Every finding on record at MS Care Center of Dekalb

Based on observation, staff interview, and facility policy review, the facility failed to ensure refrigerated and frozen food items were properly labeled and dated and failed to discard expired and spoiled food items in the dietary department for one (1) of three (3) kitchen observations, with the potential to affect all residents who receive meals from the kitchen.Findings include:Review of the facility's Food Safety Policy, with a revision date of 11/16, revealed It is the policy that this facility ensures the quality and safety of refrigerated foods through accepted storage practices.Procedure.2. Foods will be stored, prepared, distributed and served in accordance with professional standards for food service safety. All non-hazardous, opened foods are labeled with name of food and date stored.All hazardous foods are labeled with name of food and date to be discarded or the date stored. Cooked foods should not be held longer than 48 hours.On 6/15/26 at 11:20 AM, during an observation and interview, with the Dietary Manager (DM) revealed there was an opened bag of coleslaw stored in the milk refrigerator without a date and was brown and wilted. There was an opened bag of chopped cabbage in the milk refrigerator that was also undated. The DM removed the wilted coleslaw and explained the staff were supposed to date those food items and indicated she would discard them. In the freezer there was (1) opened package of frozen ground beef dated 04/09/2026, (1) opened bag of Salisbury steak with no date, and (1) opened bag of pork chops with no date. Observation of the small freezer revealed an open bag of onion rings with no date. Observation of Refrigerator #2 revealed (1) opened pitcher of apple juice dated 05/29/2026, (1) opened pitcher of cranberry juice dated 04/18/2026, and (1) opened pitcher of grape juice dated 04/10/2026.On 6/15/26 at 11:55 AM, during an interview, the DM confirmed all opened food items should be properly closed, labeled, and dated, and vegetables should not be stored in the milk refrigerator. The DM explained that dating opened food items helps ensure they have not expired and that improperly stored or expired food could spoil and make residents sick. She reported that juice pitchers should be dated to prevent spoilage and reduce the risk of illness.On 6/16/2026 at 2:10 PM, during an interview, the Nursing Home Administrator (NHA) stated she expected all food items to be properly labeled and dated, and that she had provided in-service education regarding these expectations. She stated that staff were aware of the requirement to date-stamp opened food items, and that by not labeling and dating the food, the residents run the risk of foodborne illness. The NHA revealed the DM was responsible for ensuring foods were properly labeled, monitored, and stored, although all kitchen staff shared responsibility.On 06/16/2026 at 2:30 PM, during an interview, the Assistant Dietary Manager stated she was still in training and planned to monitor staff practices more closely. She stated she expected staff to correctly label, date, and monitor food items for expiration. She explained that residents could get sick and that the elderly were vulnerable and required protection.

Based on staff interview, record review and facility policy review the facility failed to ensure physician orders were obtained and documented upon admission for the continuation of hospice services for one (1) of (18) sampled residents. (Resident #9)Findings include:Review of the facility policy titled, Physician's Orders, with a revised date of 2/17/2025, revealed, .3. The printed order will be routed to Medical Records daily for verification and/or chart audit.4. The original physician's order is sent for e-signature through electronic health system.5. Orders will be recorded on the Medication Administration Record (MAR) .Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/26 revealed under Section O-Special Treatments, Procedures, and Programs. Section K1. Hospice care, that Resident #9 was on Hospice services. Review of Resident #9's Order Summary Report with active orders as of 6/17/26 revealed no order for hospice services. During an interview on 06/17/2026 at 8:22 AM, Registered Nurse (RN) #1 revealed that Resident #9 was admitted to the facility while receiving hospice services. RN #1 confirmed there was no physician order in the admission orders to continue hospice services and stated that a physician order should always be present for hospice care.During an interview on 06/17/2026 at 9:05 AM, the Director of Nursing (DON) confirmed Resident #9 was receiving hospice services for Chronic Obstructive Pulmonary Disease (COPD) and acknowledged the facility failed to include an admission order documenting the continuation of hospice services upon admission to the facility.Review of the admission Record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, and Unspecified Asthma. Review of the MDS Section C with an ARD of 4/29/26 revealed Resident #9 had a Brief Interview of Mental Status (BIMS) score of 12, indicating that the resident