, which were four (4) T-shirts and two (2) bralettes. Resident #1 told CNA #1 to use her card for food for her family, which she did. CNA #1 was terminated for not following facility policy. The money was replaced. Record review of a statement dated 7/30/22 and signed by the Administrator revealed, .(Proper Name of Resident #1) said she shouldn't have asked (Proper Name of CNA #1) to shop for her and she didn't want to get her in any trouble. I (Administrator) asked (Proper Name of Resident #1) if she told (Proper Name of CNA #1) she could shop for herself with the EBT card and she said yes. It was not discussed how much she allowed (Proper Name of CNA #1) to use but (Proper Name of Resident #1) told me she figured maybe between $50.00-$75.00. Record review of the facility's Witness Interview Statement dated 7/30/22 and signed by Licensed Practical Nurse (LPN) #1 revealed, (Proper Name of Resident #1) informed this nurse that the transportation employee (Proper Name of CNA #1) had gotten resident ebt card and 140$ in cash. Resident stated that (Proper Name of CNA #1) told her she did not have money for gas or food to eat. Resident stated (Proper Name of CNA #1) asked to use the ebt card to buy grocers so she can eat and use $40.00 of the cash for gas. Resident stated about $150 was used by (CNA #1) on the EBT card and that (Proper Name of CNA #1) only used $30 of the cash on (Proper Name of Resident #1). (Proper Name of Resident #1) stated that (Proper Name of CNA #1) has gave her the run around and that there are text messages about the situation as well. Record review of the facility's Witness Interview Statement dated 7/30/22 and signed by Registered Nurse (RN) #1 revealed, Resident stated to this nurse and (Proper Name of LPN #1) that a staff member (Proper Name of CNA #1) spent money on her EBT card and took cash from her that she did not get back. Resident showed me and (Proper Name of LPN #1) text messages on her phone .DON notified and aware. Record review of a handwritten statement (undated) and signed by CNA #1 revealed, .(Proper Name of Resident #1 asked me to get her money off a treasury card. She also asked me to take her EBT card and get her and her roommate some snacks. I got her money and food and brought everything back to her cash, food & 2 cards. When I come to work the following day she said when she called her ebt card that I left too much money on it and I should get myself some snacks for work. She gave me a list of things she wanted, non food items & gave me $140.00 in cash. I bought every-thing on her list and gave her back her ebt card and $40. The only thing I didn't give her was 4 shirts & 2 bras which was lost in my car. Those 4 shirts & 2 bras and $20 have been given to her. The $20.00 for the headache I caused for her worrying. I got everything she asked for and returned it. I did not intend on the delay to get her stuff back. Things happened out of my control and I was without a vehicle for several days . During an interview with Resident #1 on 8/29/22 at 10:40 AM, she stated that during the time the event happened in July of this year (2022), the Activities person was out sick. Activities staff would usually pick up items at the store for her as needed. CNA #1 offered to pick up what Resident #1 needed from the store. Resident #1 asked CNA #1 to pick up some snacks, T-shirts, bralettes, shampoo and hair spray. Resident #1 said that she gave CNA #1 her Treasury Card to get $140 cash and her Electronic Benefit Transfer (EBT) card. Resident #1 stated that she told CNA #1 that she could use $50 from the EBT card to get food for her (CNA #1) and her (CNA #1) family. Resident #1 explained that she was trying to help the CNA out because she was having a hard time and she felt sorry for her. Resident #1 became concerned when CNA #1 did not return to work for three (3) days. She called to check on any transactions related to her EBT card and was informed that an additional $70 had been spent from the card. At that time, Resident #1 canceled her Treasury Card and EBT card. She then notified the staff that CNA #1 only brought back some of the items she had requested. The Administrator made CNA #1 bring the remaining items and $20 of the cash. The facility also gave Resident #1 $20 in cash. Resident #1 said she only got $40 dollars back and she didn't want to get her in trouble, but I am out $70 dollars that I did not authorize her to use on my EBT card. Resident #1 commented that she really felt sorry for her and I don't want to get her in trouble. Resident #1 pulled up text messages from her phone between her and CNA #1 from Sunday, 7/24/22 at 2:28 PM, CNA #1 texted Resident #1 Hey Mrs. (Proper Name of Resident #1) .I would have brought you the stuff Friday but I literally had no gas. And had a flat tire. I have your ebt card and I only spent 100.00 of your money .there's 40 .do you mind if I use it for gas. Resident #1 did not respond to the text. The next text was Monday, 7/25/22 at 9:25 AM, Mrs. (Proper Name of Resident #1) I will see you around 6 this evening. I have stuff for you to bring. Also I am having issues with the bosses there at (Proper Name of Facility). So if you don't mind. Don't let them know we have spoke. I hope things can be worked out but I will see you this afternoon. An interview with LPN #1, on 8/29/22 at 1:47 PM, revealed that Resident #1 had told her that the CNA told the resident she was broke and did not have money for food or gas. The resident told me she gave the CNA her treasure card to get cash and her EBT card. She told the CNA she could use $50 off the EBT card to buy groceries for her family. The CNA still had the resident's stuff, and the resident said the CNA used about $110 to $120 off her EBT card. On 8/29/22 at 1:57 PM, in an interview with Registered Nurse (RN) #1, she stated that LPN #1 asked her to witness Resident #1's statement. RN #1 confirmed her written statement that the resident stated CNA #1 spent money on her EBT card and took cash from her and did not repay her. Resident #1 then showed LPN #1 and RN #1 the text message exchange between her and CNA #1 that she kept on her phone. The Director of Nurse (DON) was then notified. During an interview with the Administrator on 8/30/22 at 1:46 PM, she stated Resident #1 gave the staff (CNA #1) permission to use the EBT card and gave her the password. The resident told the staff to buy her family groceries. The Administrator verified that she had read the text messages exchanged between Resident #1 and CNA #1 in which CNA #1 was asking to use the resident's money for gas. The Administrator stated she did not see anything that would indicate the staff (CNA #1) had manipulated the resident. Record review of the Admission Record revealed that Resident # 1 was admitted by the facility on 6/16/22, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/24/22 revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15, indicated the resident was cognitively intact. Record review of the Freedom from Abuse, Neglect and/or Exploitation Prevention Plan Education and the Vulnerable Adults' Prevention Policy revealed, CNA #1 signed the document on 3/10/22, which indicated she received training related to abuse, including misappropriation of personal property and vulnerable adults.

Based on interviews, record review, and facility policy review, the facility failed to protect a resident from misappropriation of a medication for one (1) of three (3) sampled residents. Resident #1 Findings Include: A record review of the facility's policy, Freedom from Abuse, Neglect and/or Exploitation Prevention Plan Education, with a revision date of 11/14/17, revealed The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation . On 07/25/2022 at 12:15 PM, during an interview with the Director of Nursing (DON), she explained that on 03/22/2022, she received a call from the Administrator that the facility had a narcotic discrepancy and she needed to come and investigate. She instructed all nurses to lock the carts and she would be on her way. It was discovered that Resident #1 was missing a card of [MEDICATION(S)] 5/325 milligram (mg) tablets that had been received from the pharmacy the week before on 03/14/2022. The medication card could not be located after a thorough search and an investigation was initiated. The DON notified the Corporate Regional Nurse Consultant and the Corporate Regional Director of Operations who came and assisted in the investigation. The DON interviewed all nurses related to the missing medication card. The procedure is that at shift change, the nurses compare a resident's individual narcotic sheet located on the narcotic book to the individual narcotic card that is kept in the locked drawer of the medication cart. They also ensure the master narcotic log matches the total number of narcotic medication cards for all residents. The master narcotic log is used to log in every card of a narcotic for residents when it is received from the pharmacy. The same log is used to subtract an empty or depleted card of narcotics for residents so that a running total of all narcotic cards is kept and compared to the overall number of narcotic medication cards on the medication cart for residents at every shift change. During the investigation, there was no discrepancy noted in the individual narcotic sheets kept in the narcotic book on each cart when compared to the individual narcotic medication cards kept in the narcotic drawer of the medication cart. There was also no discrepancy in the total number of narcotic cards as compared to the master narcotic log, however, the investigation concluded there were four (4) medication cards that were logged out (empty/depleted cards) on the master narcotic log by Licensed Practical Nurse (LPN) #1 past the receipt date of the [MEDICATION(S)] on 03/14/2022 and the individual narcotic sheets were not located. All empty cards that are logged out of the master narcotic log should be witnessed and signed by another nurse, and these 4 entries did not have a witnessed signature. The Pharmacy found that two (2) of the four (4) cards that had been logged out as depleted by LPN #1 had correct prescription numbers and matched with the names of residents, and one (1) card had an incorrect prescription number but matched a resident and medication. There was one entry in the master narcotic log for one (1) card that had a prescription number that did not match any of the residents' prescription numbers or medications in the facility. The investigation concluded that LPN #1 had taken Resident #1's [MEDICATION(S)] medication card from the narcotic drawer on the cart and the individual narcotic sheet from the narcotic book. She then entered a made up prescription number and medication for the resident to subtract from the master narcotic log so the overall count and the master log would match. Therefore, the counts would always match when the nurses counted at shift change. LPN #1 was suspended during the investigation and was terminated on 03/25/2022. The DON said that the nurses were not specifically trained to ensure there was another nurse to witness when a completed medication card was removed from the master narcotic log, but she thought that it was rules of nursing. After the incident, every nurse received training to obtain two signatures on the master narcotic log when adding or subtracting a narcotic card. Prior to the incident, the nurses would remove a completed card from the locked narcotic box on the cart and the induvial narcotic sheet from the narcotic book and place them together in a medical record box, but now all narcotic sheets for depleted narcotic medication cards must be turned in to the DON. Every nurse that had been on the cart with Resident #1's medication had a drug test, a 100% audit of all narcotic drawers on medication carts were completed, in-service training was completed for all nurses on signing in and removing a narcotic medication card, and 100% pain assessments were completed on each resident. The Attorney General Office, Board of Nursing, and Board of Pharmacy was notified of the findings after the investigation was completed. At 4:30 PM on 07/25/2022, during an interview with Registered Nurse (RN) #2, she stated that on 03/22/2022 during shift change report, she overheard a nurse saying that Resident #1 was out of [MEDICATION(S)] and needed a new written prescription. She told the nurses that Resident #1 had received a new card of 60 tablets of [MEDICATION(S)] last week from pharmacy and she and LPN #4 had logged it into the master narcotic count log. All nurses looked for the missing [MEDICATION(S)] card but was unable to locate it. The Administrator and the DON were notified. The master narcotic log matched the overall narcotic card count, but the card of [MEDICATION(S)] that had been logged in on 03/14/2022 could not be located. On 07/26/2022 09:00 AM, during an interview with Resident #1, she explained a few months ago a nurse had stolen her pain medications, but she didn't know exactly who took the medication. On 07/26/2022 at 11:30 AM, during an interview with the Corporate Regional Director of Operations, she stated that she and the Regional Nurse Consultant assisted with the investigation of the missing narcotic card, and they, along with the Pharmacy, reviewed the errors made by LPN #1 in removing completed narcotic cards from the master narcotic log. The missing card of [MEDICATION(S)] was never located. LPN #1 was terminated on the last day of the investigation on 03/25/2022. LPN #1 denied making up the prescription numbers and did not recall seeing the card of [MEDICATION(S)], even though she was the last nurse to administer [MEDICATION(S)] to Resident #1. On 07/26/2022 at 12:20 PM, during an interview with the Administrator, she explained she was at the facility when two nurses, RN #5 and RN #2, came to her on 03/22/2022 to inform her there was a problem with the Resident #1's [MEDICATION(S)]. A new nurse, RN #4, had worked the cart and was leaving and RN #5 was coming on. RN #2 said a medication was there for Resident #1 four (4) days ago because she had signed them in with another nurse, but the medication was missing. She called the DON right away and she came to the facility and began the investigation. On 07/26/2022 at 12:30 PM, during an interview with RN #4, she explained she was working an eight (8) week contract for the facility back in March 2022. On the day of the incident, she had completed her shift and was giving report to the oncoming nurse. She gave report that Resident #1 had asked for a [MEDICATION(S)], but she did not have any on the cart and she needed a new prescription. Another nurse, RN #2, heard the conversation about the [MEDICATION(S)] and said that Resident #1 had just received [MEDICATION(S)] about four (4) days ago because she signed the [MEDICATION(S)] in with the night shift nurse. After hearing what RN #2 said, they all went straight to the Administrator and informed her of the missing medication and waited for the DON to return to the facility. On 07/26/2022 at 2:15 PM, during a phone interview with the facility's Pharmacist, he confirmed the DON notified him of the missing medication in March 2022 and he notified the Board of Pharmacy. He and someone from the Board of Pharmacy visited the facility and investigated the incident and concluded there was a drug diversion. The LPN had made up false prescription numbers on the master narcotic log. On 07/26/2022 at 2:30 PM, during an interview with the DON, she reported the Attorney General (AG) office came to the facility and investigated the drug diversion. The outcome of their investigation was four (4) medication cards and matching narcotic sheets that had been subtracted from the master narcotic log by LPN #1 were never found. The DON also stated the facility held an Emergency Quality Assurance and Performance Improvement (QAPI) meeting, Hospice was notified, and the resident and responsible party was notified. The incident was also reported to the State Agency (SA). A record review of the investigation of the event Narcotic Diversion from South Hall Narcotic Box dated 03/22/2022 at 5:29 PM, and completed by the DON, revealed a narcotic diversion was reported and investigated. The DON advised that no nursing staff should leave the facility and that all medication carts remain locked until she arrived. Written statements were recorded from each nurse, and all denied knowledge of any aberrant behaviors, knowledge of diversion by any staff member or personal drug abuse or the whereabouts of any missing narcotics. All narcotics were counted for each medication cart and Emergency Kits (E-Kits). It was determined that the narcotic count and card count was accurate for each cart. Facts of investigation revealed the DON identified by review of the South Hall (Master) Narcotic Log in Sheet that two nurses logged in [MEDICATION(S)] for Resident #1 on 03/14/2022. The DON reviewed Resident #1's electronic Medication Administration Record (MAR) to determine if [MEDICATION(S)] had been administered past the receiving date of 03/14/2022. The DON attempted to locate Resident #1's narcotic administration sheet for the [MEDICATION(S)] with an RX of 859. The DON was unable to locate the sheet. The DON reviewed Resident #1's MAR and noted that the last nurse to document removing and administering a [MEDICATION(S)] to Resident #1 was LPN #1 on 03/15/2022 at 7:57 PM. The MAR did not identify the recording of administering 60 doses of [MEDICATION(S)] past the date the medication card was received on 03/14/2022. The DON notified the Regional Nurse Consultant at 6:30 PM on 03/22/2022 of a possible drug diversion. A record review of the facility's Potential Narcotic Diversion investigation dated 03/29/2022 revealed on 03/22/2022, RN #2 reported to the Administrator that Resident #1 did not have a card of [MEDICATION(S)] in the medication cart, and she had just received one last week. The Administrator contacted the DON and instructed all nurses to wait until she arrived. On 03/23/2022, the DON verified with the pharmacy that a card of [MEDICATION(S)] was received for the resident on 03/14/2022 and signed by RN #2 and was logged into the (master) narcotic log. The DON began interviewing nurses to determine if anyone could recall the last time the card was present, and if any doses administered that may not have been documented on the MAR. The DON also searched for the individual narcotic sheet to determine if information was logged incorrectly on the log and the card was removed. 03/24/2022, the DON was unable to locate the individual narcotic sheet for Resident #1 and no one had been able to recall the last time the card was present. The DON began searching for the individual narcotic logs for all the cards that were logged as removed since the [MEDICATION(S)] was delivered. The investigation was primarily focused specifically on South Hall narcotic recordings to compare all RX numbers with each narcotic recorded in and out for the month of March on the cart to determine how the card count would be consistent but still missing a card of 60 [MEDICATION(S)]. The Focus was determined that to make an accurate count, the thought or concern would be that one of the prescriptions that were entered into the South (master) narcotic log after the date of receipt (03/14/2022) would have to be non-existing or altered in number and /or removed without witness. Further findings included that it was noted that LPN #1 was removing and documenting that she was removing depleted cards of narcotics without witness. Past the date of receipt (03/14/2022), it is noted and recorded that four narcotics on the South (master) narcotic log were removed by LPN #1 without being witnessed by another nurse; and none of these four depleted individual narcotic sheets were provided to the DON or medical records department. It is noted and recorded that one of the four that were removed unwitnessed from the south (master) narcotic log was a suspicious prescription number that did not exist, as confirmed by the pharmacy. The DON confirmed through back up pharmacy that no such RX existed as being delivered to the facility. The RX number was written and recorded as removed by LPN #1 on 03/15/2022 the following morning after RN #2 and LPN #4 had logged the medication into the South (master) log. A record review of a Pharmacy Packing Slip, dated 03/14/2022, revealed [MEDICATION(S)]/Apap (Generic medication for [MEDICATION(S)]) 5-325 mg tablet for Resident #1, RX number 859, with a quantity of 60.00, was delivered to the facility and signed by RN #2. A record review of the south master narcotic log revealed an entry recorded on 3-14 (03/14/2022) on 3-11 shift for +1 package with an RX number of 859 for Resident #1/ [MEDICATION(S)]. The Quantity in Package was entered as 60 and was signed by RN #2. An entry is also recorded on 3-15 (03/15/2022) on 3-11 shift for -1 package with an RX number of 232 for [MEDICATION(S)]/(Proper Name of Unsampled Resident). The Quantity in Package was entered as 0 and was signed by LPN #1. A record review of Resident #1's Order Summary Report for active orders as of 03/01/2022 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #1's MAR for March of 2022 revealed [MEDICATION(S)] 5-325 mg was administered on 03/04/2022 at 8:22 AM, 03/06/2022 at 1:47 PM, 03/07/2022 at 11:40 AM, 03/09/2022 at 9:00 AM, 03/09/2022 at 3:47 PM, and 03/15/2022 at 7:57 PM. The last dose administered on 03/15/2022 at 7:57 PM was administered by LPN #1 and was after the new card of 60 tablets was received from the pharmacy on 03/14/2022. The MAR also revealed that Acetaminophen Tablet 325 mg two tablets was also administered on 03/15/2022 at 7:57 PM by LPN #1, which is the exact time and date that [MEDICATION(S)] is also recorded as administered by LPN #1 for Resident #1. A record review of the Admission Record for Resident #1 revealed the facility admitted her on 09/21/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/08/2022 revealed Section C0500 Brief Interview for Mental Status (BIMS) Summary score of 15, which indicated she was cognitively intact. A record review of personnel file for LPN #1 revealed her hire date as 01/05/2022 and her termination date as 03/25/2022. LPN #1 had a criminal background check showing no disqualifying events and confirmed suitability for employment based on the criminal record. Her license was verified with an expiration date of 12/31/2023. LPN #1 completed in-service training for Vulnerable Adults' Prevention, Abuse, Neglect, and Exploitation and Drugs, Narcotics, on 01/05/2022. On 07/26/2022, the State Agency validated through interviews, record review, facility policy review and observations with residents and staff, the facility had begun an immediate investigation when the suspicion of misappropriation of the resident's medications had occurred. The facility held a QAPI meeting on 03/25/2022 with all required disciplines present, gathered interviews and statements, completed a pain assessment on 100% of residents, audited all resident's narcotic medications at 100%, reported the incident to all appropriate authorities, and terminated the nurse involved. The facility also completed in-service trainings regarding having two signatures when logging narcotics into and out of the master narcotic log and the proper procedure when a narcotic card is completed. The SSA validated that the facility had taken all necessary measures to be at past noncompliance by 03/25/2022 with the deficient practice that occurred on 03/22/2022. A record review of sign in sheets for in-service trainings dated 03/25/2022 revealed the titles Narcotic Diversion and Narcotic Control/Recording/Securing revealed . Nursing staff will immediately begin and continue throughout employment safe and required practice at all times with the receiving, recording, administering, wasting, and/securing of narcotics in this facility. 1. Narcotics entered into this facility will be recorded and logged into the medication carts by two nurses. 2. Each narcotic sheet will have two nursing signatures when logging in any and all narcotics. 3. Narcotics that have been depleted by a zero recording will additionally be recorded by two nurses . 4. All narcotic sheets that are zeroed out will be signed out by two nurses and this sheet will be provided in hand to the DON or placed under her door .

Based on observation, interview, record review, and review of the facility policy it was determined that the facility failed to ensure that all parts/entities of the resident call system were functioning properly for 31 of 44 resident call systems observed. The resident call system was not monitored at the nursing station/desk and did not sound with audio signaling at the nursing station panel/board for 31 resident rooms (resident rooms 1-31). There was no facility staff observed at the nursing station/desk from 7:45 A.M. - 11:30 A.M. on 03/18/2021. The facility's failure to provide supervision and to devise appropriate monitoring and surveillance for all residents while the resident call system was malfunctioning was likely to cause serious harm, injury, impairment, or death. The noncompliance with the monitoring and surveillance of the resident call system and the nursing station/desk subsequently constituted the Immediate Jeopardy (IJ). The State Agency (SA) identified an Immediate Jeopardy (IJ) that began on 01/09/2021, which was the original date that the complaint, CI MS # , alleged the Resident Call System(s) were not answered timely. On 03/30/2021 at 9:30 A.M. the (SA) notified the facility Administrator and the Director of Nursing (DON) of the (IJ) and provided the IJ Template to the Administrator. (IJ) existed at: 42 CFR 483.90 (g)(1)(2)-Resident Call System, (F919). The facility submitted an acceptable Removal Plan on 03/31/2021 at 5:00 P.M. in which the facility alleged all corrective actions were completed on 3/31/2021, and the (IJ) removed on 03/31/2021 at 5:00 P.M. The (SA) validated the facility's Removal Plan on 4/2/2021, and determined the IJ was removed on 03/31/2021, prior to exit. Therefore, the scope and severity for 42 CFR(s) 483.90 (g) (1) (g) (2) -Resident Call System, (F919) was lowered from K to a scope and severity of E while the facility develops and implements a plan of correction and monitors the effectiveness of the systematic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Record review of the complaint information for CI MS # revealed the complaint alleged that the call lights were not answered timely when residents rang for assistance and that the nursing station at the facility was not attended by staff. Review of the facility policy titled Call Light Use Of, Current Revision Date: November 15, 2019, read: It is the policy of this facility to have an adequately equipped communication system that allows residents to call for staff. All personnel should be aware of call lights at all times. In the event the primary call light system fails to function properly, the facility will have a backup call system in place. The backup system will be of a manner to include audible and/or visual notification of the need of assistance. Backup systems may include but not be limited to bells, [NAME], and any other device that a resident can use based on their physical capabilities to alert staff. The facility will routinely inspect: The functionality of the call light system to ensure the system is working properly. Record review revealed complaint, CI MS # , for a facility resident that alleged she had called the facility numerous times on 01/09/2021 and could not obtain an answer to the call system and/or the facility nursing station. Interview on 03/19/2021 at 11:00 A.M. with complainant for CI MS # , revealed that Resident #245 had a personal cell phone and that the resident had attempted to call the facility nursing station when her call system was not answered on 01/09/2021. Complainant stated that the facility would not answer the call lights timely and resident laid in a dirty brief for over two (2) hours. Complainant stated that she telephoned the facility over and over and no one would answer the telephone, so she got in her car and drove to the facility to get staff to change the resident. Complainant (CI MS # ) stated that resident was only in the facility for about a week and because of the issues of not answering the call lights and telephones at the nursing station and not changing and assisting resident in a timely matter, they decided to move the resident to another facility. Record review of the discharge Minimum Data Set (MDS) dated [DATE], revealed that Resident # 245(CI MS # ) had an admitted [DATE]. There was no Brief Interview of Mental Status (BIMS) score obtained for this resident (CI MS # ) for the short period of facility stay. All call lights in the building were checked on 03/18/21 between 7:45 A.M.-11:30 A.M., by the SA and found that the resident call system was malfunctioning. The resident call system for 31 resident rooms (rooms #1-#31) did not sound with audio signaling at the nursing station. No one was at the nursing station/desk to answer the telephone and/or to monitor the resident call system. Resident rooms #12, #14, #17, #18 and #22 did not light up above the resident's doors. Resident rooms #5, #7, #9, 15, and #16, call system did not light up at the nursing station. During observtion Registered Nurse (RN #2) was in the area of the nurses station and rooms #12, #14, #17, and #18. Observations revealed 8:58 AM to 11:30 AM that the light for room #14 continued to light up at the nursing station with no one answering for 152 minutes (2.5 hours). Interview and observation on 03/18/2021 at 11: 30 A.M. with RN#2 confirmed that the nursing station had a light signaling for resident room #14 and the light over the door of room #14 was not signaling/working. RN#2 stated that she had been working part time at the facility for three (3) weeks and she had not noticed this issue prior to 03/18/2021. RN#2 went with surveyor to resident room #14 and verified the light above the door was not working. RN#2 confirmed that the audio sound at the nursing station was not signaling for resident room #14. RN#2 confirmed that the resident in room #14 was a [CONDITION(S)] resident. RN#2 stated that the telephones at the nursing station were not available to the nursing staff during the time that they were delivering care and during medication administration. RN#2 stated that the nursing staff could not run back and forth to the nursing station to answer telephones. RN#2 stated that there was no assigned staff for monitoring the nursing station and for answering the telephones and that she had requested a cordless telephone for the medication carts. Interview on 03/18/2021 at 11:30 A.M., with Maintenance Manager (MM) revealed that he had been working at the facility for one and a half years as Maintenance Manager. He verified the call lights were not working properly for room #14. He donned PPE and went in room #14 and repaired the call light. MM stated a wire was loose. MM also confirmed that the call lights for resident rooms #17 and #18 were not working properly. MM stated that the resident call system board/panel at the nursing station was broken between room #17 and room #18. Interview and observation on 03/18/21 at 11:30 A.M., with Resident #92 revealed that he was in his bed and had catheter tubing in bed with him as surveyor entered his room to check his call light operation. Resident #92 stated that he had been waiting for a long time for someone to come and finish helping him with his catheter. Resident #92 stated that last night (03/17/21) he rang his call light for hours (three (3) to five (5) hours) for assistance and never could get any one to come help him. Resident #92 was in room alone with no roommate on 03/18/21. Record review of the Face Sheet revealed that resident #92 had an admitted [DATE] and had admission diagnoses of Type 2 Diabetes Mellitus; Obstructive Sleep Disturbance; Essential (Primary) Hypertension; Weakness; Epilepsy; Metabolic Encephalopathy; Lack of Coordination; Weakness; Chronic Kidney Disease; Long Term (Current) Insulin Use; Chronic Respiratory Failure; and numerous other diagnoses. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 09 which indicated some moderate cognitive deficits. Record review revealed that resident #92 was to be discharged from the facility on 03/19/2021. RN #2 was back and forth making emergency calls from 10:00-10:30 A.M. arranging for admits to the hospital per doctor's orders. The physician was observed in the facility making rounds and issuing orders for resident care. Resident Room #18's call system was observed not to light above the resident's door. Resident room #14 was observed to be signaling visually with a light at the nursing station but was not signaling above the resident's door. There was no auto sound signaling at the nurses station for resident rooms 1-31. Interview on 3/19/21 at 9:50 A.M., with Resident #92 revealed that prior to yesterday it was difficult to get staff assistance when call system was used. Resident stated that he had been here for 10 days and that up until yesterday when he used the call system it would take more than an hour to get assistance. He stated that he slept better last night and was checked on regularly through the night last night, which had not occurred until yesterday when the call system was repaired. EXTENDED SURVEY 03/30/2021-04/02/2021 The State Agency (SA) re-entered the facility for the Extended Survey on 03/30/2021 and relayed to the Director of Nursing (DON) and the facility Administrator (ADM) that an Administrative Review had identified an Immediate Jeopardy (IJ) for the Resident Call System (s) not properly functioning at all entities. The (SA) gave the DON and ADM the IJ Template at 9:15 A.M. on 3/30/21. Observation on 3/30/21 at 9:20 A.M., the SA toured all 44 of the Resident rooms in the facility and engaged all resident bedside call systems. The resident call system/ lights that were not working at all entities on 03/30/21 were resident rooms #2; #8; #9; #22; and #24. Room #2 was not in use for residents. Observations on 03/30/2021 from 9:30 A.M.-10:30 A.M. revealed that there was no alternative resident call systems at the resident bedsides. There were no bells, whistles, [NAME], or call devices observed for any of the 44 resident rooms in the facility. On 3/30/2021, at 9:53 AM, the State Agency (SA) activated the call light for Resident # 4. The light was visible outside the resident's door and the sound was audible at the nursing station. The light for the activated call light did not light up at the nursing station. Interview on 3/30/2021 at 10:30 A.M., with the Maintenance Manager (MM) revealed that resident room #2 was closed off for the past 4-5 days due to the fact that the call light was not operable at any entity. He stated he had to take the call lights apart in room #2 to repair Resident's call light in resident room #4. MM confirmed that the call system in room #2 was not operable. MM stated that he had placed a call in to the Regional Director of Maintenance (RDM) for his assistance with the repairs. MM stated that the Regional Director of Maintenance (RDM) had been contacted and he was suppose to be on his way to the facility to repair the resident call system. MM stated that he had called a local call system repair company to come out on 03/18/2021 to repair the call system. The MM stated that this local company was the company who they always call when call system repairs were needed. The MM confirmed that he was in the process of repairing the call system. MM confirmed that currently the call system was not functioning properly at all entities. MM observed, along with surveyors, and verbally confirmed that resident Rooms #2; #8; #9; #22; and room #24; were not working at all entities on 03/30/2021 at 10:30 A.M. Interview on 03/30/2021 at 10:43 A.M. via telephone with the local call system repair Company's Representative revealed that the Company was called on 03/18/21 to come to the facility to repair the call system due to no audio sound working at the nursing station. Company stated that the (RDM) was also on the scene and that the (RDM) discovered that the wires for the audio/sound at the nursing station panel was not working and the wires had to be replaced in order to make it sound. (RDM) had repaired the sound at the nursing station and told the local Company that there was no other need for repairs at that time. The local Company Representative stated that the system was not complicated and could be repaired by a good maintenance worker and/or a local electrician. Company Representative stated that to his knowledge his Company had not been to the facility to repair the resident call system in over two (2) years. Observation and Interview with Maintenance Manager (MM) on 03/30/2021 at 11:10 A.M., of call system for resident room #8 revealedthe call system would not light at the nursing station on the panel/board. MM confirmed that the bulb on the panel/board at the nursing station had a short in it and would not visually light up. In an interview on 03/30/2021 at 11:45 A.M., with Registered Nurse (RN) #4, she stated that she has not, to date, received any In-service training in reference to the resident call system. RN#4 stated that the alternate call system that they put in place was to make rounds on the residents every two (2) hours. The certified staff make rounds every two (2) hours and the licensed staff make rounds on the residents every two (2) hours. This process would make rounds every hour by either certified staff or licensed staff. RN#4 stated that she had no other knowledge of an alternate resident call system other than making rounds every two (2) hours. Interview on 03/30/2021 at 11:45 A.M., with LPN#2 revealed that she had only been working at the facility for three (3) weeks and she had not attended any In-Services concerning the call system and/or an alternate call system. LPN#2 stated that if the call system was found not to work she would contact Maintenance to report the resident call system. She stated that she had no knowledge concerning an alternate call system to put in place while the resident call system was malfunctioning. LPN#2 stated that to her knowledge there were no bells, whistles, [NAME], and/or devices placed at the residents' bedside when the call system was malfunctioning. Observation and Interview on 03/30/21 at 2:30 P.M., of Resident #12 revealed that he was sitting in the dark in his room with a lunch tray in front of him eating. Resident #12 stated that the staff were slow to answer the call system when he used it. Resident #12 stated that it takes forever to get someone to answer the call lights. Resident #12 stated that he had been a resident at the facility for about a year and the call lights had always been a problem with staff not answering them timely. Record review of the Face Sheet of Resident #12 revealed that he was admitted on [DATE]. Minimum Data Set (MDS) dated [DATE] documented a BIMS Score of 15 for resident #12 indicating intact cognitive skills for daily decision making. Resident #12's Face Sheet revealed had diagnoses of Heart Failure, Unspecified; Dependence on Renal [CONDITION(S)], and Type I Diabetes Mellitus with Foot Ulcer. Interview on 03/30/2021 at 2:50 P.M., with the Administrator (ADM), the Nurse Consultant (RN#6), and the Director of Nursing (DON) confirmed that the facility did not have an alternate call system in place on 03/30/21 at 2:50 P.M. There were no bells, whistles, [NAME] or alternate devices placed within the reach of residents to call for assistance while the call system was being repaired. The ADM stated that they had just instituted 15 minute rounds checks and had devised a rounds report to sign by staff every 15 minutes. The ADM stated that they were currently in-servicing all staff on the resident call system and the alternate resident call system to put in place. The Nurse Consultant (RN#6) stated that she was going to send someone to the store to purchase bells and whistles to put at the resident bedsides as an alternate call system. The Nurse Consultant (RN#6) confirmed that at 2:50 P.M. on 03/30/2021 the facility did not have the alternative devices for the alternate resident call system in place at the facility. Observations on 03/30/2021 at 2:50 P.M. were made of random resident rooms between rooms #1-#31 and of the emergency kit kept in the medication room. No alternate devices were observed to be in the building and/or at resident bedside and/or within resident reach during the malfunctioning of the call system on 03/30/2021. The MM and the RDM along with others were observed to be engaged in the resident call system repair. In an interview on 03/30/2021 at 3:00 P.M., the MM stated that he had never seen any alternate resident call system devices at the facility. MM stated that they were working hard to get the call system repaired. MM confirmed that as of 3:00 P.M. on 03/30/2021 the facility's resident call system was malfunctioning and repairs were in process. Observations on 3/30/2021 at 4:30 P.M. revealed that the call system at the nursing station was being repaired by the facility MM. The facility submitted a Removal Plan on 3/31/2021 for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan: On March 30, 2021 at 9:30 A.M. State Agency (SA) notified facility Administrator of Immediate Jeopardy (IJ). The SA provided the facility Administrator the IJ template. Brief Summary of Events The facility failed to ensure that all components of the Resident Call Light System were properly functioning, and call lights were being answered. There were no staff members monitoring the nurses' station call light system. Failure to ensure a proper call light system could have a serious adverse outcome of serious injury, serious harm, serious impairment or death to all residents, and there was a need for immediate action. The state surveyors identified call light malfunctions for rooms #2, 8, 9, 22 and 24. Malfunction being light malfunctioning above door and/or light alert at nurses' station not working. Corrective Actions: 1. On March 30, 2021 at 9:30 A.M. the Administrator immediately implemented procedures to protect the residents by implementing 15-minute rounding. The facility also assigned (2) Licensed Practical Nurses, (1) Registered Nurse, and (1) Social Services Director to observe mid-way of each unit. 2. On March 30, 2021 Regional Maintenance Director immediately changed bulbs at the nurses' desk on room #2, 8, 9, 22 and 24. On 03/30/21 at 11:55 A.M. Vendor (1) was contacted, and Vendor (1) placed Laurelwood on route to further investigate repairs of system malfunction for clarity and further repairs to room #2 and #24. 3. On March 30, 2021 at 11:30 A.M. a replacement cord was ordered and the wrong part came in, so it was reordered and it is scheduled to arrive to the facility on [DATE] for room #2. 4. On March 30, 2021 an Emergency Quality Assurance Performance Improvement meeting was called for review and discussion of the cited Immediate Jeopardy at 12:10 P.M. The call light policy was discussed and found sufficient; no corrections needed. The back-up/alternate system was discussed, the repairs and malfunction of the call light system was presented by Regional Maintenance Director with the following staff in attendance and the Medical Director via phone, Administrator, MDS Registered Nurse Coordinator, MDS Licensed Practical Nurse Coordinator, Director of Nursing/Infection Preventionist, Maintenance Director, Medical Records Coordinator, Rehabilitation Director. Dietary Manager, Housekeeping Supervisor, Regional Director of Operations, and Regional Nurse Consultant. Recommendations were made on all findings for process of starting a plan of corrective action. 5. On March 30, 2021 at 1:00 P.M. a staff member was assigned to the nurses' station and will be continued until call light system is working properly. 6. On March 30, 2021 at 2:00 P.M. an in-service was conducted by the Regional Nurse consultant for direct (11) and non-direct care staff (11) to include the call light process and back up procedures on March 30, 2021. 7. On March 30, 2021 Vendor one (1) arrived at 3:43 P.M. to further investigate the call light system. 8. On March 30, 2021 at 3:45 P.M. the back-up system was implemented which includes calls bells and whistles for residents to utilize to call for assistance. 9. No staff will be allowed to work until in-serviced on call-light policy and procedures. 10. The facility alleges the Immediate Jeopardy (IJ) was removed on March 31, 2021 at 5:00 P.M. The SA validated on 04/02/2021, that all corrective actions had been taken by the facility to remove the IJ during the extended survey on 03/30/2021-04/02/2021, and the IJ was removed on 03/31/2021 at 5:00 P.M. The State Agency (SA) validated the facility's approved Removal Plan on April 2, 2021 as follows: 1. On March 30, 2021 at 9:30 A.M. the Administrator immediately implemented procedures to protect the residents by implementing 15-minute rounding. The facility also assigned (2) Licensed Practical Nurses, (1) Registered Nurse, and (1) Social Services Director to observe mid-way of each unit. Validations were completed by the SA on 04/02/2021, through interviews, observations, and record reviews, that the facility had assigned specific staff including one (1) Registered Nurse (RN), two (2) Licensed Practical Nurses (LPN's), one (1) Social Worker, one (1) Activity Director, and four (4) Certified Nursing Assistance (CNA's), to complete and document the 15 minute rounds for each of the residents in the facility. 2. On March 30, 2021 Regional Maintenance Director immediately changed bulbs at the nurses' desk on room #2, 8, 9, 22 and 24. On 03/30/21 at 11:55 A.M. Vendor (1) was contacted, and Vendor (1) placed Laurelwood on route to further investigate repairs of system malfunction for clarity and further repairs to room #2 and #24. The SA validated on 04/02/2021, through interview, observation, and record review that the Regional Maintenance Director and the local maintenance Vendor were in the facility making the repairs to the resident call system. 3. On March 30, 2021 at 11:30 A.M. a replacement cord was ordered and the wrong part came in, so it was reordered and it is scheduled to arrive to the facility on [DATE] for room #2. The SA validated on 04/02/2021, through observation, interview, and review of maintenance invoices that repair parts were ordered for the repair and/or replacement of the resident call system in the facility. 4. On March 30, 2021 an Emergency Quality Assurance Performance Improvement meeting was called for review and discussion of the cited Immediate Jeopardy at 12:10 P.M. The call light policy was discussed and found sufficient; no corrections needed. The back-up/alternate system was discussed, the repairs and malfunction of the call light system was presented by Regional Maintenance Director with the following staff in attendance and the Medical Director via phone, Administrator, MDS Registered Nurse Coordinator, MDS Licensed Practical Nurse Coordinator, Director of Nursing/Infection Preventionist, Maintenance Director, Medical Records Coordinator, Rehabilitation Director. Dietary Manager, Housekeeping Supervisor, Regional Director of Operations, and Regional Nurse Consultant. Recommendations were made on all findings for process of starting a plan of corrective action. On April 2, 2021 the SA validated through interviews, and record review of the sign in sheet for the Emergency Quality Assurance Performance Improvement meeting, that the committee had met on 03/30/2021 and all were present at the meeting via validation of signatures and validation through interviews. 5. On March 30, 2021 at 1:00 P.M. a staff member was assigned to the nurses' station and will be continued until call light system is working properly. The SA validated on 04/02/2021 through interview and observation that there was assigned staff at the nursing station. 6. On March 30, 2021 at 2:00 P.M. an in-service was conducted by the Regional Nurse consultant for direct (11) and non-direct care staff (11) to include the call light process and back up procedures on March 30, 2021. The SA validated on April 2, 2021 through interviews, and record review of the documented In-Service and sign in sheets that staff at the facility had been In-Serviced on the resident call system and the process for implementing a back up plan. 7. On March 30, 2021 Vendor one (1) arrived at 3:43 P.M. to further investigate the call light system. The SA validated on 04/02/2021 through interview and observation that the Vendor was present in the facility to assist with the repairs to the resident call system. 8. On March 30, 2021 at 3:45 P.M. the back-up system was implemented which includes calls bells and whistles for residents to utilize to call for assistance. The SA validated through observation, and interview, on 04/02/2021, that each resident bedside had been equipped with a back-up devise of a bell and/or a whistle, for use in case the resident call system filed. 9. No staff will be allowed to work until in-serviced on call-light policy and procedures. The SA validated on 04/02/2021 through interviews and review of the In-Service meeting records and sign in sheets, that no employee would be allowed to work until they were In-serviced on the resident call system and back up plan. 10. The facility alleges the Immediate Jeopardy (IJ) was removed on March 31, 2021 at 5:00 P.M. The SA validated through record reviews, interviews, observations, and through hands on testing of each resident call system that the IJ was removed as per the facility's approved Removal Plan on March 31, 2021 at 5:00 P.M. The SA validated on 04/02/2021, that all corrective actions had been taken by the facility to remove the IJ during the extended survey on 03/30/2021-04/02/2021, and the IJ was removed on 03/31/2021 at 5:00 P.M.

CI MS # Based on record review, staff interview, and facility policy review, the facility failed to develop a Care Plan for Resident #4's fractured right hip, identified by X-ray on 07/19/17, for complaint of right leg pain. Resident #4 continued to use a stand-up lift for transfer, bearing weight on the [MEDICAL CONDITION] until 07/27/17, when a new order was received for no weight bearing to the lower right extremity. This was for one (1) of seven (7) resident care plans reviewed. On 07/19/17, the facility obtained an X-ray on Resident #4's right hip, which revealed a [MEDICAL CONDITION]. The facility failed to develop a care plan for staff to be aware of the [MEDICAL CONDITION], so that treatment/care could be altered. The facility continued to use the standup lift, which required the Resident to bear weight on the [MEDICAL CONDITION], until 07/27/17. The failure to ensure a Care Plan was developed and/or revised after the [MEDICAL CONDITION]'s hip, so the resident's care could be altered related to weight bearing status on a [MEDICAL CONDITION], placed this resident, and other residents at risk, in a situation that was likely to cause serious harm, injury, impairment or death. The situation was determined to be an Immediate Jeopardy (IJ) which began on 07/19/17, when the resident was identified with a [MEDICAL CONDITION]. On 08/11/17 at 2:40 PM, the State Agency (SA) notified the facility's Administrator of the IJ. An acceptable Allegation of Compliance (A(NAME)) was received on 08/15/17, in which the facility alleged removal of the IJ on 08/13/17. The SA determined the IJ was removed on 08/14/17, prior to exit. Therefore, the scope and severity for 42 CFR 483.20 (d) and CFR 483.21 (b)(1) Developing Comprehensive Care Plans (F279) 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 policy titled, Care Plan - Comprehensive, not dated, revealed it is the policy of this facility to develop a comprehensive care for each resident that includes measurable objectives, and timetables to meet the resident's medical, nursing, and psychological needs. The Care Plans are revised as changes in the resident's condition dictates. Review of the facility's policy titled, Care Plan - Interim, not dated, revealed interim Care Plans are revised as needed to address short term or self-limiting conditions. Individual interim Care Plans are incorporated into the resident's total care plan. Review of Resident #4's Care Plan revealed there were no Focus areas, Goals, or Interventions to address Resident #4's fractured right hip, identified on 07/19/17, until 07/28/17. Review of Resident #4's clinical record revealed an X-ray was completed on the resident's right hip for complaint of pain on 07/19/17. The Significant Findings revealed: Impression: Acute mildly displaced fracture of medial wall of acetabulum (right hip). Interview, on 08/09/17 at 11:30 AM, with the Director of Nursing (DON), revealed she realized there was a problem for Resident #4 on 07/24/17, when the X-ray on 07/19/17 revealed a fracture which had not been addressed until an Orthopedic (Bone) Physician gave the facility orders, on 07/27/17, which included no weight bearing to the right leg. The DON stated there had been no incident report or documentation of the fracture in the nurses progress notes. She stated since there had been no communication of the fracture, the Care Plan could not have been updated when the fracture was first diagnosed . An interview, on 08/07/17 at 4:15 PM, revealed Registered Nurse (RN) #3/Minimum Data Set (MDS) Nurse reported Resident #4's fall on 07/02/17, and the X-ray done on 07/19/17, (identifying the right [MEDICAL CONDITION]) was reported during the morning stand-up meeting on 7/27/17. RN #3 stated that the Care Plan could not have been revised because she was unaware of the fall and [MEDICAL CONDITION] until 07/27/17. During an interview, on 08/12/17 at 9:50 AM, Licensed Practice Nurse (LPN) #4 stated the Care Plan for Resident #4's right [MEDICAL CONDITION] was not initiated until 07/28/17, because she had no knowledge of the X-ray done on 07/19/17. LPN #4 stated they were made aware of the fracture on 07/27/17, and entered it on 07/28/17. She stated that the initial fall for Resident #4 was on 07/02/17, and was initialed by the DON on 08/04/17. LPN #4 stated they check the Risk Management Dash Board daily for falls, but Resident #4's fall was not on there and the incident report was locked, on 08/08/17, by the DON. Review of the Admission Record revealed the facility readmitted Resident #4 on 10/08/16, with diagnoses, which included [MEDICAL CONDITION], and End Stage [MEDICAL CONDITION]. Review of the Significant Change MDS, with an Assessment Reference Date (ARD) of 07/24/17, revealed she scored 15 of 15 on the BIMS, which indicated she was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance (A(NAME)) on 08/15/17, for the Immediate Jeopardy (IJ) for Resident #4. Review of the A(NAME) revealed the facility took the following actions to remove the IJ: 1. On 08/10/17 at 2:20 PM, the State Agency (SA) team leader informed the Administrator the facility was in Immediate Jeopardy status concerning Resident #4. On 07/02/17, Resident #4 had a fall in her room, and at that time the Resident had no complaints of pain or injury. 2. On 07/16/17 at 5:30 PM, Resident #4 complained of right hip pain to Registered Nurse (RN)/Charge Nurse #1. RN/Charge Nurse #1 called Physician #1 at 5:37 PM, and obtained an order for [REDACTED]. 3. On 07/19/17 at 4:15 PM, an X-ray to Resident #4's right hip was completed, and the results were faxed to the facility at approximately 6:20 PM. The RN/Charge Nurse #1 received the report which revealed an acute mildly displaced [MEDICAL CONDITION] wall acetabulum. 4. The facility failed to notify Physician #1 on 07/19/17, of the fracture to the acetabulum until 08/01/17 at 10:30 AM. Physician #2 was notified on 07/26/17 at 10:00 AM of the X-ray results which showed a fracture to the right acetabulum. 5. On 08/01/17, written disciplinary action was taken against RN/Charge Nurse #1 related to failure to ensure proper follow- through for X-ray results revealing a fracture for Resident #4. On 08/14/17 at 2:30 PM, RN/Charge Nurse #1 was reported to the Mississippi State Board of Nursing Intake Coordinator #1 by RN Consultant #1. On 08/01/17, written disciplinary action was taken against the Director of Nursing related to failure to ensure proper follow-through for X-ray results revealing a fracture for Resident #4. On 08/14/17 at 2:30 PM, the Director of Nursing was reported to Mississippi State Board of Nursing Intake Coordinator #1 by RN Consultant #1. 6. On 08/01/17, an emergency Quality Assurance Performance Improvement plan (QAPI) was implemented. The QAPI plan was reviewed and accepted by the facility Medical Director, on 08/01/17, with the following staff members present: Director of Nursing, Facility Administrator, RN Charge Nurse #1, Transitional Care Unit (TCU) Manager, Medical Records Coordinator, and the Facility Medical Director (Physician #1). The following procedures were set up, and adopted by the Medical Director and QA team regarding resident RP/family notification with changes of conditions for residents: All changes in condition for residents will be documented at the time of the occurrence. All changes will be reviewed by the clinical start up meeting team in clinical start up meeting attended by Director of Nursing, Medical Records Coordinator, Minimum Data Set Nurse, Facility Administrator, Social Services Coordinator, Dietary Manager, RN Charge Nurses on duty that day, and the Transitional Care Unit Nurse. Any residents with no RP/family notification documentation found during the morning start up meeting by startup clinical team will be notified at that time by the RN Charge Nurse for that day to ensure they are aware. Nursing staff were in-serviced on 08/01/17 on RP/family notification by the Director of Nursing. The following procedures were set up, and adopted by the Medical Director and the QA team regarding ensuring follow up for radiology reports: All radiology ordered/performed will be added to the 24 hour report sheets at the time the appointment is made to ensure all other nursing staff and shifts have knowledge to follow up for results of testing. New 24 hour report sheets were initiated on 08/01/17, by the Director of Nursing, for Charge Nurses for communication to be completed by Charge Nurses. All reports received will have MD notification at the time the report is received. The 24 hour report sheet is being checked for follow-through by the Director of Nursing and/or RN Charge Nurse for that day during morning start up clinical meeting, and is being continued on an on-going basis. Nursing staff were in-serviced, on 08/01/17, on radiology report follow through by the Director of Nursing. Radiology Company contract was reviewed by the facility Administrator, on 08/11/17, with no revisions made. The following procedures were set up, and adopted by the Medical Director and Quality Assurance (QA) team regarding Physician notification of abnormal radiology reports: All radiology reports will be tracked, and the Physician/primary care provider will be notified at the time the facility received them. Physician/Primary care provider notification is being checked during clinical start up meeting by startup clinical team, and any found that are not notified will be notified at that time by RN Charge Nurse for that day. Nursing staff was in-serviced on Physician/primary care provider notification of all radiology reports by Director of Nursing. 100% audit completed, on 08/12/17- 08/13/17, for all new orders received in the past three (3) months for completion and follow-through by the Medical Records Coordinator, Director of Nursing, Minimum Data Set Nurse #1, Transitional Care Unit Nurse, and RN Charge Nurse #1. Any orders found not completed have been corrected by the auditing nurse. The following procedures were set up, and adopted by the Medical Director and QA team regarding completing incident/accident reports in a timely manner: All 24 hour reports are being checked during clinical start up meeting. 7. The following audits were performed: 100% audit of Incident and Accident reports for the last three (3) months have been completed by the Medical Records Coordinator for order completion, and follow-through, beginning 08/09/17, and completed 08/12/17. 100% audit of facility orders written/obtained in the past three (3) months, to include care plans, audited by the Director of Nursing, Minimum Data Set Nurse #1, Transitional Care Unit Nurse, RN Charge Nurse #1, and Medical Records Coordinator, and any found to be incomplete were completed by the auditing nurse, beginning 08/12/17, and completed 08/13/17. 8. Nursing staff were in-serviced on completing incidents/accidents of occurrences, on 08/01/17, by the Director of Nursing. In-servicing for all staff began on 08/01/17, and in-services are on-going. All staff will be in-serviced prior to returning to work. The following is the total of employees that have currently attended in-services: Seven (7) of seven (7) RNs, eight (8) of nine (9) Licensed Practical Nurses, 19 of 19 Certified Nursing Assistants, nine (9) of nine (9) Dietary Staff, one (1) of one (1) Business Office Personnel, one (1) of one (1) Administrator, one (1) of one (1) Life Connections Staff, two (2) of two (2) Maintenance, 24 of 24 Therapists and one (1) of one (1) Director of Nursing. 9. The facility alleges the IJ was removed on 08/13/17. On 08/15/17, the State Survey Agency surveyors validated the facility had implemented the following measure to remove the Immediate Jeopardy: The acceptable Credible Allegation of Compliance was verified by staff interviews and record/document review and review of in-services, on 08/15/17, across all disciplines beginning at 12:57 PM, and ending at 3:52 PM. These interviews included the Director of Physical Therapy, Certified Occupational Therapy Assistant (COTA), COTA - L (Licensed), Occupational Therapist Registered (OT-R), OT-R Licensed, Director of Nursing (DON), Certified Nursing Assistants (CNAs), Registered Nurses (RNs), Medical Records Licensed Practical Nurses (LPNs), Environmental staff, Maintenance staff, Administrator/Marketing Director, Business Office Manager, Transportation, Physical Therapy Assistant (PTA), Occupational Therapist (OT), Physical Therapist (PT), Licensed Physical Therapy Assistant (L-PTA), Dietary Manager, Social Services, Dietary Aide and Activity Director. 1. The SA verified Resident #4's fall on 7/2/17, by document review of the Incident report and interview with the DON and nursing staff. 2. The SA verified through review of progress notes and interview that an order for [REDACTED]. 3. The SA verified through review of X-ray results, dated 7/19/17, that Resident #4 had a [MEDICAL CONDITION]. 4. The SA verified through review of progress notes and interview that Physician #1 was notified, on 08/01/17 at 10:30 AM, and Physician #2 was notified, on 07/26/17 at 10:00 AM, of the fractured right acetabulum of Resident #4. 5. The SA verified through document review and interview that on 08/01/17, written disciplinary action was taken against RN Charge Nurse #1 related to failure to ensure proper follow-through for X-ray results revealing a fracture for Resident #4. On 08/14/17 at 2:30 PM, RN Charge Nurse #1 was reported to the Mississippi State Board of Nursing Intake Coordinator #1 by RN Consultant #1. On 08/01/17, written disciplinary action was taken against the Director of Nursing related to failure to ensure proper follow through for X-ray results revealing a fracture for Resident #4. On 08/14/17 at 2:30 PM, the Director of Nursing was reported to Mississippi State Board of Nursing Intake Coordinator #1 by RN Consultant #1. 6. The SA verified by the sign-in sheet and interviews that on 08/01/17, an emergency Quality Assurance Performance Improvement plan (QAPI) was implemented. The QAPI plan was reviewed, and accepted by the facility Medical Director on 08/01/17, with the following staff members present: the DON, Facility Administrator, RN Charge Nurse #1, Transitional Care Unit (TCU) Manager, Medical Records Coordinator, and the Facility Medical Director/Physician #1. Review of the QA/QAPI meeting, dated 08/01/17, confirmed the meetings consisted of All changes in condition for residents were documented at the time of the occurrence, and reviewed by the nursing staff, RP/family notification were monitored. Any residents with no RP/family notification documentation found during the morning start up meeting by startup clinical team will be notified at that time by the RN Charge Nurse for that day to ensure they are aware. The radiology reports were added to the 24 hour report and initiated and also included Physician notification, and were checked for follow-through. Radiology reports were tracked, and Physician notification of the results were tracked. The Radiology Company contract was reviewed by the facility Administrator on 08/11/17, with no revisions made. Review of sign-in sheets verified Nursing staff were in-serviced on Physician/primary care provider notification of all radiology reports by DON. Review of documentation and interview with staff revealed that a 100% audit was completed on 08/12/17- 08/13/17 for all new orders received in the past three (3) months for completion and follow-through by the Medical Records Coordinator, DON, MDS Nurse #1, Transitional Care Unit Nurse, and RN Charge Nurse #1. 7. The SA verified through review of documentation and interview with staff that the following audits were performed: 100% audit of Incident and Accident reports for the last three (3) months have been completed by the Medical Records Coordinator for order completion and follow through, beginning 08/09/17 and completed 08/12/17. 100% audit of facility orders written/obtained in the past three (3) months to include care plans were audited by DON, MDS Nurse #1, Transitional Care Unit Nurse, RN Charge Nurse #1, and Medical Records Coordinator and any found to be incomplete were completed by the auditing nurses beginning 08/12/17 and completed 08/13/17. 8. The SA validated through in-service documentation sign-in sheets and staff interview that in-services were provided. The following staff were interviewed to confirm they were in-serviced on completing incidents/accidents of occurrences, notification of RP/family, radiology report follow through: One (1) Dietary Aide, COTA, COTA -L, OT-R, OTR-L, DON, LPTA, Activity Director, Social Services Director, Dietary Manager, Environmental staff, Maintenance staff, Admissions/Marketing, Business Office Manager and Dietary staff received in-services. Two (2) DPTs, COTAs and PTs received in-services. Three (3) PTAs and OTs received in-services. Four (4) LPNs received in-services. Six (6) RNs received in-services. 10 CNAs received in-services.

CI MS # Based on record review, staff interview, review of Manufacturer's Guidelines/Instructions for Heated Gel Mitts, and Microwave Oven, and facility policy review, the facility failed to follow Resident #1's Care Plan for Occupational Therapy (OT) Services to provide hot therapy per heated gel mittens (mitts) per the recommendations and guidelines. As a result, Resident #1 sustained second [MEDICAL CONDITION] the right index and middle fingers, which required a new treatment until [MEDICAL CONDITION]. This was for one of seven (1 of 7) resident care plans reviewed. On 07/27/17, a Certified Occupational Therapy Assistant (COTA) provided treatment related to the OT care plan for hot/cold pack treatment for [REDACTED]. The recommendations for heating the gel mitts were for a 800 watt microwave. This resulted in Resident #1 sustaining second [MEDICAL CONDITION] the loss of her fingernails on two (2) fingers on her right hand. The facility's failure to ensure Resident #1 was not injured due to failure to follow manufacturer's guidelines and the OT care plan for heat therapy, put Resident #1 and other residents at risk [MEDICAL CONDITION] a situation that is 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) on 07/27/17, when Resident #1 [MEDICAL CONDITION] the inappropriate use of the gel mittens. The facility Administrator was notified on 08/11/17 at 2:40 PM, of the IJ and SQC. The facility provided an acceptable Allegation of Compliance (A(NAME)) on 08/15/17, which alleged the IJ was removed on 08/13/17. The State Agency validated the A(NAME) and determined the IJ was removed on 08/14/17, prior to exit. The scope and severity for the IJ at 42 CFR 483.21 (b)(3)(ii)-Services by Qualified Persons/Per Care Plan (F282) was lowered to an D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic change. Findings include: Review of the facility's policy titled, Using the Care Plan, undated, revealed: Policy Statement: It is the policy of this facility that the care plan be used in developing the resident's daily care routines. Procedure: 4. Daily care and documentation should be consistent with the resident's care plan. Review of Resident #1's Care Plan revealed a Focus initiated, on 10/20/15, for help needed with ADLs (Activities of Daily Living). The target date was 09/21/17. Interventions included the resident wanted to continue OT/PT (Occupational and Physical Therapy) as ordered. Review of Resident #1's Occupational Therapy Recertification & (and) Updated Plan of treatment for [REDACTED].#1's ability to decrease pain, and use upper extremities (arms and hands) to allow for ADL participation. treatment approaches included: Hot or cold packs therapy. (This would include the need to follow manufacturer's recommendations). Review of the (Name of Heated Gel Mittens) Manufacturer Guidelines/Instructions, (no date), revealed the mittens were microwaveable in order to obtain the desired level of heat. The Directions included: Microwaves are different and heating times may vary. The recommended heating time periods are based on an 800-watt microwave. The Directions also included: Heat with full power for 1 (one) minute 45 seconds. Review of the (Name Brand) Microwave Oven Instructions, pulled from the Internet by therapy staff, revealed the microwave oven operated at 1100 watts. Review of the OT Treatment Encounter Note, dated 7/28/17 at 6:06 PM, and documented by COTA #1, revealed swelling and blisters were noted to the resident's second and third digit on the right hand and she reported to nursing immediately, and discussed with OT supervisor. The heat modalities will be discontinued to the right hand. Further review of the OT Treatment Encounter Notes revealed, on 7/27/17 at 5:37 PM, and signed by COTA #1, documented Resident #1 had received the heated gel mitt treatment to her right hand, and the skin condition before and after the treatment was intact, with no signs and symptoms of redness or problems noted. An interview, on 08/07/17 at 2:30 PM, with COTA #1, revealed she heated the mitt in the microwave for one (1) minute and 45 seconds on 07/27/17, and applied the heated mitt to Resident #1's right hand for 10 to 12 minutes. COTA #1 stated she had not noticed any unusual findings on the resident's hand or fingers when the mitt was removed on 07/27/17. COTA #1 stated, on 07/28/17, when Resident #1 returned to therapy, she noticed Resident #1's fingers looked, swollen, and then discovered the blisters on the index and middle fingers on the resident's right hand. Interview, on 08/07/17 at 3:35 PM, with COTA #1 revealed Resident #1's heated gel mitt therapy care had not been provided correctly (as care planned for the heat therapy) due to the recommended microwave wattage for heating was 800, and not 1100. COTA #1 stated she was not aware of the wattage for the therapy microwave, and how long the mitts should have been warmed since the microwave used was 1100 watts instead of the 800 watts listed in the heated mitt instructions. Interview with COTA #1 on 08/15/17 at 1:18 PM, confirmed she did not follow the OT care plan when she didn't provide therapy appropriately by using the gel mitts that were heated incorrectly, [MEDICAL CONDITION] the resident's fingers. Review of the Admission Record revealed the facility admitted Resident #1, on 12/20/12, with [DIAGNOSES REDACTED]. Review of Resident #1's 30-day Scheduled Assessment Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/09/17, revealed Resident #1 scored 15 of 15 on the Brief Interview for Mental Status (BIMS), which indicated she was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance on 08/15/17, for the Immediate Jeopardy for Resident #1. Review of the facility's A(NAME) revealed the facility took the following actions to remove the IJ: 1. On 08/10/17 at 2:20 PM, the State Agency (SA) Team leader informed the Administrator that the facility was in Immediate Jeopardy status concerning Resident #1. The Immediate Jeopardy status was due to the Certified Occupational Therapist Assistant (COTA) #1 failed to adhere to manufacture guidelines for microwavable heating mitts. 2. Occupational therapy order received and evaluation completed on 06/20/17, which did include the use of hot/cold therapy. On 07/27/17 at 12:55 PM, COTA #1 carried out a treatment session on Resident #1, utilizing a microwavable hot mitt with no signs of skin irritation prior to or after application. Mitt was heated for one (1) minute then taken out and adjusted and placed back in microwave for 45 more seconds. After removing from microwave it was tested by COTA #1 on herself and then applied to Resident #1's right hand for 10 minutes. 3. On 07/28/17 at 12:10 PM, COTA #1 noted prior to treatment session that Resident #1 had visible signs of blistering on the right middle and index fingers, at that time COTA # 1 asked Nurse # 1 to assess Resident # 1's hand for skin blistering on the right middle and index fingers. On 07/28/17 at 12:15 PM, Nurse #1 assessed and notified the Medical Director (MD) and family of Resident #1 of the new blisters on the right middle and index finger. A new order was obtained for (Name Brand Silver [MEDICATION NAME] cream) to blisters on right middle and index finger twice daily (BID) until healed. COTA #1 did not apply any heat modality to Resident #1's right hand on 07/28/17. On 07/28/17 at 4:30 PM, the Director of Nursing (DON) completed a Weekly Wound Record that described the areas to be non- pressure wounds that were facility acquired, and the wounds were described as blisters to the right middle and index fingers. On 07/28/17 at 4:30 PM, the microwavable mitts were discarded by the DON/COTA #1 and the use of microwave for a heat modality purpose was no longer allowed at the therapy department. The DON in-serviced staff on 07/28/17 at 4:45 PM, on Skin Care/Burns, abuse/ neglect and microwave heating modality of mitts to be discontinued: One (1)-Occupational Therapist - Registered (OTR), two (2) Physical Therapy Assistants (PTAs), one (1)-COTA, three (3) Licensed Practical Nurses (LPNs), three (3) Registered Nurses (RNs) and, 12 Certified Nursing Assistants (CNAs). On 07/31/17 at 7:45 AM, the MD did a face to face visit with Resident #1 and made a physician's progress note which revealed: Sick visit- 2nd (second) degree burn R (right) 2nd (second) and 3rd (third) fingertip. Blisters have ruptured. Looks clean. Continue (Name Brand Silver [MEDICATION NAME] cream) topical. Do not use heated gloves on this patient. On 08/10/17 at 8:30 AM, the microwave was removed from the therapy department by the Regional Rehabilitation (Rehab) Director. 4. On 07/31/17, a facility Quality Assurance (QA) meeting was held with the following people in attendance: DON, Administrator, Staff Development Coordinator, Social Services, Medical Record Director and Medical Director. The following items were identified and accepted by the Medical Director and QA team: No microwavable hot packs will be utilized in the building. Discontinued use of all heat modality mitts in the Therapy department as of 7/28/17. Initiated that therapy department will follow manufacturer guidelines for any heat modality. Initiated Pre/post skin checks by therapy staff will be documented in the therapist daily encounter notes. If there are any signs and symptoms of adverse reactions, therapy is to utilize therapy nursing communication form/verbally to notify nursing at the time of incident. Therapy will initiate a plan for following manufacturer guidelines for ensuring proper [MEDICATION NAME] temperature checks as this will be the only heat modality to be used in therapy department going forward. Initiated in-servicing on 07/28/17 with therapy team on use of heat modality. 5. Written disciplinary action has been taken against COTA #1 for not following manufacturer guidelines for ensuring safe use of a heat modality per human resource policy. This was a result of interviews with COTA #1 and Registered Occupational Therapist (OTR) #1, by the Regional Rehab Director, on 07/28/17 at 5:00 PM. Interviews revealed that COTA #1 utilized the microwave mitt as a heat modality and independently did not follow manufacturer guidelines. On 08/02/17 at 12:00 PM, one of one (1/1) residents had microwave heat mitts in the plan of care. On 08/02/17 at 12:00 PM, Resident #1's therapy plan of care was revised to reflect the therapy department no longer uses microwave heat mitts. On 08/14/17 at 2:00 PM, the President of the therapy provider called and spoke with the Governing Body of Occupational Therapists (OTs) in Mississippi to discuss the incident and whether it needed to be reported to the Licensure Board. 6. Facility in-servicing began on 08/10/17, between the hours of 5:00 PM and until 11:30 PM, by the Director of Clinical Services and Regional Rehab Director. Resumed in-services on 08/11/17, by the Director of Clinical Services at 6:30 AM, 8:00 AM and 1:00 PM, as well as conducted phone interviews between the hours of 6:30 AM and 4:00 PM on 08/11/17. The total of 30 therapists included: four (4) Physical Therapists, eight (8) Physical Therapist Assistants, five (5) Occupational Therapists, six (6) Occupational Therapist Assistants, six (6) Speech Therapists, and one (1) Rehab Technician. The in-servicing agendas included the following: No microwavable hot packs will be utilized in building and the microwave has been removed from therapy department. Manufacturer guidelines for any heat modality will be followed by the therapy department. Skin checks will be done before and after use of a heat modality and nursing is to be notified if any signs of skin irritation, redness, blistering and/or rash are present utilizing the therapy nursing communication form and verbal communication and to be documented in their daily treatment encounter note. This includes hot/cold discrimination testing prior to use of any heat modality by evaluating therapist and to be documented on the evaluation. Pre/post skin checks by therapy staff will be documented in the therapist daily encounter notes. If there are any signs and symptoms of adverse reactions therapy is to utilize therapy nursing communication form and verbal communication to notify nursing at the time of the incident. [MEDICATION NAME] temperature is to be checked prior to every resident application. No therapy staff member can perform the use of a heat modality without completing mandatory heat modality in-service. 7. On 07/28/17 at 5:00 PM, the Regional Rehab Director spoke with COTA #1 and there were no other current residents that were receiving a heat modality with the microwavable mitts. An audit was performed by Regional Rehab Director and COTA#1 which revealed that no other residents have received treatment intervention of the microwavable hand mitts from the dates of May 2017 to current. On 08/10/17 at 8:00 AM, an audit tool was established to ensure that therapy department is following the correction items listed below: [MEDICATION NAME] temperature is being checked prior to every resident use. No therapy staff member can utilize a heat modality without completing mandatory heat modality in-service. No microwave heating modality is to be utilized. 8. On 08/11/17, the Facility Therapy provider held a meeting with the President of the facility therapy provider, the Director of Clinical Services, and the Regional Rehab Director with the facility Medical Director (MD), and the Director of Nursing (DON). The Administrator was notified on 08/14/17, of meeting minutes for approval of plan. The following plans from the facility Quality Assurance (QA) meeting held on 07/31/17, have been completed as of 08/11/17 at 5:00 PM. All in-services for the therapy staff have been completed by the Director of Clinical Services and/or Regional Rehabilitation (Rehab) Director for 30/30 staff members by verbal and/or face to face meetings: All microwavable hot packs were discarded on 07/28/17. The microwave was removed from the therapy gym on 08/10/17. All staff have been in-serviced that no microwavable heat modalities will be utilized going forward. 30/30 therapy staff members have been in-serviced that all manufacturer guidelines will be followed for any heat modality. 30/30 therapy staff members have been in-serviced that skin checks are to be done before and after use of heat modalities and documented in daily encounter notes. 30/30 therapy staff members have been in-serviced that the therapy to nursing communication form and verbal communication are to be utilized when any skin related issues occur in the therapy department. 30/30 therapy staff members have been in-serviced on the use of heat modalities and an audit tool has been initiated to ensure all staff going forward will receive the in-service by the Rehab Director, Director of Clinical Services and/or the Regional Rehab Director prior to working at the facility. 9. The facility alleges IJ was removed on 8/14/17. On 8/15/17, the SA validated the facility had implemented the following measures to remove the IJ: 1. The SA validated through record review and staff interview that on 08/10/17 at 2:20 PM, the facility was in Immediate Jeopardy status concerning Resident #1, due to the Certified Occupational Therapist Assistant (COTA) #1 failed to adhere to manufacture guidelines for microwavable heating mitts. 2. The SA validated through record review and staff interview that an Occupational therapy order was received and an evaluation completed on 06/20/17, which did include the use of hot/cold therapy. Interview with COTA #1 confirmed COTA #1 treated Resident #1 on 07/27/17 at 12:55 PM, utilizing a microwavable hot mitt with no signs of skin irritation prior to or after application. Mitt was heated up for one (1) minute then taken out and adjusted and placed back in microwave for 45 more seconds. After removing from microwave it was tested by COTA #1 on herself and then applied to Resident #1's right hand for 10 minutes. 3. The SA validated through record review and staff interview that on 07/28/17 at 12:10 PM, COTA #1 noted prior to treatment session that Resident #1 had visible signs of blistering on right middle and index fingers, and RN #1 assessed the resident with skin blistering on right middle and index fingers, on 07/28/17 at 12:15 PM, with notification to the physician and family. Record review validated that a new order was obtained for (Name Brand Silver [MEDICATION NAME] cream) to blisters on right middle and index finger twice daily (BID) until healed. Interview with COTA #1 confirmed no heat treatment was provided to Resident #1's right hand on 07/28/17. Review of the Wound Record validated that on 07/28/17 at 4:30 PM, the Director of Nursing (DON) completed a Weekly Wound Record that described the areas to be non- pressure wounds that were facility acquired, and the wounds were described as blisters to right middle and index fingers. Interview and observation on 8/15/17, revealed that there was no microwavable mitts in the therapy department and they were discarded by DON/COTA # 1 on 07/28/17 at 4:30 PM. Interview validated that the use of microwave for a heat modality purpose was no longer allowed at the therapy department. Review of in-service sign in sheets and random interviews with staff confirmed that the DON in-serviced on 07/28/17 at 4:45 PM, on Skin Care/Burns, abuse/ neglect and microwave heating modality of mitts to be discontinued: One (1)-Occupational Therapist - Registered (OTR), two (2) Physical Therapy Assistants (PTAs), one (1) COTA, three (3) Licensed Practical Nurses (LPNs), three (3) Registered Nurses (RNs) and, 12 Certified Nursing Assistants (CNAs). Record review validated that on 07/31/17 at 7:45 AM, the MD made a physician's progress note which revealed: Sick visit- 2nd (second) degree burn R (right) 2nd (second) and 3rd (third) fingertip. Blisters have ruptured. Looks clean. Continue (Name Brand Silver [MEDICATION NAME] cream) topical. Do not use heated gloves on this patient. Interview revealed that on 08/10/17, the microwave was removed from the therapy department by Regional Rehabilitation (Rehab) Director. 4. The SA validated through interview and sign-in sheets that on 07/31/17, a facility Quality Assurance (QA) meeting was held with the following people in attendance: DON, Administrator, Staff Development Coordinator, Social Services, Medical Record Director and Medical Director. The following items were identified and accepted by the Medical Director and QA team: No microwavable hot packs will be utilized in building. Discontinued use of all heat modality mitts in the Therapy department as of 7/28/17. Initiated that therapy department will follow manufacturer guidelines for any heat modality. Initiated Pre/post skin checks by therapy staff will be documented in the therapist daily encounter notes. If there are any signs and symptoms of adverse reactions, therapy is to utilize therapy nursing communication form/verbally to notify nursing at the time of incident. Therapy will initiate a plan for following manufacturer guidelines for ensuring proper [MEDICATION NAME] temperature checks as this will be the only heat modality to be used in therapy department going forward. Random interviews revealed in-servicing on 07/28/17, with the therapy team on use of heat modality. 5. The SA validated through document review and staff interview that a written disciplinary action had been taken against COTA #1 for not following manufacturer guidelines for ensuring safe use of a heat modality per human resource policy, due to COTA #1 had utilized the microwave mitt as a heat modality and independently did not follow manufacturer guidelines. Review of Care plans and interviews validated that on 08/02/17 at 12:00 PM, one of one (1/1) residents had microwave heat mitts in the plan of care. On 08/02/17 at 12:00 PM, Resident #1's therapy plan of care was revised to reflect the therapy department no longer uses microwave heat mitts. Interview with staff validated that on 08/14/17 at 2:00 PM, the President of the therapy provider called and spoke with the Governing Body of Occupational Therapists (OTs) in Mississippi to discuss the incident and whether it needed to be reported to the Licensure Board. 6. The SA validated through review of in-service sign-in sheets/content and random interviews, that facility in-servicing began on 08/10/17, between the hours of 5:00 PM and until 11:30 PM, by the Director of Clinical Services and Regional Rehab Director. In-services on 08/11/17, by the Director of Clinical Services at 6:30 AM, 8:00 AM and 1:00 PM, as well as phone interviews between the hours of 6:30 AM and 4:00 PM on 08/11/17. The total of 30 therapists included: four (4) Physical Therapists, eight (8) Physical Therapist Assistants, five (5) Occupational Therapists, six (6) Occupational Therapist Assistants, six (6) Speech Therapists, and one (1) Rehab Technician. The in-servicing agendas included the following: No microwavable hot packs will be utilized in the building and the microwave has been removed from therapy department. Manufacturer guidelines for any heat modality will be followed by the therapy department. Skin checks will be done before and after use of a heat modality and nursing is to be notified if any signs of skin irritation, redness, blistering and/or rash are present utilizing the therapy nursing communication form and verbal communication and to be documented in their daily treatment encounter note. This includes hot/cold discrimination testing prior to use of any heat modality by evaluating therapist and to be documented on the evaluation. Pre/post skin checks by therapy staff will be documented in the therapist daily encounter notes. If there are any signs and symptoms of adverse reactions therapy is to utilize therapy nursing communication form and verbal communication to notify nursing at the time of the incident. [MEDICATION NAME] temperature is to be checked prior to every resident application. Interview and schedule review revealed no other Therapy staff have been hired or at the facility since 8/14/17. 7. The SA validated through record review, documented audit review, and staff interview that on 07/28/17 at 5:00 PM, the Regional Rehab Director spoke with COTA #1 and there were no other current residents that were receiving a heat modality with the microwavable mitts. An audit was performed by Regional Rehab Director and COTA#1 revealed that no other residents have received treatment intervention of the microwavable hand mitts from the dates of May 2017 to current. On 08/10/17 at 8:00 AM, an audit tool was established to ensure that therapy department is following the correction items listed below: [MEDICATION NAME] temperature is being checked prior to every resident use. No therapy staff member can utilize a heat modality without completing mandatory heat modality in-service. No microwave heating modality is to be utilized. 8. The SA validated through observation of the therapy department, staff interview, and document review, that on 8/11/17 the Facility Therapy provider held a meeting with the President of the facility therapy provider, the Director of Clinical Services, and the Regional Rehab Director with the facility Medical Director (MD), and the Director of Nursing (DON), and the Administrator was notified on 08/14/17, of meeting minutes for approval of plan. The following plans from the facility Quality Assurance (QA) meeting held on 07/31/17, have been completed as of 08/11/17 at 5:00 PM. All in-services for the therapy staff have been completed by the Director of Clinical Services and/or Regional Rehabilitation (Rehab) Director for 30/30 staff members by verbal and/or face to face meetings: All microwavable hot packs were discarded on 07/28/17. The microwave was removed from the therapy gym on 08/10/17. All staff have been in-serviced that no microwavable heat modalities will be utilized going forward. 30/30 therapy staff members have been in-serviced that all manufacturer guidelines will be followed for any heat modality. 30/30 therapy staff members have been in-serviced that skin checks are to be done before and after use of heat modalities and documented in daily encounter notes. 30/30 therapy staff members have been in-serviced that the therapy to nursing communication form and verbal communication are to be utilized when any skin related issues occur in the therapy department. 30/30 therapy staff members have been in-serviced on the use of heat modalities and an audit tool has been initiated to ensure all staff going forward will receive the in-service by the Rehab Director, Director of Clinical Services and/or the Regional Rehab Director prior to working at the facility.

CI MS CI MS Based on observation, record review, resident and staff interview, Manufacturer's Recommendation/Instruction review, and facility policy review, the facility failed to ensure residents received necessary care and services for two (2) of seven (7) residents reviewed, Resident #1 and Resident #4. Resident #1: On 07/27/17, the facility failed to ensure Resident #1 was provided the appropriate care and treatment by a therapy staff member, who was untrained, when using a microwave to heat gel mittens for treatment of [REDACTED]. This resulted in Resident #1 sustaining second [MEDICAL CONDITION] the loss of her fingernails on two (2) fingers on her right hand. The facility's failure to ensure Resident #1 was provided care, which included following manufacturer's guidelines when heating gel mittens in an approved wattage microwave, put Resident #1 and other residents at risk, in a situation that is 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) on 07/27/17, when Resident #1 [MEDICAL CONDITION] the inappropriate use of the gel mittens. The facility Administrator was notified on 08/11/17 at 2:40 PM, of the IJ and SQC. The facility submitted an acceptable Allegation of Compliance (A(NAME)) on 08/15/17, in which the facility alleged removal of the Immediate Jeopardy on 08/14/17, for Resident #1. Resident #4: On 07/19/17, the facility obtained an X-ray of Resident #4's right hip, due to the resident's complaint of pain, which revealed a fracture in the acetabulum. The facility failed to notify a physician of the fracture until 07/27/17, when the Resident was evaluated by an Orthopedic surgeon, which delayed treatment for [REDACTED]. The facility continued to use the stand-up lift, which required the resident to bear weight on the [MEDICAL CONDITION], from 07/19/17 until 07/27/17, which caused pain for Resident #4 while bearing weight. The failure to ensure the Resident did not experience pain and discomfort, related to weight bearing status on a [MEDICAL CONDITION], placed this resident and other residents at risk, in a situation that was likely to cause serious harm, injury, impairment or death. This situation was determined to be an IJ and SQC, which began on 07/19/17, when the facility failed to ensure Resident #4 didn't suffer increased pain and discomfort related to a [MEDICAL CONDITION] that was identified on 07/19/17, and physician notification and treatment was not altered until 07/27/17. On 08/11/17 at 2:40 PM, the SA notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Allegation of Compliance (A(NAME)) on 08/15/17, in which the facility alleged removal of the IJ on 08/13/17, for Resident #4. The State Agency (SA) validated the A(NAME) and determined the IJ was removed on 8/14/17, prior to exit. The scope and severity for the IJ at 42 CFR 483.24, 483.25 (k)(l)-Provide Care/Services For Highest Well Being (F309), was lowered to a D while the facility develops and implements the 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 signed statement by the Rehab Director, on facility letterhead, dated 8/9/17, revealed there was no policy/procedure for the (Brand Name) gel mittens, they used the manufacturer's recommendations. Review of the (Name of Heated Gel Mittens) Manufacturer Guidelines/Instructions, (no date), revealed the mittens were microwaveable in order to obtain the desired level of heat. The Directions included: Microwaves are different and heating times may vary. The recommended heating time periods are based on an 800-watt microwave. The Directions also included: Heat with full power for 1 (one) minute 45 seconds. A policy and procedure for pain assessment and management was not provided by the facility. Review of the facility's policy titled, Notification of Changes in a Resident's Condition or Status, undated, revealed: Procedure: 1. Nursing services shall be responsible for notifying the resident's attending physician when: b. There is a significant change in the resident's physical, mental, or psychosocial status, and, d. There is a need to alter the resident's treatment significantly; (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. 4. Notification must be made as soon as practical, but should not exceed 24 hours. Resident #1 Review of the Unusual Incident Report, revealed on 7/28/17 at 2:59 PM, Resident #1 had orders for Occupational Therapy (OT) to apply hot/cold therapy as needed for pain. Resident #1 sustained second [MEDICAL CONDITION] the right middle and index finger tips from the gel mittens that were heated in a microwave and applied to the resident's hands. Review of the facility's Report titled Other, dated 7/28/17 at 2:59 PM, and Revision Date 7/31/17, prepared by Licensed Practical Nurse (LPN) #1, revealed LPN #1 was called to the Therapy Gym by Certified Occupational Therapy Assistant (COTA #1). A large blister, and a raised fingernail was noted on the posterior side of the right middle finger, and a small blister was on the index finger of Resident #1's right hand. The therapist stated she had used warming mitts on that hand yesterday. Resident #1 had not voiced complaints thus far these hours. Physician #1, and the resident's family were notified. Resident stated she does not know how it happened. The injuries were identified [MEDICAL CONDITION] the right fingers. New orders were obtained to apply [MEDICATION NAME] twice a day until healed. Review of the facility's Investigation Summary, not dated, revealed Resident #1 sustained 2nd (second) [MEDICAL CONDITION] the right index and middle fingers from warming mitts that were heated in the microwave, and applied to the resident's hands for 10 minutes by the COTA (#1) in the Therapy Department on 07/27/17. The COTA (#1) stated she did not notice blisters or redness after the treatment was completed on 07/27/17, but noticed the blisters on 07/28/17, prior to initiating the heated gel mitts. The heat therapy was withheld, and the MD was notified, on 07/28/17, with a new order for [MEDICATION NAME] to the blisters/burns to the right index and middle fingers twice a day until healed. The resident was interviewed on 07/28/17, and stated she did not know what happened, or how she obtained the blisters. The resident does have a [DIAGNOSES REDACTED]. The MD visited on 07/31/17, and evaluated the resident's wounds for any further treatment, and/or orders. There were no new wound care orders. On 08/07/17 at 4:50 PM, an observation and interview with Resident #1 and her Responsible Party (RP), revealed the resident stated she hurt her hand in a machine in the laundry. The RP stated Resident #1 had worked in the laundry in the past. Resident #1 had a dressing on her right index finger, and the right middle finger did not have a dressing. The end of the right middle finger had a black discolored area. Observation, on 08/10/17 at 8:50 AM, revealed Registered Nurse (RN) #1 removed the dressings from Resident #1's right middle and index fingers. There were no fingernails on the fingers, and RN #1 stated the fingernails came off a few days after [MEDICAL CONDITION] found. The brown/black area on the middle finger was initially bloody. There was a pinpoint open area on the index finger, and the skin was peeling at the tip of the finger. Review of Resident #1's July 2017, cumulative physician's orders [REDACTED].#1 five (5) x weekly x 15 weeks. Tx to include U/S (ultrasound), therapeutic activities, manual therapy, therex (therapeutic exercises), self-care management training, NMR (neuromuscular reprogramming), WC (wheelchair) management training, E-stim (electronic stimulation), hot/cold therapy prn (as needed). Review of Resident #1's Progress Notes, dated 07/28/17 at 3:15 PM, and signed by LPN #1, revealed she was called to therapy by COTA #1 for Resident #1. Upon inspection, she noted a large blister, raised fingernail posterior on right middle finger and small blister to index finger. The COTA stated Resident #1 wore warming mitts (mitts) on that hand yesterday. Resident #1 has had no voiced complaints thus far these hours and stated her fingers were sore. The note further stated Physician #1 was notified, and treatment orders were received. In an interview, on 08/07/17 at 2:30 PM, COTA #1 revealed she heated the mitten in the microwave for one (1) minute and 45 seconds on 07/27/17, and applied the heated mitten to Resident #1's right hand for 10 to 12 minutes. COTA #1 stated she had not noticed any unusual findings on the resident's hand or fingers when the mitten was removed on 07/27/17. COTA #1 stated, on 07/28/17, when Resident #1 returned to therapy, she noticed Resident #1's fingers looked, swollen, and then discovered the blisters on the index and middle fingers on the resident's right hand. COTA #1 said she immediately notified LPN #1. COTA #1 stated they discontinued using the mitts at that time. COTA #1 reported she had been a COTA for [AGE] years, and had worked at this facility for five (5) and one half (1/2) years, and this was the first time this had ever happened. In an interview, on 08/08/17 at 2:30 PM, Registered Occupational Therapist (OTR) #2, revealed she covered the facility during OTR #1's medical leave. OTR #2 stated she came to the supervisory meeting weekly. OTR #2 reported Resident #1 could stand and walk, but would not be able to do the [MEDICATION NAME] wax treatment to her hand safely, so that is why therapy used the mitt. A review of Resident #1's Weekly Wound Record, dated 07/28/17 at 4:30 PM, revealed the presence of a non-pressure wound, a fluid filled blister to the right middle finger, from the fingernail around to the fingerpad. The record described there was serous exudate present. The second Weekly Wound Record, dated 07/28/17 at 4:53 PM, revealed a non-pressure wound, a fluid filled blister to the right index finger from the fingernail around to the fingerpad. There was serous exudate (clear drainage) present, and peripheral tissue [MEDICAL CONDITION] (finger swelling). Both reports revealed the Physician and Family were notified, and a new treatment for [REDACTED]. The report also stated Resident #1 did not complain of pain. Review of Resident #1's Physician's Progress Notes revealed the following: 07/31/2017 at 7:45 AM, Sick Visit - 2nd [MEDICAL CONDITION] 2nd and third fingertip. Blisters have ruptured. Looks clean. Cont (continue) [MEDICATION NAME] topical. Do not use heated gloves on this patient. An entry 08/11/2017 at 8 AM, noted Wounds examined. Clean. Healing as expected. No drainage. No odor. Cont tx (treatment) plan. Dx (Diagnosis): Thermal Burn. The notes were documented by Physician #2. An observation, on 08/07/17 at 3:35 PM, revealed there was only one (1) microwave in the Therapy Department, (Name Brand) with Model Number JES1139. There was no indication on the microwave of the number of watts the microwave delivered. The Therapy Department staff was unable to locate the Owner's Manual at this time, but was able to print the instruction manual from the Internet. Review of the instructions at this time for the (Name Brand) microwave revealed it was an 1100 watt microwave. An interview, on 08/07/17 at 3:35 PM, with COTA #1 revealed she was unaware of the wattage for the therapy microwave. COTA #1 confirmed she was unsure of how long the mittens should have been warmed since the microwave used was 1100 watts instead of the 800 watts listed in the instructions. COTA #1 stated less time should have been used to warm the mittens for Resident #1 since there was more power in the microwave used. On, 08/07/17 at 5:15 PM, an interview and record review with COTA #1 revealed she had attended an in-service, on 05/23/16, for E-STIM, Ultrasound, and Diatherapy. COTA #1 stated she had not been provided in-services for the heated gel mitts. Review of a typed statement on the facility's letterhead, dated 08/11/17, and signed by the Regional Therapy Director revealed, COTA #1 did not receive any formal training on use of microwavable hot mitts prior to her utilizing these as a treatment intervention. Review of the Admission Record revealed the facility admitted Resident #1 on 12/20/12, with [DIAGNOSES REDACTED]. Review of Resident #1's 30-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/09/17, revealed Resident #1 scored 15 of 15 on the Brief Interview for Mental Status (BIMS), which indicated she was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance on 08/15/17, for the Immediate Jeopardy for Resident #1. Review of the facility's A(NAME) revealed the facility took the following actions to remove the IJ: 1. On 08/10/17 at 2:20 PM, the State Agency (SA) Team leader informed the Administrator that the facility was in Immediate Jeopardy status concerning Resident #1. The Immediate Jeopardy status was due to the Certified Occupational Therapist Assistant (COTA) #1 failed to adhere to manufacture guidelines for microwavable heating mitts. 2. Occupational therapy order received and evaluation completed on 06/20/17, which did include the use of hot/cold therapy. On 07/27/17 at 12:55 PM, COTA #1 carried out a treatment session on Resident #1, utilizing a microwavable hot mitt with no signs of skin irritation prior to or after application. Mitt was heated for one (1) minute then taken out and adjusted and placed back in microwave for 45 more seconds. After removing from microwave it was tested by COTA #1 on herself and then applied to Resident #1's right hand for 10 minutes. 3. On 07/28/17 at 12:10 PM, COTA #1 noted prior to treatment session that Resident #1 had visible signs of blistering on the right middle and index fingers, at that time COTA # 1 asked Nurse # 1 to assess Resident # 1's hand for skin blistering on the right middle and index fingers. On 07/28/17 at 12:15 PM, Nurse #1 assessed and notified the Medical Director (MD) and family of Resident #1 of the new blisters on the right middle and index finger. A new order was obtained for (Name Brand Silver [MEDICATION NAME] cream) to blisters on right middle and index finger twice daily (BID) until healed. COTA #1 did not apply any heat modality to Resident #1's right hand on 07/28/17. On 07/28/17 at 4:30 PM, the Director of Nursing (DON) completed a Weekly Wound Record that described the areas to be non- pressure wounds that were facility acquired, and the wounds were described as blisters to the right middle and index fingers. On 07/28/17 at 4:30 PM, the microwavable mitts were discarded by the DON/COTA #1 and the use of microwave for a heat modality purpose was no longer allowed at the therapy department. The DON in-serviced staff on 07/28/17 at 4:45 PM, on Skin Care/Burns, abuse/ neglect and microwave heating modality of mitts to be discontinued: One (1)-Occupational Therapist - Registered (OTR), two (2) Physical Therapy Assistants (PTAs), one (1)-COTA, three (3) Licensed Practical Nurses (LPNs), three (3) Registered Nurses (RNs) and, 12 Certified Nursing Assistants (CNAs). On 07/31/17 at 7:45 AM, the MD did a face to face visit with Resident #1 and made a physician's progress note which revealed: Sick visit- 2nd (second) degree burn R (right) 2nd (second) and 3rd (third) fingertip. Blisters have ruptured. Looks clean. Continue (Name Brand Silver [MEDICATION NAME] cream) topical. Do not use heated gloves on this patient. On 08/10/17 at 8:30 AM, the microwave was removed from the therapy department by the Regional Rehabilitation (Rehab) Director. 4. On 07/31/17, a facility Quality Assurance (QA) meeting was held with the following people in attendance: DON, Administrator, Staff Development Coordinator, Social Services, Medical Record Director and Medical Director. The following items were identified and accepted by the Medical Director and QA team: No microwavable hot packs will be utilized in the building. Discontinued use of all heat modality mitts in the Therapy department as of 7/28/17. Initiated that therapy department will follow manufacturer guidelines for any heat modality. Initiated Pre/post skin checks by therapy staff will be documented in the therapist daily encounter notes. If there are any signs and symptoms of adverse reactions, therapy is to utilize therapy nursing communication form/verbally to notify nursing at the time of incident. Therapy will initiate a plan for following manufacturer guidelines for ensuring proper [MEDICATION NAME] temperature checks as this will be the only heat modality to be used in therapy department going forward. Initiated in-servicing on 07/28/17 with therapy team on use of heat modality. 5. Written disciplinary action has been taken against COTA #1 for not following manufacturer guidelines for ensuring safe use of a heat modality per human resource policy. This was a result of interviews with COTA #1 and Registered Occupational Therapist (OTR) #1, by the Regional Rehab Director, on 07/28/17 at 5:00 PM. Interviews revealed that COTA #1 utilized the microwave mitt as a heat modality and independently did not follow manufacturer guidelines. On 08/02/17 at 12:00 PM, one of one (1/1) residents had microwave heat mitts in the plan of care. On 08/02/17 at 12:00 PM, Resident #1's therapy plan of care was revised to reflect the therapy department no longer uses microwave heat mitts. On 08/14/17 at 2:00 PM, the President of the therapy provider called and spoke with the Governing Body of Occupational Therapists (OTs) in Mississippi to discuss the incident and whether it needed to be reported to the Licensure Board. 6. Facility in-servicing began on 08/10/17, between the hours of 5:00 PM and until 11:30 PM, by the Director of Clinical Services and Regional Rehab Director. Resumed in-services on 08/11/17, by the Director of Clinical Services at 6:30 AM, 8:00 AM and 1:00 PM, as well as conducted phone interviews between the hours of 6:30 AM and 4:00 PM on 08/11/17. The total of 30 therapists included: four (4) Physical Therapists, eight (8) Physical Therapist Assistants, five (5) Occupational Therapists, six (6) Occupational Therapist Assistants, six (6) Speech Therapists, and one (1) Rehab Technician. The in-servicing agendas included the following: No microwavable hot packs will be utilized in building and the microwave has been removed from therapy department. Manufacturer guidelines for any heat modality will be followed by the therapy department. Skin checks will be done before and after use of a heat modality and nursing is to be notified if any signs of skin irritation, redness, blistering and/or rash are present utilizing the therapy nursing communication form and verbal communication and to be documented in their daily treatment encounter note. This includes hot/cold discrimination testing prior to use of any heat modality by evaluating therapist and to be documented on the evaluation. Pre/post skin checks by therapy staff will be documented in the therapist daily encounter notes. If there are any signs and symptoms of adverse reactions therapy is to utilize therapy nursing communication form and verbal communication to notify nursing at the time of the incident. [MEDICATION NAME] temperature is to be checked prior to every resident application. No therapy staff member can perform the use of a heat modality without completing mandatory heat modality in-service. 7. On 07/28/17 at 5:00 PM, the Regional Rehab Director spoke with COTA #1 and there were no other current residents that were receiving a heat modality with the microwavable mitts. An audit was performed by Regional Rehab Director and COTA#1 which revealed that no other residents have received treatment intervention of the microwavable hand mitts from the dates of May 2017 to current. On 08/10/17 at 8:00 AM, an audit tool was established to ensure that therapy department is following the correction items listed below: [MEDICATION NAME] temperature is being checked prior to every resident use. No therapy staff member can utilize a heat modality without completing mandatory heat modality in-service. No microwave heating modality is to be utilized. 8. On 08/11/17, the Facility Therapy provider held a meeting with the President of the facility therapy provider, the Director of Clinical Services, and the Regional Rehab Director with the facility Medical Director (MD), and the Director of Nursing (DON). The Administrator was notified on 08/14/17, of meeting minutes for approval of plan. The following plans from the facility Quality Assurance (QA) meeting held on 07/31/17, have been completed as of 08/11/17 at 5:00 PM. All in-services for the therapy staff have been completed by the Director of Clinical Services and/or Regional Rehabilitation (Rehab) Director for 30/30 staff members by verbal and/or face to face meetings: All microwavable hot packs were discarded on 07/28/17. The microwave was removed from the therapy gym on 08/10/17. All staff have been in-serviced that no microwavable heat modalities will be utilized going forward. 30/30 therapy staff members have been in-serviced that all manufacturer guidelines will be followed for any heat modality. 30/30 therapy staff members have been in-serviced that skin checks are to be done before and after use of heat modalities and documented in daily encounter notes. 30/30 therapy staff members have been in-serviced that the therapy to nursing communication form and verbal communication are to be utilized when any skin related issues occur in the therapy department. 30/30 therapy staff members have been in-serviced on the use of heat modalities and an audit tool has been initiated to ensure all staff going forward will receive the in-service by the Rehab Director, Director of Clinical Services and/or the Regional Rehab Director prior to working at the facility. 9. The facility alleges IJ was removed on 8/14/17. On 8/15/17, the SA validated the facility had implemented the following measures to remove the IJ: 1. The SA validated through record review and staff interview that on 08/10/17 at 2:20 PM, the facility was in Immediate Jeopardy status concerning Resident #1, due to the Certified Occupational Therapist Assistant (COTA) #1 failed to adhere to manufacture guidelines for microwavable heating mitts. 2. The SA validated through record review and staff interview that an Occupational therapy order was received and an evaluation completed on 06/20/17, which did include the use of hot/cold therapy. Interview with COTA #1 confirmed COTA #1 treated Resident #1 on 07/27/17 at 12:55 PM, utilizing a microwavable hot mitt with no signs of skin irritation prior to or after application. Mitt was heated up for one (1) minute then taken out and adjusted and placed back in microwave for 45 more seconds. After removing from microwave it was tested by COTA #1 on herself and then applied to Resident #1's right hand for 10 minutes. 3. The SA validated through record review and staff interview that on 07/28/17 at 12:10 PM, COTA #1 noted prior to treatment session that Resident #1 had visible signs of blistering on right middle and index fingers, and RN #1 assessed the resident with skin blistering on right middle and index fingers, on 07/28/17 at 12:15 PM, with notification to the physician and family. Record review validated that a new order was obtained for (Name Brand Silver [MEDICATION NAME] cream) to blisters on right middle and index finger twice daily (BID) until healed. Interview with COTA #1 confirmed no heat treatment was provided to Resident #1's right hand on 07/28/17. Review of the Wound Record validated that on 07/28/17 at 4:30 PM, the Director of Nursing (DON) completed a Weekly Wound Record that described the areas to be non- pressure wounds that were facility acquired, and the wounds were described as blisters to right middle and index fingers. Interview and observation on 8/15/17, revealed that there was no microwavable mitts in the therapy department and they were discarded by DON/COTA # 1 on 07/28/17 at 4:30 PM. Interview validated that the use of microwave for a heat modality purpose was no longer allowed at the therapy department. Review of in-service sign in sheets and random interviews with staff confirmed that the DON in-serviced on 07/28/17 at 4:45 PM, on Skin Care/Burns, abuse/ neglect and microwave heating modality of mitts to be discontinued: One (1)-Occupational Therapist - Registered (OTR), two (2) Physical Therapy Assistants (PTAs), one (1) COTA, three (3) Licensed Practical Nurses (LPNs), three (3) Registered Nurses (RNs) and, 12 Certified Nursing Assistants (CNAs). Record review validated that on 07/31/17 at 7:45 AM, the MD made a physician's progress note which revealed: Sick visit- 2nd (second) degree burn R (right) 2nd (second) and 3rd (third) fingertip. Blisters have ruptured. Looks clean. Continue (Name Brand Silver [MEDICATION NAME] cream) topical. Do not use heated gloves on this patient. Interview revealed that on 08/10/17, the microwave was removed from the therapy department by Regional Rehabilitation (Rehab) Director. 4. The SA validated through interview and sign-in sheets that on 07/31/17, a facility Quality Assurance (QA) meeting was held with the following people in attendance: DON, Administrator, Staff Development Coordinator, Social Services, Medical Record Director and Medical Director. The following items were identified and accepted by the Medical Director and QA team: No microwavable hot packs will be utilized in building. Discontinued use of all heat modality mitts in the Therapy department as of 7/28/17. Initiated that therapy department will follow manufacturer guidelines for any heat modality. Initiated Pre/post skin checks by therapy staff will be documented in the therapist daily encounter notes. If there are any signs and symptoms of adverse reactions, therapy is to utilize therapy nursing communication form/verbally to notify nursing at the time of incident. Therapy will initiate a plan for following manufacturer guidelines for ensuring proper [MEDICATION NAME] temperature checks as this will be the only heat modality to be used in therapy department going forward. Random interviews revealed in-servicing on 07/28/17, with the therapy team on use of heat modality. 5. The SA validated through document review and staff interview that a written disciplinary action had been taken against COTA #1 for not following manufacturer guidelines for ensuring safe use of a heat modality per human resource policy, due to COTA #1 had utilized the microwave mitt as a heat modality and independently did not follow manufacturer guidelines. Review of Care plans and interviews validated that on 08/02/17 at 12:00 PM, one of one (1/1) residents had microwave heat mitts in the plan of care. On 08/02/17 at 12:00 PM, Resident #1's therapy plan of care was revised to reflect the therapy department no longer uses microwave heat mitts. Interview with staff validated that on 08/14/17 at 2:00 PM, the President of the therapy provider called and spoke with the Governing Body of Occupational Therapists (OTs) in Mississippi to discuss the incident and whether it needed to be reported to the Licensure Board. 6. The SA validated through review of in-service sign-in sheets/content and random interviews, that facility in-servicing began on 08/10/17, between the hours of 5:00 PM and until 11:30 PM, by the Director of Clinical Services and Regional Rehab Director. In-services on 08/11/17, by the Director of Clinical Services at 6:30 AM, 8:00 AM and 1:00 PM, as well as phone interviews between the hours of 6:30 AM and 4:00 PM on 08/11/17. The total of 30 therapists included: four (4) Physical Therapists, eight (8) Physical Therapist Assistants, five (5) Occupational Therapists, six (6) Occupational Therapist Assistants, six (6) Speech Therapists, and one (1) Rehab Technician. The in-servicing agendas included the following: No microwavable hot packs will be utilized in the building and the microwave has been removed from therapy department. Manufacturer guidelines for any heat modality will be followed by the therapy department. Skin checks will be done before and after use of a heat modality and nursing is to be notified if any signs of skin irritation, redness, blistering and/or rash are present utilizing the therapy nursing communication form and verbal communication and to be documented in their daily treatment encounter note. This includes hot/cold discrimination testing prior to use of any heat modality by evaluating therapist and to be documented on the evaluation. Pre/post skin checks by therapy staff will be documented in the therapist daily encounter notes. If there are any signs and symptoms of adverse reactions therapy is to utilize therapy nursing communication form and verbal communication to notify nursing at the time of the incident. [MEDICATION NAME] temperature is to be checked prior to every resident application. Interview and schedule review revealed no other Therapy staff have been hired or at the facility since 8/14/17. 7. The SA validated through record review, documented audit review, and staff interview that on 07/28/17 at 5:00 PM, the Regional Rehab Director spoke with COTA #1 and there were no other current residents that were receiving a heat modality with the microwavable mitts. An audit was performed by Regional Rehab Director and COTA#1 revealed that no other residents have received treatment intervention of the microwavable hand mitts from the dates of May 2017 to current. On 08/10/17 at 8:00 AM, an audit tool was established to ensure that therapy department is following the correction items listed below: [MEDICATION NAME] temperature is being checked prior to every resident use. No therapy staff member can utilize a heat modality without completing mandatory heat modality in-service. No microwave heating modality is to be utilized. 8. The SA validated through observation of the therapy department, staff interview, and document review, that on 8/11/17 the Facility Therapy provider held a meeting with the President of the facility therapy provider, the Director of Clinical Services, and the Regional Rehab Director with the facility Medical Director (MD), and the Director of Nursing (DON), and the Administrator was notified on 08/14/17, of meeting minutes for approval of plan. The following plans from the facility Quality Assurance (QA) meeting held on 07/31/17, have been completed as of 08/11/17 at 5:00 PM. All in-services for the therapy staff have been completed by the Director of Clinical Services and/or Regional Rehabilitation (Rehab) Director for 30/30 staff members by verbal and/or face to face meetings: All microwavable hot packs were discarded on 07/28/17. The microwave was removed from the therapy gym on 08/10/17. All staff have been in-serviced that no microwavable heat modalities will be utilized going forward. 30/30 therapy staff members have been in-serviced that all manufacturer guidelines will be followed for any heat modality. 30/30 therapy staff members have been in-serviced that skin checks are to be done before and after use of heat modalities and documented in daily encounter notes. 30/30 therapy staff members have been in-serviced that the therapy to nursing communication form and verbal communication are to be utilized when any skin related issues occur in the therapy department. 30/30 therapy staff members have been in-serviced on the use of heat modalities and an audit tool has been initiated to ensure all staff going forward will receive the in-service by the Rehab Director, Director of Clinical Services and/or the Regional Rehab Director prior to working at the facility. Resident #4: Review of the facility's Unusual Incident Report, undated, revealed Resid(TRUNCATED)

CI MS Based on record review, staff interview, and facility policy review, the facility failed to ensure accurate medical record documentation for three (3) of seven (7) residents reviewed as evidenced by, (1) No documentation in the progress notes of Resident #4's fall or follow-up on 07/02/17. No documentation for the fractured right hip or follow-up to the fracture, which was identified by X-ray on 07/19/17. (2) No follow up documentation after Resident #5's fall on 07/08/17, and (3) No documentation regarding Resident #7's new orders for antibiotic therapy and diet change on 06/20/17. On 7/19/17, the facility obtained an X-ray of Resident #4's right hip, which revealed a fracture in the acetabulum, and failed to document an assessment, the X-ray report/results, or notification to the physician of the fracture until 7/27/17. The facility's failure to document the X-ray results, notify to the physician, or document an assessment of Resident #4's [MEDICAL CONDITION] when the fracture was identified, so that treatment could be altered and maintain accurate information to identify a serious injury, placed this 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) that began on 07/19/17. On 8/11/17 at 2:40 PM, the SA notified the facility's Administrator of the IJ. An acceptable Allegation of Compliance was received on 08/15/17, in which the facility alleged removal of the IJ on 08/13/17. The SA determined the IJ was removed on 08/14/17, prior to exit. The scope and severity for 42 CFR 483.70(i)(1)(5)-Resident Record Complete-Administration (F514) was lowered to an E while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic change to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy titled, Charting and Documentation Guidelines, dated 06/20/12, revealed, Standards, 10. Changes in a residents condition or care should be charted for 3 (three) days or until the situation has stabilized or resolved. Procedures 1. Accidents/incidents -Documentation pertaining to accidents or incidents involving residents should include but not limited to: a. Circumstances surrounding the accident or incident; b. Where the accident or incident took place; c. Date and time the accident or incident occurred, d. Name of witnesses and their account of the accident or incident; e. Resident's account of the accident or incident, f. Time the physician was notified as well as the time the physician responded; g.The date and time family was notified and by whom; h. The condition of the resident, to include vital signs (blood pressure, pulse, respirations and temperature); i. Two (2) day follow-up charting every shift if no injury occurred to the resident and a three (3) day follow-up charting if resident was injured in the incident/accident; j. Disposition of the resident (i.e. (such as) transferred to hospital, put to bed, etc.); k. All pertinent observations. Review of the facility's policy titled, Charting, dated 06/01/17, revealed, Policy Statement, It is the policy of this facility that all services provided to the resident or any changes in the resident's condition be recorded in the resident's medical record. Resident #4: Review of the facility's Fall report, with a Revision Date of 07/29/17 at 11:12 AM, revealed on 07/02/17 at 10:11 AM, The Resident slipped out of bed onto floor. There were no injuries noted at that time, the resident denied any pain, and declined to go to the emergency room for evaluation. The resident stated she slid off the bed. The report was completed by Licensed Practical Nurse (LPN) #1. There was no documentation on 07/2/17, of the resident's fall or follow-up to the fall until 07/29/17. An interview with Registered Nurse (RN) #4/Charge Nurse, on 08/09/17 at 11:10 AM, revealed she observed Resident #4 sliding off the bed as she walked into the resident's room on 07/02/17 at approximately 10 :00 AM. RN #4 reported the resident's back was against the bed, and her buttocks were on the floor. RN #4 stated she and other staff got her back in the bed using the draw sheet. RN #4 reported they asked Resident #4 several times if she was hurting, and she denied pain, but failed to document the incident in the nurse's notes. Review of Registered Nurse #4/Charge Nurse's Witness Report of the 7/2/17 fall for Resident #4 was dated 8/2/17. The witness report revealed that she assessed the resident for injury and asked her if she was having any pain, which the resident denied. The report documented that a body audit was performed with no abnormalities noted. The resident had no signs/symptoms of injury such as bruising, redness, or swelling and was able to move all extremities. Neuro check and vital signs were within normal limits. There was no documentation of assessments or follow up of Resident #4's on the day of the fall (7/2/17) in the medical record. During an interview on 8/9/17 at 11:30 AM, the Director of Nursing (DON) stated she realized on 7/28/17, there was no incident report and no nurse's note for Resident #4's fall on 7/2/17, and they did a late entry for the fall. Review of Resident #4's progress notes, dated 07/16/17 at 5:37 PM, revealed an entry by RN #4, which noted: Resident complaining of pain in right hip. New order received for X-ray to right hip to be obtained on 07/18/17. Review of the physician's orders [REDACTED]. Review of the X-ray report for Resident #4's right hip revealed it was completed, on 07/19/17 at 12:39 PM, and reported there was an acute mildly displaced fracture of medial wall of acetabulum (hip). There was no documentation in the medical record of the X-ray results, notification to the physician, or follow-up documentation and assessment of the resident after the fracture was identified until 7/27/17, when Resident #4 went to the Orthopedic physician. There was no documentation of a physical assessment of Resident #4 from 7/19/17-7/27/17. An interview with RN #4/Charge Nurse, on 08/09/17 at 11:10 AM, revealed that on 07/16/17, Resident #4 complained of pain in her right hip, going down her leg. RN #4 notified the Physician on call, and obtained an order for [REDACTED].#4 reported when she returned to work, on 07/19/17, she realized the X-ray had not been done, on 07/18/17. RN #4 stated the X-ray was completed on 07/19/17, and a report was received, and the X-ray report was placed in the communication book for the Physician to review, and placed on the Director's of Nurse's (DON's) desk. RN #4 revealed she had received the abnormal X-ray, which revealed Resident #4's [MEDICAL CONDITION], on 07/19/17, but had failed to notify the resident's Physician of the report or document in the medical record. Review of Resident #4's Physician's Progress Notes, dated 07/26/17, revealed Physician #1 documented, No new problem. Pt. (Patient) stable. (Physician #1 was not aware of the [MEDICAL CONDITION] at that time.) Interview, on 08/09/17 at 11:30 AM, with the DON, confirmed both she and RN #4 had knowledge of Resident #4's [MEDICAL CONDITION] on 07/19/17, but neither made an entry in the clinical record. Review of the medical record revealed no order for Resident #4 to go to an Orthopedic appointment on 7/27/17. On 07/27/17 at 4:41 PM, the Director of Nurses (DON) documented in the Progress Notes, Returned from Ortho consult today with new orders for CT (Computer Topography) Right hip; no weight bearing right lower ext. (extremity/leg). During an interview on 8/9/17 at 11:30 AM, the DON confirmed there was no order for the Orthopedic appointment on 07/27/17, for Resident #4. She stated she made the appointment herself on 07/24/17, when she returned to the facility and realized nothing had been done about the resident's fracture, but failed to obtain a written order for the appointment. Review of the Admission Record revealed the facility readmitted Resident #4, on 10/08/16, with [DIAGNOSES REDACTED]. Review of the Significant Change MDS, with an ARD of 07/24/17, revealed Resident #4 scored 15 of 15 on the BIMS, which indicated she was cognitively intact. Resident #5 Review of the facility's Fall report for Resident #5, dated 07/08/17 at 4:43 PM, revealed a CNA observed Resident #5 attempting to transfer himself to the wheelchair, and when he stood up, he began easing himself to the floor, and onto his knees. No signs of injury was noted. There was no documentation that Physician #2, the resident's attending Physician, was notified of the incident. There was no documented vital signs or follow-up documentation noted for the fall for the required two (2) days following a fall with no injury. Review of the Progress Notes for Resident #5, revealed an entry, dated 07/08/17 at 4:57 PM, Resident attempting to transfer to wheelchair, when he stood up he was noted to be easing to the floor in front of chair onto knees. No noted area upon audit. There were no vital signs or additional Progress Notes related to the fall through 07/11/17. Interview, on 08/09/17 at 3:20 PM, with RN #1, revealed the required documentation was not completed for follow up after Resident #5's falls. Review of the Admission Record revealed the facility admitted Resident #5 on 11/08/12, with [DIAGNOSES REDACTED]. Review of the Annual MDS, with an ARD of 06/09/17, revealed Resident #5 scored 13 of 15 on the BIMS, which indicated he was cognitively intact. Resident #7: Review of the handwritten physician's orders [REDACTED]. Mech soft (No Added Salt Mechanical Soft). The order had been signed by RN #2. Review of the Progress Notes for Resident #7, revealed there had been no entry on 06/20/17, regarding the [MEDICATION NAME] and diet change orders. There were no additional entries which related to the change in medication or diet. There was no documented evidence that the family had been notified of the new orders. Interview, on 08/09/17 at 2:20 PM, with RN #2, revealed she did not recall the 06/20/17 order for Resident #7. She confirmed there was no evidence of documentation for the diet and medication change for Resident #7, and stated she guessed she had forgotten to document. Review of the Admission Record revealed the facility admitted Resident #7 on 01/31/17, with [DIAGNOSES REDACTED]. Review of Resident #7's Quarterly MDS, with an ARD of 07/28/17, revealed she scored 1 of 15 on the BIMS, which indicated severe cognitive impairment. The facility submitted an acceptable credible Allegation of Compliance (A(NAME)) on 08/15/17, for the Immediate Jeopardy (IJ) for Resident #4. Review of the facility's A(NAME) revealed the facility took the following actions to remove the IJ: 1. On 08/10/17 at 2:20 PM, the State Agency (SA) team leader informed the Administrator the facility was in Immediate Jeopardy status concerning Resident #4. On 07/02/17, Resident #4 had a fall in her room, and at that time the Resident had no complaints of pain or injury. 2. On 07/16/17 at 5:30 PM, Resident #4 complained of right hip pain to Registered Nurse (RN)/Charge Nurse #1. RN/Charge Nurse #1 called Physician #1 at 5:37 PM, and obtained an order for [REDACTED]. 3. On 07/19/17 at 4:15 PM, an X-ray to Resident #4's right hip was completed, and the results were faxed to the facility at approximately 6:20 PM. The RN/Charge Nurse #1 received the report which revealed an acute mildly displaced [MEDICAL CONDITION] wall acetabulum. 4. The facility failed to notify Physician #1 on 07/19/17, of the fracture to the acetabulum until 08/01/17 at 10:30 AM. Physician #2 was notified on 07/26/17 at 10:00 AM of the X-ray results which showed a fracture to the right acetabulum. 5. On 08/01/17, written disciplinary action was taken against RN/Charge Nurse #1 related to failure to ensure proper follow- through for X-ray results revealing a fracture for Resident #4. On 08/14/17 at 2:30 PM, RN/Charge Nurse #1 was reported to the Mississippi State Board of Nursing Intake Coordinator #1 by RN Consultant #1. On 08/01/17, written disciplinary action was taken against the Director of Nursing related to failure to ensure proper follow-through for X-ray results revealing a fracture for Resident #4. On 08/14/17 at 2:30 PM, the Director of Nursing was reported to Mississippi State Board of Nursing Intake Coordinator #1 by RN Consultant #1. 6. On 08/01/17, an emergency Quality Assurance Performance Improvement plan (QAPI) was implemented. The QAPI plan was reviewed and accepted by the facility Medical Director, on 08/01/17, with the following staff members present: Director of Nursing, Facility Administrator, RN Charge Nurse #1, Transitional Care Unit (TCU) Manager, Medical Records Coordinator, and the Facility Medical Director (Physician #1). The following procedures were set up, and adopted by the Medical Director and QA team regarding resident RP/family notification with changes of conditions for residents: All changes in condition for residents will be documented at the time of the occurrence. All changes will be reviewed by the clinical start up meeting team in clinical start up meeting attended by Director of Nursing, Medical Records Coordinator, Minimum Data Set Nurse, Facility Administrator, Social Services Coordinator, Dietary Manager, RN Charge Nurses on duty that day, and the Transitional Care Unit Nurse. Any residents with no RP/family notification documentation found during the morning start up meeting by startup clinical team will be notified at that time by the RN Charge Nurse for that day to ensure they are aware. Nursing staff were in-serviced on 08/01/17 on RP/family notification by the Director of Nursing. The following procedures were set up, and adopted by the Medical Director and the QA team regarding ensuring follow up for radiology reports: All radiology ordered/performed will be added to the 24 hour report sheets at the time the appointment is made to ensure all other nursing staff and shifts have knowledge to follow up for results of testing. New 24 hour report sheets were initiated on 08/01/17, by the Director of Nursing, for Charge Nurses for communication to be completed by Charge Nurses. All reports received will have MD notification at the time the report is received. The 24 hour report sheet is being checked for follow-through by the Director of Nursing and/or RN Charge Nurse for that day during morning start up clinical meeting, and is being continued on an on-going basis. Nursing staff were in-serviced, on 08/01/17, on radiology report follow through by the Director of Nursing. Radiology Company contract was reviewed by the facility Administrator, on 08/11/17, with no revisions made. The following procedures were set up, and adopted by the Medical Director and Quality Assurance (QA) team regarding Physician notification of abnormal radiology reports: All radiology reports will be tracked, and the Physician/primary care provider will be notified at the time the facility received them. Physician/Primary care provider notification is being checked during clinical start up meeting by startup clinical team, and any found that are not notified will be notified at that time by RN Charge Nurse for that day. Nursing staff was in-serviced on Physician/primary care provider notification of all radiology reports by Director of Nursing. 100% audit completed, on 08/12/17- 08/13/17, for all new orders received in the past three (3) months for completion and follow-through by the Medical Records Coordinator, Director of Nursing, Minimum Data Set Nurse #1, Transitional Care Unit Nurse, and RN Charge Nurse #1. Any orders found not completed have been corrected by the auditing nurse. The following procedures were set up, and adopted by the Medical Director and QA team regarding completing incident/accident reports in a timely manner: All 24 hour reports are being checked during clinical start up meeting. 7. The following audits were performed: 100% audit of Incident and Accident reports for the last three (3) months have been completed by the Medical Records Coordinator for order completion, and follow-through, beginning 08/09/17, and completed 08/12/17. 100% audit of facility orders written/obtained in the past three (3) months, to include care plans, audited by the Director of Nursing, Minimum Data Set Nurse #1, Transitional Care Unit Nurse, RN Charge Nurse #1, and Medical Records Coordinator, and any found to be incomplete were completed by the auditing nurse, beginning 08/12/17, and completed 08/13/17. 8. Nursing staff were in-serviced on completing incidents/accidents of occurrences, on 08/01/17, by the Director of Nursing. In-servicing for all staff began on 08/01/17, and in-services are on-going. All staff will be in-serviced prior to returning to work. The following is the total of employees that have currently attended in-services: Seven (7) of seven (7) RNs, eight (8) of nine (9) Licensed Practical Nurses, 19 of 19 Certified Nursing Assistants, nine (9) of nine (9) Dietary Staff, one (1) of one (1) Business Office Personnel, one (1) of one (1) Administrator, one (1) of one (1) Life Connections Staff, two (2) of two (2) Maintenance, 24 of 24 Therapists and one (1) of one (1) Director of Nursing. 9. The facility alleges the IJ was removed on 08/13/17. On 08/15/17, the State Survey Agency surveyors validated the facility had implemented the following measure to remove the Immediate Jeopardy: The acceptable Credible Allegation of Compliance was verified by staff interviews and record/document review and review of in-services, on 08/15/17, across all disciplines beginning at 12:57 PM, and ending at 3:52 PM. These interviews included the Director of Physical Therapy, Certified Occupational Therapy Assistant (COTA), COTA - L (Licensed), Occupational Therapist Registered (OT-R), OT-R Licensed, Director of Nursing (DON), Certified Nursing Assistants (CNAs), Registered Nurses (RNs), Medical Records Licensed Practical Nurses (LPNs), Environmental staff, Maintenance staff, Administrator/Marketing Director, Business Office Manager, Transportation, Physical Therapy Assistant (PTA), Occupational Therapist (OT), Physical Therapist (PT), Licensed Physical Therapy Assistant (L-PTA), Dietary Manager, Social Services, Dietary Aide and Activity Director. 1. The SA verified Resident #4's fall on 7/2/17, by document review of the Incident report and interview with the DON and nursing staff. 2. The SA verified through review of progress notes and interview that an order for [REDACTED]. 3. The SA verified through review of X-ray results, dated 7/19/17, that Resident #4 had a [MEDICAL CONDITION]. 4. The SA verified through review of progress notes and interview that Physician #1 was notified, on 08/01/17 at 10:30 AM, and Physician #2 was notified, on 07/26/17 at 10:00 AM, of the fractured right acetabulum of Resident #4. 5. The SA verified through document review and interview that on 08/01/17, written disciplinary action was taken against RN Charge Nurse #1 related to failure to ensure proper follow-through for X-ray results revealing a fracture for Resident #4. On 08/14/17 at 2:30 PM, RN Charge Nurse #1 was reported to the Mississippi State Board of Nursing Intake Coordinator #1 by RN Consultant #1. On 08/01/17, written disciplinary action was taken against the Director of Nursing related to failure to ensure proper follow through for X-ray results revealing a fracture for Resident #4. On 08/14/17 at 2:30 PM, the Director of Nursing was reported to Mississippi State Board of Nursing Intake Coordinator #1 by RN Consultant #1. 6. The SA verified by the sign-in sheet and interviews that on 08/01/17, an emergency Quality Assurance Performance Improvement plan (QAPI) was implemented. The QAPI plan was reviewed, and accepted by the facility Medical Director on 08/01/17, with the following staff members present: the DON, Facility Administrator, RN Charge Nurse #1, Transitional Care Unit (TCU) Manager, Medical Records Coordinator, and the Facility Medical Director/Physician #1. Review of the QA/QAPI meeting, dated 08/01/17, confirmed the meetings consisted of All changes in condition for residents were documented at the time of the occurrence, and reviewed by the nursing staff, RP/family notification were monitored. Any residents with no RP/family notification documentation found during the morning start up meeting by startup clinical team will be notified at that time by the RN Charge Nurse for that day to ensure they are aware. The radiology reports were added to the 24 hour report and initiated and also included Physician notification, and were checked for follow-through. Radiology reports were tracked, and Physician notification of the results were tracked. The Radiology Company contract was reviewed by the facility Administrator on 08/11/17, with no revisions made. Review of sign-in sheets verified Nursing staff were in-serviced on Physician/primary care provider notification of all radiology reports by DON. Review of documentation and interview with staff revealed that a 100% audit was completed on 08/12/17- 08/13/17 for all new orders received in the past three (3) months for completion and follow-through by the Medical Records Coordinator, DON, MDS Nurse #1, Transitional Care Unit Nurse, and RN Charge Nurse #1. 7. The SA verified through review of documentation and interview with staff that the following audits were performed: 100% audit of Incident and Accident reports for the last three (3) months have been completed by the Medical Records Coordinator for order completion and follow through, beginning 08/09/17 and completed 08/12/17. 100% audit of facility orders written/obtained in the past three (3) months to include care plans were audited by DON, MDS Nurse #1, Transitional Care Unit Nurse, RN Charge Nurse #1, and Medical Records Coordinator and any found to be incomplete were completed by the auditing nurses beginning 08/12/17 and completed 08/13/17. 8. The SA validated through in-service documentation sign-in sheets and staff interview that in-services were provided. The following staff were interviewed to confirm they were in-serviced on completing incidents/accidents of occurrences, notification of RP/family, radiology report follow through: One (1) Dietary Aide, COTA, COTA -L, OT-R, OTR-L, DON, LPTA, Activity Director, Social Services Director, Dietary Manager, Environmental staff, Maintenance staff, Admissions/Marketing, Business Office Manager and Dietary staff received in-services. Two (2) DPTs, COTAs and PTs received in-services. Three (3) PTAs and OTs received in-services. Four (4) LPNs received in-services. Six (6) RNs received in-services. 10 CNAs received in-services.

CI MS # Based on record review, staff interview, and facility policy review, the facility failed to notify the Responsible Party (RP), and/or Physician of changes in the resident's condition, or treatments for Residents #4, #5, and #7, for three (3) of seven (7) residents reviewed. On 7/19/17, the facility obtained an X-ray of Resident #4's right hip, which revealed a fracture in the acetabulum, and failed to notify the physician of the fracture until 7/27/17, which caused a delay in treatment. During the time from 7/19/17 through 7/27/17, the facility continued to get Resident #4 up with the stand-up lift, which caused the resident to bear weight on the [MEDICAL CONDITION] causing pain and potential for further injury. The facility's failure to notify the physician of Resident #4's [MEDICAL CONDITION] and continued weight bearing status on a [MEDICAL CONDITION], placed this and other residents in a situation that was likely to cause serious injury, harm, impairment or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 7/19/17. On 8/11/17 at 2:40 PM, the SA notified the facility's Administrator of the IJ. An acceptable Allegation of Compliance was received on 8/15/17, in which the facility alleged removal of the IJ on 8/13/17. The SA determined the IJ was removed on 8/14/17, prior to exit. The scope and severity for 42 CFR 483.10 (g)(14) Notification of Change-Resident Rights (F157) was lowered to an E while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic change to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy titled, Notification of Changes in a Resident's Condition or Status , undated, revealed: Policy Statement: It is the policy of this facility to inform the resident, consult with his or her physician, and notify, consistent with his/her authority, the resident's representative of changes in the resident's condition, and/or status . Procedure: 1. Nursing services shall be responsible for notifying the resident's attending physician when: b. There is a significant change in the resident's physical, mental, or psychosocial status, and, d. There is a need to alter the resident's treatment significantly; (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment), 2. Nursing services shall be responsible for notifying the resident, family, or responsible party when b. There is a significant change in the resident's physical, mental, or emotional status. Resident #4 Review of the facility's fall report for Resident #4, with a revision date of 07/29/17 at 11:12 AM, revealed on 07/02/17 at 10:11 AM, The Resident slipped out of bed onto floor. There were no injuries noted at that time, the resident denied any pain, and declined to go to the emergency room for evaluation. The report's Agencies/Persons Notified indicated Resident #4 was notified, on 07/02/17 at 10:11 AM, of the fall, but there was no documented evidence the Responsible Party (RP) had been notified of the fall. An interview, on 08/08/17 at 12:15 PM, with Resident #4's RP/Niece revealed she came to visit her Aunt. The RP reported her Aunt told her she had an appointment because her hip hurt, and it was about three (3) weeks ago she fell . The RP said her aunt did not know it was a fracture, and she had asked the nurses about it, and they informed her it was a fracture. The RP stated there had been a set of X-rays done at the facility, and the appointment today would be a second set of X-rays. The RP stated the facility did not notify her of the results of the first set of X-rays done in-house. The RP stated that she was not notified of Resident #4's fall, but if the facility had notified her of the the fall, she would told them to take her Aunt to the hospital to be evaluated. Interview with Resident #4 on 8/11/17 at 1:50 PM, revealed that it had made her hip hurt when she stood during transfers with the lift. She stated it really began to hurt about five (5) days after the fall. Review of Resident #4's Progress Notes revealed a late entry (late entry date not identified) for 07/02/17 at 10:13 AM, for the fall documented by Licensed Practical Nurse (LPN) #1. The late entry noted that Registered Nurse (RN) #4/Charge Nurse had witnessed Resident #4 slide off the edge of the bed onto the floor, the bed was in a low position with the wheels locked, and the resident denied pain, and refused to go to the hospital for evaluation. There was no documented evidence that the RP was notified of the fall. Review of the Order Recap Report, for Resident #4, revealed an order, dated 07/16/17 to, Obtain an X-ray of the right hip secondary to hip pain for two (2) days. Review of the X-ray report, dated 7/19/17, revealed an acute mildly displaced [MEDICAL CONDITION] wall of the acetabulum (right hip). Review of Resident #4's Progress Notes revealed there were no entries, on 07/19/17, to indicate the right hip X-ray had been obtained, or the X-ray report, which revealed a fractured right acetabulum (hip), had been received/reviewed. Further review of the Progress Notes revealed there was no notification to the resident's Physician and RP regarding the X-ray report/results. Review of the Physician's Progress Notes, for Resident #4, revealed Physician #1 documented on 07/26/17, No new problems. Further review of the physician progress notes [REDACTED]. An interview with Physician #2, on 08/08/17 at 2:55 PM, revealed he was shown the X-ray result for Resident #4 that had been done the prior week. The Ortho appointment had been made. Physician #2 stated the X-ray was for a right [MEDICAL CONDITION]. Physician #2 stated the result of the X-ray should have been reported before then (so treatment could be initiated). He stated the resident's attending physician was out of town, so he was notified of the results of the X-ray. Interview, on 08/09/17 at 11:10 PM, with Registered Nurse (RN) #4, revealed she worked on 07/2/17, the day Resident #4's fall occurred. RN #4 confirmed she had not notified Resident #4's RP of the fall incident. RN #4 reported she saw the resident sliding down the the side of the bed, and caught her before she hit the floor. She stated she and other staff assisted the resident back onto the bed and asked the resident several times if she was hurt and she denied any pain/discomfort. RN #4 reported Resident #4 later (7/16/17) complained of right hip pain that ran down her leg. RN #4 notified the Physician on call, and a new order for a right hip X-ray was obtained. RN #4 stated when she came back to work on 07/19/17, she realized the X-ray had not been done, and contacted the X-ray staff again. RN #4 reported the X-ray staff dispatched someone to come on 07/19/17. RN #4 stated she had put the results of the X-ray in the Physician's book and did not call the physician. She stated she would normally call the Physician to notify them if a fracture had been identified. Interview, on 08/09/17 at 11:30 AM, with the Director of Nursing (DON), revealed she was aware of Resident #4's X-ray report of the fractured acetabulum, on 07/19/17, but did not notify the Physician, or the RP. The DON stated Resident #4 had complained of pain to RN #4/Charge Nurse on 07/16/17. RN #4 notified the Physician, and had received the order for a right hip X-ray. The DON stated she had spoken with Resident #4's RP, on 07/28/17, after the visit with the Orthopedic Physician, and the RP was upset because she had not been notified of the fall, on 07/02/17, or the fractured acetabulum identified on 07/19/17. During an interview, on 08/11/17 at 1:30 PM, the Orthopedic Physician stated when the resident stood on her right leg for transfer, this would have caused her pain, and he would have ordered non-weight bearing on Resident #4's right leg on the day the X-ray was obtained (07/19/17), which revealed a fractured right hip. His first knowledge of the fracture however, was when he evaluated Resident #4 in his office on 07/27/17 and got X-rays, which again revealed the fracture. Review of the Mechanical Lift Assessment, dated 4/24/17, revealed Resident #4 had partial weight-bearing status and required the stand-up lift with two (2) person assistance. Review of the task history, revealed the CNAs were to transfer Resident #4 with the mechanical stand up lift with two (2) person assistance beginning 5/25/16. On 7/28/17, it was changed to the total body lift with two (2) person assist. On 7/29/17, the CNAs were to use the total body lift with non-weight bearing to the right lower extremity, with two (2) person assist. Review of the Admission Record revealed the facility readmitted Resident #4, on 10/08/16, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/17, revealed Resident #4 scored 15 of 15 on the Brief Interview for Mental Status (BIMS), which indicated she was cognitively intact. Resident #4 required extensive assistance of two (2) persons for transfer. Resident #5 Review of the facility's Fall report for Resident #5, dated 07/08/17 at 4:43 PM, revealed a CNA observed Resident #5 attempting to transfer himself to the wheelchair, and when he stood up, he began easing himself to the floor, and onto his knees. No sign of injury was noted. Further review of the report revealed no documentation that Physician #2, the resident's attending Physician, was notified of the incident. Review of Resident #5's Progress Notes, dated 07/08/17 at 4:57 PM, revealed LPN #1 documented the fall, but there was no notification of the resident's Physician documented. Interview, on 08/09/17 at 3:20 PM, with Registered Nurse (RN) #1, revealed Resident #5's Fall report, on 07/08/17 at 4:57 PM, did not include notification of the resident's Physician. RN #1 stated even if there were no injuries, you would still notify the physician. An interview, on 08/10/17 at 10:20 AM, with LPN #1, revealed she did not recall if the Physician was notified of Resident #5's fall on 07/08/17. LPN #1 stated she would usually notify the Physician in the case of a fall. Review of the facility's Fall report, dated 08/04/17 at 5:46 PM, revealed Resident #5 was trying to pull up his pants, lost his balance, and slid down on to the floor. Nurses were called to the room by another resident, and found Resident #5 lying on the floor. Resident #5 denied any pain/discomfort, and there were no injuries noted. There was no documentation that the resident's physician was notified of the fall. Review of Resident #5's Progress Notes, dated 08/04/17 at 6:00 PM, and 11:00 PM, revealed LPN #2 documented the fall, and neurological checks, but there was no documentation the resident's Physician was notified. An interview, on 08/10/17 at 10:40 AM, with LPN #2, revealed she had completed the Fall report, dated 8/4/17, for Resident #5 because she was assisting another nurse. LPN #2 stated Resident #5 was not assigned to her, and she did not notify the Physician of the fall. LPN #2 revealed she was unsure if the nurse assigned to Resident #5 had notified the Physician of the fall. Review of the Admission Record revealed the facility admitted Resident #5 on 11/08/12, with [DIAGNOSES REDACTED]. Review of the Annual MDS, with an ARD of 06/09/17, revealed Resident #5 scored 13 of 15 on the BIMS, which indicated he was cognitively intact. Resident #7 Review of the handwritten physician's orders [REDACTED].#2. Review of Resident #7's Progress Notes revealed there were no entries on 06/20/17, regarding Family/Resident notification of the antibiotic medication order or diet change for Resident #7. An interview, on 08/09/17 at 2:20 PM, with RN #2 revealed she did not recall the 06/20/17 order for Resident #7. She confirmed there was no documented evidence the resident's RP was notified of the antibiotic and diet change. Review of the Admission Record revealed the facility admitted Resident #7 on 01/31/17, with [DIAGNOSES REDACTED]. Review of Resident #7's Quarterly MDS, with an ARD of 07/28/17, revealed she scored 1 of 15 on the BIMS, which indicated severe cognitive impairment. The facility submitted an acceptable credible Allegation of Compliance (A(NAME)) on 08/15/17, for the Immediate Jeopardy (IJ) for Resident #4. Review of the A(NAME) revealed the facility took the following actions to remove the IJ: 1. On 08/10/17 at 2:20 PM, the State Agency (SA) team leader informed the Administrator the facility was in Immediate Jeopardy status concerning Resident #4. On 07/02/17, Resident #4 had a fall in her room, and at that time the Resident had no complaints of pain or injury. 2. On 07/16/17 at 5:30 PM, Resident #4 complained of right hip pain to Registered Nurse (RN)/Charge Nurse #1. RN/Charge Nurse #1 called Physician #1 at 5:37 PM, and obtained an order for [REDACTED]. 3. On 07/19/17 at 4:15 PM, an X-ray to Resident #4's right hip was completed, and the results were faxed to the facility at approximately 6:20 PM. The RN/Charge Nurse #1 received the report which revealed an acute mildly displaced [MEDICAL CONDITION] wall acetabulum. 4. The facility failed to notify Physician #1 on 07/19/17, of the fracture to the acetabulum until 08/01/17 at 10:30 AM. Physician #2 was notified on 07/26/17 at 10:00 AM of the X-ray results which showed a fracture to the right acetabulum. 5. On 08/01/17, written disciplinary action was taken against RN/Charge Nurse #1 related to failure to ensure proper follow- through for X-ray results revealing a fracture for Resident #4. On 08/14/17 at 2:30 PM, RN/Charge Nurse #1 was reported to the Mississippi State Board of Nursing Intake Coordinator #1 by RN Consultant #1. On 08/01/17, written disciplinary action was taken against the Director of Nursing related to failure to ensure proper follow-through for X-ray results revealing a fracture for Resident #4. On 08/14/17 at 2:30 PM, the Director of Nursing was reported to Mississippi State Board of Nursing Intake Coordinator #1 by RN Consultant #1. 6. On 08/01/17, an emergency Quality Assurance Performance Improvement plan (QAPI) was implemented. The QAPI plan was reviewed and accepted by the facility Medical Director, on 08/01/17, with the following staff members present: Director of Nursing, Facility Administrator, RN Charge Nurse #1, Transitional Care Unit (TCU) Manager, Medical Records Coordinator, and the Facility Medical Director (Physician #1). The following procedures were set up, and adopted by the Medical Director and QA team regarding resident RP/family notification with changes of conditions for residents: All changes in condition for residents will be documented at the time of the occurrence. All changes will be reviewed by the clinical start up meeting team in clinical start up meeting attended by Director of Nursing, Medical Records Coordinator, Minimum Data Set Nurse, Facility Administrator, Social Services Coordinator, Dietary Manager, RN Charge Nurses on duty that day, and the Transitional Care Unit Nurse. Any residents with no RP/family notification documentation found during the morning start up meeting by startup clinical team will be notified at that time by the RN Charge Nurse for that day to ensure they are aware. Nursing staff were in-serviced on 08/01/17 on RP/family notification by the Director of Nursing. The following procedures were set up, and adopted by the Medical Director and the QA team regarding ensuring follow up for radiology reports: All radiology ordered/performed will be added to the 24 hour report sheets at the time the appointment is made to ensure all other nursing staff and shifts have knowledge to follow up for results of testing. New 24 hour report sheets were initiated on 08/01/17, by the Director of Nursing, for Charge Nurses for communication to be completed by Charge Nurses. All reports received will have MD notification at the time the report is received. The 24 hour report sheet is being checked for follow-through by the Director of Nursing and/or RN Charge Nurse for that day during morning start up clinical meeting, and is being continued on an on-going basis. Nursing staff were in-serviced, on 08/01/17, on radiology report follow through by the Director of Nursing. Radiology Company contract was reviewed by the facility Administrator, on 08/11/17, with no revisions made. The following procedures were set up, and adopted by the Medical Director and Quality Assurance (QA) team regarding Physician notification of abnormal radiology reports: All radiology reports will be tracked, and the Physician/primary care provider will be notified at the time the facility received them. Physician/Primary care provider notification is being checked during clinical start up meeting by startup clinical team, and any found that are not notified will be notified at that time by RN Charge Nurse for that day. Nursing staff was in-serviced on Physician/primary care provider notification of all radiology reports by Director of Nursing. 100% audit completed, on 08/12/17- 08/13/17, for all new orders received in the past three (3) months for completion and follow-through by the Medical Records Coordinator, Director of Nursing, Minimum Data Set Nurse #1, Transitional Care Unit Nurse, and RN Charge Nurse #1. Any orders found not completed have been corrected by the auditing nurse. The following procedures were set up, and adopted by the Medical Director and QA team regarding completing incident/accident reports in a timely manner: All 24 hour reports are being checked during clinical start up meeting. 7. The following audits were performed: 100% audit of Incident and Accident reports for the last three (3) months have been completed by the Medical Records Coordinator for order completion, and follow-through, beginning 08/09/17, and completed 08/12/17. 100% audit of facility orders written/obtained in the past three (3) months, to include care plans, audited by the Director of Nursing, Minimum Data Set Nurse #1, Transitional Care Unit Nurse, RN Charge Nurse #1, and Medical Records Coordinator, and any found to be incomplete were completed by the auditing nurse, beginning 08/12/17, and completed 08/13/17. 8. Nursing staff were in-serviced on completing incidents/accidents of occurrences, on 08/01/17, by the Director of Nursing. In-servicing for all staff began on 08/01/17, and in-services are on-going. All staff will be in-serviced prior to returning to work. The following is the total of employees that have currently attended in-services: Seven (7) of seven (7) RNs, eight (8) of nine (9) Licensed Practical Nurses, 19 of 19 Certified Nursing Assistants, nine (9) of nine (9) Dietary Staff, one (1) of one (1) Business Office Personnel, one (1) of one (1) Administrator, one (1) of one (1) Life Connections Staff, two (2) of two (2) Maintenance, 24 of 24 Therapists and one (1) of one (1) Director of Nursing. 9. The facility alleges the IJ was removed on 08/13/17. On 08/15/17, the State Survey Agency surveyors validated the facility had implemented the following measure to remove the Immediate Jeopardy: The acceptable Credible Allegation of Compliance was verified by staff interviews and record/document review and review of in-services, on 08/15/17, across all disciplines beginning at 12:57 PM, and ending at 3:52 PM. These interviews included the Director of Physical Therapy, Certified Occupational Therapy Assistant (COTA), COTA - L (Licensed), Occupational Therapist Registered (OT-R), OT-R Licensed, Director of Nursing (DON), Certified Nursing Assistants (CNAs), Registered Nurses (RNs), Medical Records Licensed Practical Nurses (LPNs), Environmental staff, Maintenance staff, Administrator/Marketing Director, Business Office Manager, Transportation, Physical Therapy Assistant (PTA), Occupational Therapist (OT), Physical Therapist (PT), Licensed Physical Therapy Assistant (L-PTA), Dietary Manager, Social Services, Dietary Aide and Activity Director. 1. The SA verified Resident #4's fall on 7/2/17, by document review of the Incident report and interview with the DON and nursing staff. 2. The SA verified through review of progress notes and interview that an order for [REDACTED]. 3. The SA verified through review of X-ray results, dated 7/19/17, that Resident #4 had a [MEDICAL CONDITION]. 4. The SA verified through review of progress notes and interview that Physician #1 was notified, on 08/01/17 at 10:30 AM, and Physician #2 was notified, on 07/26/17 at 10:00 AM, of the fractured right acetabulum of Resident #4. 5. The SA verified through document review and interview that on 08/01/17, written disciplinary action was taken against RN Charge Nurse #1 related to failure to ensure proper follow-through for X-ray results revealing a fracture for Resident #4. On 08/14/17 at 2:30 PM, RN Charge Nurse #1 was reported to the Mississippi State Board of Nursing Intake Coordinator #1 by RN Consultant #1. On 08/01/17, written disciplinary action was taken against the Director of Nursing related to failure to ensure proper follow through for X-ray results revealing a fracture for Resident #4. On 08/14/17 at 2:30 PM, the Director of Nursing was reported to Mississippi State Board of Nursing Intake Coordinator #1 by RN Consultant #1. 6. The SA verified by the sign-in sheet and interviews that on 08/01/17, an emergency Quality Assurance Performance Improvement plan (QAPI) was implemented. The QAPI plan was reviewed, and accepted by the facility Medical Director on 08/01/17, with the following staff members present: the DON, Facility Administrator, RN Charge Nurse #1, Transitional Care Unit (TCU) Manager, Medical Records Coordinator, and the Facility Medical Director/Physician #1. Review of the QA/QAPI meeting, dated 08/01/17, confirmed the meetings consisted of All changes in condition for residents were documented at the time of the occurrence, and reviewed by the nursing staff, RP/family notification were monitored. Any residents with no RP/family notification documentation found during the morning start up meeting by startup clinical team will be notified at that time by the RN Charge Nurse for that day to ensure they are aware. The radiology reports were added to the 24 hour report and initiated and also included Physician notification, and were checked for follow-through. Radiology reports were tracked, and Physician notification of the results were tracked. The Radiology Company contract was reviewed by the facility Administrator on 08/11/17, with no revisions made. Review of sign-in sheets verified Nursing staff were in-serviced on Physician/primary care provider notification of all radiology reports by DON. Review of documentation and interview with staff revealed that a 100% audit was completed on 08/12/17- 08/13/17 for all new orders received in the past three (3) months for completion and follow-through by the Medical Records Coordinator, DON, MDS Nurse #1, Transitional Care Unit Nurse, and RN Charge Nurse #1. 7. The SA verified through review of documentation and interview with staff that the following audits were performed: 100% audit of Incident and Accident reports for the last three (3) months have been completed by the Medical Records Coordinator for order completion and follow through, beginning 08/09/17 and completed 08/12/17. 100% audit of facility orders written/obtained in the past three (3) months to include care plans were audited by DON, MDS Nurse #1, Transitional Care Unit Nurse, RN Charge Nurse #1, and Medical Records Coordinator and any found to be incomplete were completed by the auditing nurses beginning 08/12/17 and completed 08/13/17. 8. The SA validated through in-service documentation sign-in sheets and staff interview that in-services were provided. The following staff were interviewed to confirm they were in-serviced on completing incidents/accidents of occurrences, notification of RP/family, radiology report follow through: One (1) Dietary Aide, COTA, COTA -L, OT-R, OTR-L, DON, LPTA, Activity Director, Social Services Director, Dietary Manager, Environmental staff, Maintenance staff, Admissions/Marketing, Business Office Manager and Dietary staff received in-services. Two (2) DPTs, COTAs and PTs received in-services. Three (3) PTAs and OTs received in-services. Four (4) LPNs received in-services. Six (6) RNs received in-services. 10 CNAs received in-services.

CI MS # Based on record review, staff interview and pharmacy interview, the facility failed to ensure each resident was free from the potential for misappropriation of controlled medication for 8 (eight) of 9 (nine) residents reviewed. (Resident #1, #2, #3, #4, #5, #6, #7 and #8.) On 5/23/12 at 9:00 a.m. a facility reported complaint investigation was initiated in response to possible misappropriation of controlled medication. The facility had been notified of unusual medication removals from the facility's Pyxis System by a representative of their contracted pharmacy. Registered Nurse (RN) #1 had removed controlled medication ([MEDICATION NAME]) under several different resident profiles and there was no documentation on resident charts that medication was given. When the DON interviewed RN #1, RN #1 stated that "I have a problem, I took it". RN #1 was terminated at that time and escorted from the facility. Findings Include: Interview on 5/23/12 at 9:30 a.m. with the Director of Nursing (DON) revealed the facility had been notified of unusual medication removals from the facility's Pyxis System by a representative of their contracted pharmacy. The report indicated that RN (Registered Nurse) #1 had removed the controlled medication [MEDICATION NAME] in several different strengths. The DON stated RN #1 was not responsible for administering medications unless one of the medication nurses called in (to work). Documentation revealed in almost all instances where RN #1 had removed [MEDICATION NAME] from the Pyxis, that monthly cycle medications were available in the medication carts. The DON stated that medications are not routinely removed from the Pyxis system unless newly ordered medications had not been delivered to the facility. The DON revealed that during her in house investigation, she found that none of the medications which RN #1 had removed from the Pyxis had been documented as given in each resident's record. The DON stated she had immediately called RN #1 to inquire why the medications were removed from the Pyxis System. The DON stated RN #1 had confessed to taking the medications by answering "I have a problem, I took it". The DON stated RN #1 was terminated at that time and escorted out of the facility. Resident #1 A closed record review for Resident #1 revealed the resident was admitted on [DATE] with diagnosis' which included [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] Fibrillation and [MEDICAL CONDITION]. Record review of Resident #1's March and April 2012 Medication Administration Records (MAR) revealed the resident had a current order for [MEDICATION NAME] 50 milligrams (mg) and did not have a current order to receive [MEDICATION NAME] 7.5 mg. Record review of the Pyxis Activity report revealed 20 tablets of [MEDICATION NAME] 7.5.mg were removed from the Pyxis System from 3/15/12 - 4/11/12 under Resident #1's profile by Registered Nurse (RN) #1 . Record review revealed there was no documented evidence that Resident #1 received the [MEDICATION NAME] 7.5 mg that RN #1 removed from the Pyxis System. Interview with the DON, on 5/25/12 at 12:15 p.m., confirmed Resident #1 did not have an order for [REDACTED]. Resident # 2 Record review for Resident #2 revealed the resident was admitted on [DATE] and had diagnosis' of Hypertension, [MEDICAL CONDITIONS], Dementia, [MEDICAL CONDITION] and a [DIAGNOSES REDACTED] to right upper arm. Record review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/24/12 revealed Resident #2 had a Brief Interview for Metal Status (BIMS) of 15, indicating Resident #2 was cognitively intact. Record review of the Pyxis Activity report revealed RN #1 had removed 18 tablets of [MEDICATION NAME] 10 mg from the Pyxis System under Resident #2's profile from 3/16/12 - 4/6/12. Record review revealed there was no documented evidence that Resident #2 received any of the medication which RN #1 removed from the Pyxis System. Interview with the DON, on 5/25/12 at 12:10 p.m., revealed Resident #2 was a long term care resident who rarely complained of pain. The DON confirmed Resident #2's record had no documentation to support he received the pain medication that RN #1 removed from the Pyxis System. The DON stated there was documentation that Resident #2 received pain medication from the medication nurses when he complained of pain. On 5/25/12 at 1:00 p.m. an observation of Resident #2 revealed the resident was up in his wheelchair in the living area. Resident #2 was neat, clean, well groomed and appropriately dressed. Resident # 3 Record review for Resident #3 revealed the resident was admitted on [DATE] with diagnosis' which included [MEDICAL CONDITION], Dysphagia, Alzheimer's and a Delusional Disorder. Record review of Resident #3's MDS with ARD of 2/29/12 revealed Resident #3 had long and short term memory problems. The MDS also revealed that Resident #3 had indicators of possible pain observed daily. Record Review of Resident #3's March and April 2012 MAR indicated [REDACTED]. Record review of the Pyxis Activity report revealed RN #1 removed one [MEDICATION NAME] 10 mg from the Pyxis System on 3/22/12 at 8:54 a.m. (Resident #3 did receive their routine order of [MEDICATION NAME] 10 mg from the medication nurse at 8:00 am.) Record review revealed there was no documented evidence in Resident #3's record of receiving [MEDICATION NAME] 10 mg from RN #1. Interview with the DON, on 5/25/12 at 12:05 p.m., confirmed Resident #3 is on scheduled pain medication twice a day and as needed for break through pain. The DON further confirmed that documentation revealed Resident #3 received all medications ordered and requested from medication cart. Observation of Resident #3, on 5/25/12 at 12:30 p.m., revealed Resident #3 resting in bed. Resident #3 exhibited no signs and symptoms of pain during the observation. Resident # 4 Record review for Resident #4 revealed the resident was admitted on [DATE] with diagnosis' which included Generalized Pain, Shortness of Breath, Diabetes, Hypertension and Muscle Spasms. Record Review of Resident #4's MDS with ARD of 4/18/12 revealed a BIMS score of 15, indicating Resident #4 was cognitively intact. MDS also revealed that Resident #4 indicated severe pain that limited daily activities. Record review of the Pyxis activity report revealed RN #1 removed 15 tablets of [MEDICATION NAME] 7.5 mg from 3/22/12-4/14/12 from Resident #4's profile. Record review revealed there was no documented evidence that Resident #4 received any of the [MEDICATION NAME] 7.5 mg that RN #1 removed from the Pyxis System. Observation of Resident #4, on 5/24/12 at 11:30 p.m., revealed Resident #4 was up in wheelchair, propelling himself without difficulty. Resident #4 was neat, clean, well groomed and appropriately dressed. No sign and symptoms of pain were noted during the observation of Resident #4. Interview with the DON, on 5/25/12 at 11:00 a.m., revealed Resident #4 had been admitted with [MEDICAL CONDITION]. The DON stated Resident #4 does complain of pain and has documentation of the administration of pain medication by the medication nurses. The DON confirmed the record did not contain documentation that Resident #4 received the [MEDICATION NAME] which RN #1 removed from the Pyxis System. Resident # 5 A closed record review for Resident #5 revealed the resident was admitted on [DATE] with Diagnosis' which [MEDICAL CONDITION], Shortness of Breath, [MEDICAL CONDITION] Reflux, Hypertension and [MEDICAL CONDITION] Fibrillation. Record review of the Pyxis Activity report revealed between the dates of 3/17/12 - 4/11/12, RN #1 had removed 11 tablets of [MEDICATION NAME] 7.5 mg under Resident #5's profile. Record review revealed there was no documented evidence that Resident #5 received the [MEDICATION NAME] removed from the Pyxis System by RN #1. Interview with the DON, on 5/25/12 at 12:00 p.m., revealed Resident #5 was in the facility for rehabilitation. The DON stated Resident #5 did not routinely complain of pain. The DON confirmed there was no documentation that Resident #5 complained of pain at the times that RN #1 removed the medication from the Pyxis System. Resident # 6 A closed record review for Resident #6 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the Pyxis Activity Report revealed RN #1 had removed 22 [MEDICATION NAME] 7.5 mg tablets from the Pyxis System under Resident #6's profile. Record review revealed there was no documented evidence that Resident #6 received the medication removed by RN #1. Interview with the DON, on 5/25/12 at 11:50 a.m., revealed Resident #6 had been admitted after suffering a [MEDICAL CONDITION]. The DON stated Resident #6 did not complain of pain often. Resident #6 did well with therapy and was discharged home. The DON further confirmed there was no documentation that Resident #6 received the [MEDICATION NAME] which RN #1 removed from the Pyxis system. Resident # 7 A closed record review for Resident #7 revealed the resident was admitted on [DATE] with diagnosis' which included a Status/Post Left [MEDICAL CONDITION]. Resident #7 was admitted for therapy. Record review of the Pyxis Activity Report revealed RN #1 had removed 14 [MEDICATION NAME] 5 mg from the Pyxis system from 3/24/12 - 4/8/12 from Resident #7's profile. Record review revealed there was no documentation to support that Resident #7 received any of the [MEDICATION NAME] 5 mg which RN #1 removed from the Pyxis System. Interview with the DON, on 5/25/12 at 11:45 a.m., revealed Resident #7 rarely complained of pain. Resident #7 was admitted for rehabilitation following a hip replacement. The DON stated Resident #7 did well with therapy and was discharged home. The DON further confirmed there was no documentation to support Resident #7 had received any of the [MEDICATION NAME] 5 mg that RN #1 had removed from the Pyxis system. Resident #8 A closed record review for Resident #8 revealed the resident was admitted on [DATE] with diagnosis' which included status [REDACTED]. Record review of the Pyxis Activity Report revealed RN #1 had removed 17 [MEDICATION NAME] 10 mg tablets from the Pyxis System from 3/23/12 - 4/7/12 under Resident #8's profile. Record review revealed there was no documented evidence that Resident #8 received any of the [MEDICATION NAME] 10 mg that RN #1 removed from the Pyxis System. Record review of the MARs dated March 2012 and April 2012 revealed Resident #8 had received scheduled pain medication and PRN medication which she received from the medication nurses. Interview with the DON, on 5/25/12 at 12:20 p.m., revealed Resident #8 was admitted following knee replacement surgery. The DON stated Resident #8 was young and was very verbal about pain. The DON revealed Resident #8 was on a routine around the clock pain management program. The DON confirmed there was no documentation to support Resident #8 received the [MEDICATION NAME] 10 mg which RN #1 removed from the Pyxis System. Interview with the Department Head of Production/Pyxis Manager for the contracting pharmacy, on 5/24/12 at 4:10 p.m., revealed they were the Certified Pharmacy Technician (CPT). The CPT stated it was her responsibility to check the Activity Reports each day generated from the Pyxis systems. CPT stated she was the only one to review the daily reports and she only "spot checked" them prior to 4/16/12. The CPT stated the problem with potentially misappropriated controlled medications was identified on 4/13/12 and 4/14/12. Interview with the Registered Pharmacist, on 5/24/12 at 4:30 p.m., revealed he worked for the contracting pharmacy. The Pharmacist stated that he started refilling the pyxis system at the end of April 2012. Prior to that, medications for the pyxis were sent to the facility and the nurses were allowed to refill the pyxis for all medications.

CI MS # Based on record review, staff and pharmacy review, the facility failed to prevent diversion and to define and adequately monitor for problems with the medication delivery system to prevent misappropriation of controlled medications for eight (8) of nine (9) residents reviewed. (Resident #1, #2, #3, #4, #5, #6, #7, and #8) On 5/23/12 at 9:00 a.m. a facility reported complaint investigation was initiated in response to possible misappropriation of controlled medication. The facility had been notified of unusual medication removals from the facility's Pyxis System by a representative of their contracted pharmacy. Registered Nurse (RN) #1 had removed controlled medication (Lortab) under several different resident profiles and there was no documentation on resident charts that medication was given. When the DON interviewed RN #1, RN #1 stated that "I have a problem, I took it". RN #1 was terminated at that time and escorted from the facility. The lack of monitoring and defining problems with a medication delivery system to prevent misappropriation of controlled medications for 8 (eight) of 9 (nine) residents reviewed (Resident #1, #2, #3, #4, #5, #6, #7, and #8) was deemed an Immediate Jeopardy (IJ) that began on 4/17/12. The Administrator, Director of Nursing and the Corporate Nurse Consultant were notified of the IJ on 5/24/12 at 1:00 p.m. The facility provided a credible Allegation of Compliance (AoC) on 5/24/12 at 6:00 p.m. Based on verification of the facility's implementation of corrective actions through observation, staff interviews and various documentation, the Immediate Jeopardy was removed and the scope and severity was lowered on 5/25/12 at 5:00 p.m.. to a "D" level, which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor and evaluate interventions for effectiveness. Findings Include: Cross refer findings to F-224 for the facility's failure to ensure that a process was in place to monitor and define problems with the facility's medication delivery system in order to prevent misappropriation of controlled medications for 8 (eight) of 9 (nine) residents reviewed. (Resident #1, #2, #3, #4, #5, #6, #7, and #8) On 5/24/12 at 6:00 p.m. the facility offered an Allegation of Compliance as follows: " 5/24/12 at 1:00PM, the facility was notified by state surveyor that a jeopardy tag was being issued in regards to misappropriation of medications. The facility had identified this possible misappropriation of medications on 4/17/12 and filled a written self report to the Ms State Department of Health, Licensure and Certification, Ms State AG Office, MS Board of Nursing on 4/23/12.The pharmacist in charge of the pyxis reported the same to the MS State Department of Pharmacy on 4/20/12 and a DEA (Drug Enforcement Agency) form 106 was completed. A full investigation was begun by the DON (Director of Nursing) and contracting pharmacy on 4/17/12 at approximately 11am. On 4/17/12 at approximately 11:00am the DON was notified by the VP (Vice President) of clinical services of possible overuse of Lortab from the pyxis station by the VP of Clinical Services at approximately 11:00 am. 4/17/12 at 11:05 am, the DON reported the possible misappropriation of Lortab from the pyxis by RN (Registered Nurse) #1 to the nursing home administrator. At 11:15 am on 4/17/12 the DON printed a copy of the Lortab signed out on pyxis by RN # 1 for the date of 4/17/12. The DON audited the medication records for the residents who had Lortab signed out under their names by RN #1 on 4/17/12. These were residents # 1,4,5,6 and sampled residents H, I, J. The medications were not charted as being given to seven of the seven residents Lortab was signed out for. 4/17/12 at approximately 1:30 the DON notified the nursing home administrator of the results of this audit. 4/17/12 at 2pm, the DON interviewed RN #1 regarding overuse of Lortab from the pyxis station. RN # 1 was terminated at this time due to admitting during the interview that she signed out Lortab for residents throughout the 7-3 shift on 4/17/12 and did not administer it to the residents. On 5/1/12 at 7:38am, the DON notified the contracting pharmacy not to charge residents #1, #4, #5, #6 and sampled residents H, I, J for Lortabs that were signed out of the pyxis on 4/17/12 by RN #1. DEA form 106 was completed by the pharmacist in charge of the pyxis Station (PIC) and submitted to the MS State Board of Pharmacy at 18:44 on 4/20/12. 4/26/12 at 12:33 pm the PIC inspected the pyxis station. May 6, 2012 at 12:33 pm the PIC also did a controlled substance inventory for the Pyxis station and no discrepancies were identified. 4/23/12 at approximately 3:00 pm, the DON reported the possible misappropriation of medications by RN # 1 to the MS State Department of Health Licensure and Certification via written report. 4/23/12 at 3:30 approximately, DON reported the actions of RN # 1 to the MS State Board of Nursing via telephone. At approximately 4pm on 4/23/12, DON reported the actions of RN #1 to the state attorney general's office via electronic submission. 4/27/12 at 11:43 am current users (all staff RNs and LPNs) to the pyxis station were disabled by the contracting pharmacy. 4/27/12 at 11:43 am,the superusers (supervisors) (DON and the RN Unit Manager) were denied access to add or delete users to the pyxis station by the contracting pharmacy. 4/27/12 throughout each shift the DON trained nurses on use of the pyxis and confidentiality of passwords. A confidentiality agreement was signed by each nurse acknowledging this training. These agreements were sent to the contracting pharmacy and the pharmacy then issued access to the pyxis station for each nurse. 5/6/12 at 12:33 pm, the pharmacist in charge of the pyxis station conducted an audit of the station with the DON and no discrepancies were identified. 5/7/12 the contracting pharmacy initiated a new policy to send a daily narcotic activity report to the facility administrator, DON and the pharmacist in charge of the pyxis station to identify overusage or diversion (no MD order, wrong strength, wrong drug) activities. This report is reviewed by the DON, nursing home administrator and pharmacist in charge of the pyxis daily and any unusual activity is investigated by the same. 5/7/12-5/24/12 there has been no identified overusage or diversion activities. 5/15/12 at 1:30 pm the medical director and the QI (Quality Improvement) committee were notified of the possible overusage of narcotics from the pyxis station by the director of nursing during the QI committee meeting. 5/23/12 at 7 pm the DON and a witness (staf RN # 3) reconciled the narcotic inventory in the pyxis station. No discrepancies were identified. 5/24/12 at 10:42 am a report of all drugs that were removed from the pyxis station by RN #1 was received from the contracting pharmacy. 18 residents were on the report as having narcotics signed out for them by staff RN # 1 from the time she had access to the pyxis (2/23/12) until her termination on 4/17/12. Staff RN #2 audited the medication administration records of the 19 residents who had a potential to be affected at 4pm on 4/24/12. The results of the investigation are 19 residents did not receive the narcotics signed out from the pyxis by RN # 1 from 2/23/12 - 4/17/12. 5/25/12 at 10:00 am, RN # 2 began an audit of the same 19 residents pain scales that were documented on the medication administration records on the day(s) narcotics were signed out to them by RN #1. The results of this audit are that 3 of the 19 had no complaints of pain. 16 were treated for [REDACTED]. 4/25/12 at 10:55 am, the DON notified the responsible party for the same 18 residents of the narcotic being signed out under the resident's name and not administered and no charge will be incurred for this medication. A total of 185 Lortab tablets were signed out of the pyxis by RN # 1 from 2/23/12 - 4/17/12 that are unaccounted for. 4/25/12 at 11:11 am, the pyxis station was changed to " witness required to remove " for all narcotic removals by the contracting pharmacy. All LPN and RN users were reset to be required to log in via Biold (bold) instead of a password at approximately 11:15 am by the consulting pharmacy. The DON and RN Unit Manager were designated as the only superusers (supervisors) on 4/25/12 at approximately 11:15 am. No new nurses will be added to the pyxis as a user until the contracting pharmacy has received written proof of training and a confidentiality agreement. Due to the policy changes implemented on May 7, 2012 at 1:06 pm, daily reports of narcotic usage from the pyxis station generated by the contracting pharmacy will be reviewed by the nursing home administrator and director of nursing daily. Any potential discrepancies will be investigated at the time of discovery and the contracting pharmacy and pharmacist in charge of the pyxis station and the medical director will be alerted. In addition, the director of nursing and a witness will reconcile the narcotics in the pyxis weekly and send a written report to the contracting pharmacy. The contracting pharmacy and the pharmacist in charge and the nursing home administrator will be alerted immediately of any discrepancies. The Director of Nursing will report the results of the daily narcotic usage reports and the weekly pyxis narcotic reconciliation report to the QI committee monthly x 3 months. The QI committee consists of the Nursing Home Administrator, Director of Nursing, Social Service Director, Activity Director, Dietary Manager and the Maintenance Director. " Verification of AoC Observation of RN #3, on 5/25/12 at 3:05 p.m., revealed RN #3 accessed the pyxis station. The observation confirmed it now requires a witness to sign out controlled medications. RN #3 signed into the pyxis station protecting her password from observers. RN #3 proceeded to remove a Lortab 10 mg. The drawer would not open until the DON witnessed the removal. Interview with LPN #1, on 5/25/12 at 3:22 p.m., confirmed LPN #1 had been in-service on the new steps added to the pyxis station which requires a witness before removing any controlled medications. LPN #1 stated she would never give a controlled medication that she did not obtain herself. LPN #1 further stated that she had never asked RN #1 to sign out a medication for her. Interview with LPN #2, on 5/25/12 at 3:32 p.m., confirmed LPN #2 had been in-service regarding the need for a witness before having access to controlled medication from the pyxis station. LPN #2 stated she would not give controlled medication that someone else had removed from the pyxis. LPN #2 further stated she had never asked anyone to get medication from the pyxis for her. Interview with LPN #3, on 5/25/12 at 3:40 p.m., revealed LPN #3 had been in-service on needing a witness before she is able to remove any controlled medications from the pyxis. LPN #3 stated she does not give medications that she has not obtained herself. LPN #3 also stated she does not ask anyone to remove controlled medications for her. Interview with the Department Head of Production/Pyxis Manager for the contracting pharmacy, on 5/24/12 at 4:10 p.m., revealed the pharmacy was still working on a system to make sure misappropriation did not happen again. The CPT revealed the daily reports are now reviewed by "four sets of eyes ". Also now the reports can be generated for controlled medications only. The CPT further stated the pharmacy is still working on a system to prevent multiple removals of medications under each resident's profile for the same medication. Interview with the Registered Pharmacist, on 5/24/12 at 4:30 p.m., revealed that the Pharmacist now gets the daily activity report from the pyxis station. Based on verification of the facility's corrective actions that was validated by staff interviews, observation and various documentation, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 5/25/12 at 5:00 p.m. to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

CI MS #9341 Based on observation, resident and staff interview, clinical record and facility policy and document review, the facility failed to protect two (2) of three (3) residents in the sample (Resident #1 and Resident #2) from verbal abuse and abusive behavior by a Certified Nursing Assistant (CNA) #1. Resident #1 was told to shut up and stay on her side of the room, and Resident #2 was spoken to in a rude and threatening manner, and told by the CNA #1 that she was not going to keep getting her up and down all night and if she did not use the bedpan she was not going to be toileted. This abusive behavior upset both Residents and Resident #2 began to cry and still cried about the incident when questioned the next day. Findings Include: Record review revealed that the Director of Nursing (DON) at Laurelwood Community Living Center reported to the state on 5/17/11 that on 5/13/11 at 7:30 p.m. two residents were allegedly verbally abused by a CNA #1. She reported that the CNA told Resident #1 to shut up, stay on her side of the room and that she was not going to keep getting Resident #2 up and down all night to use the toilet. The DON reported that the incident was overheard and witnessed by a LPN. The DON reported that the CNA was suspended and subsequently terminated due to the abusive behavior. Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) comprehensive assessment completed on 5/20/11 reflected a score of 15, indicating no problems with memory or cognitive decision making. Resident #1 required minimal assistance with activities of daily living. Interview with Resident #1 on 5/31/11 at 3:25 p.m. was conducted privately in her room. She sat on the side of her bed and stated that the aide (CNA #1) was " not as rude to me as she was to MaMaw " (indicating her roommate). Resident #1 stated that the aide told her that she'd better look and see who she was talking to. Then, she said that CNA #1 added "You get back behind that curtain and shut your mouth." Resident #1 stated that the aide told " MaMaw " to use the bed pan and MaMaw said she can't because she has a bad back and the aide said: "Well, stand up" and MaMaw said: "I can't stand up"; and that's when I (Resident #1) told the aide that MaMaw can't stand up and the aide told me to shut up. She stated that the medication nurse later helped the aide get MaMaw to the toilet. Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] reflected a score of 09, indicating some problems with memory and moderately impaired in cognitive decision making. Review of the care plans updated 5/8/11 reflected that Resident #2 required extensive staff assistance with activities of daily living including assistance with incontinence with bowel functions. Review of a social services evaluation note dated 3/11/11 reflected that the resident was oriented to person and place, able to choose clothing and was cooperative. Interview with Resident #2 on 5/31/11 at 5:45 p.m. was conducted privately in her room. The resident was in a wheelchair, an oxygen cannula in her nose. She stated that a girl was rude to her but she doesn't want to get her in trouble. She stated that she (the resident) apologized because she kept having to get up to go to the bathroom. She said CNA #1 took her twice and said she didn't have time to take her anymore. She said she didn't have time to "fool around with me." She stated that CNA#1 was real nasty saying it, and then she went out and slammed the door. She related that when CNA #1 came back later she said I'd have to stand up and walk and I told her I couldn't, then the girl said I'd have to use the bedpan. Resident #2 stated that she told the aide it hurts my back and I can't. She stated then that lady (pointing to the bed next to the window) rang her light and a nurse came and helped the girl take me to the bathroom. She stated that she "talked real ugly to me" and added that she had broken her back and can't even turn over in bed without help. She appeared to become upset in relating this, so the interview ended. Interview with CNA #2 at 3:55 p.m. on 5/21/11 revealed that he had signed a statement for the DON (Director of Nursing). This statement was read to him and he verified that it was a true statement. CNA #2 stated he had been sitting at the nurse's station when a call light went off, that it was Resident #2. He stated that CNA #1 went in and after being in there for a minute he heard her shouting to Resident #1: "You better pull that curtain back and look and see who you are hollering at." He stated that the tone of voice was "ugly" and Resident #2 was crying and that he went in later and helped her calm down. He stated that Resident #2 was still upset about it the next day. Interview with LPN #1 at 3:45 p.m. on 5/31/11 confirmed and verified the written statement dictated and signed for the DON. LPN #1 related that she heard voices raised in these two resident's room and heard CNA #1 tell Resident #1 to "shut up, pull the curtain and stay on her side of the room and mind her own business." LPN #1 stated that Resident #2 wanted to use the bathroom and CNA #1 told her she was not going to keep getting her up and down all night and she had better use the toilet now because she was not coming back into the room. LPN #1 indicated that she told CNA #1 to watch her mouth and her attitude that she could not talk like that here. LPN #1 related that she began to help CNA #1 transfer the resident and that the CNA said don't pull her, she can do it herself. The LPN stated that Resident #2 was crying and very upset and said she couldn't do it. LPN #1 stated that CNA #1 went to the nurse's station and was missing about 10:00 p.m. The LPN stated that the resident could not walk, that she is was much too weak, since she came back from the hospital; and that the CNA had worked with Resident #2 since then and knew that. Interview with CNA #3 on 3/31/11 at 4:20 p.m. revealed that she did not hear anything but saw CNA #1 at the nursing station and that she was real upset. CNA #3 stated that CNA #1 had been stressed and upset all evening. She stated that (CNA #1) related that she told Resident #2 that she was not going to keep taking her to the toilet, that she'd clean her up if need be. She related that CNA #1 stated that she told Resident #1 that she better pull that curtain back and see who she was yelling at. CNA #3 stated that Resident #1 has a speech problem and talks loud, it sounds like yelling. She stated that CNA #1 left early without clocking out. Interview with the DON on 3/31/11 at 4:25 p.m. revealed that she had investigated the incident and had found that CNA #1 gave two (2) different accounts as to what happened. She said when interviewed CNA #1 denied everything, and said she did put Resident #2 on the toilet by herself that 3rd time. However, the DON had determined that LPN #1 and Resident #1 both stated the LPN helped with that toileting. The DON stated that CNA #1 said she did not tell Resident #1 to shut up and that the LPN was not in there to hear it. The DON stated that she phoned LPN #1 and asked her if she was in the room and heard CNA #1 say "shut up". A written statement dated 5/17/11 was submitted by the DON indicating that CNA #1 had phoned her the night of 5/13/11 stating that she had a problem, saying that she was hurting in her back and was too busy to get Resident #2 up to the toilet again. The DON stated that she told CNA #1 that her job is to take care of the residents and make them happy. The DON wrote that LPN #1 communicated with her the next evening and said that she had a hard time with CNA #1 the night before, that she was lazy, wouldn't answer her lights and that she was rude and had an attitude. The DON stated that she was not aware of the gravity of the problem until she arrived at work on 5/16/11. She wrote on 5/16/11 and verified on 5/31/11 at 4:35 p.m. that she interviewed both residents; recorded their statements; and called CNA #1 in. She stated that after interviewing CNA #1, she was informed that she was suspended at that time. The DON related that the CNA had left the shift around 10:00 p.m. and was supposed to work until 11:00 p.m. Interview with the Social Service worker at 5:00 p. m. on 5/31/11 revealed that Resident #1 and Resident #2 were both upset until the DON met with them and told them how she took care of it and they were okay. Interview with CNA #1 at 5:25 p. m. on 5/31/11 revealed that she stated that she came into the lobby at 4:00 p.m. and Resident #2 had her hand up and wanted to use the bathroom then lie down. CNA #1 stated that she told the resident she'd help her as soon as she finished changing a bed in another room. CNA #1 stated that she later took her and put her on the potty and laid her down, then helped pass trays. She stated that Resident #2 then asked to be put on the pot again and that she took her, and that about 15 minutes later she wanted to use the pot again and I did it. She stated that she finished feeding and Resident #2's light was on again and she wanted to use the pot but not until after she got a pain pill because her back was hurting. CNA #1 stated that later the nurse (LPN #1) talked to me about yelling at the patient who was upset when I asked Resident #2 to use the bed pan and Resident #1 said she can't use it. CNA #1 stated that she told Resident #1 to let me ask Resident #2 and that Resident #1 was yelling and I stepped out of the room. She stated that LPN #1 went in and talked with them and asked me if I was going to put Resident #2 on the toilet and I said, yes, and she said that I had an attitude. I called the DON and she said I had to do it. CNA #1 said that the DON put words in the residents' mouth and denied any abusive conduct. Review of the personnel file on 5/31/11 reflected that CNA #1 had awareness of the facility vulnerable abuse prevention policy, signed and dated 12/22/09 which defined abuse as willful depravation of services and failing to do services necessary to maintain the mental and physical health of a resident. The facility abuse policy was signed and dated on 12/22/09 by CNA #1. This policy reflected that residents are to be treated with dignity and respect at all times under any circumstances, and that mistreatment in the form of verbal abuse of any nature will not be tolerated. Review of the abuse prevention policy and copies of in-service training on 5/31/11 revealed that CNA #1 signed attendance at training for Abuse/Neglect on 4/15/10 and training for Understanding and Dealing with Elderly Abuse on 8/11/10. This reflects the CNA's knowledge of abuse and reflects willful misconduct with these residents.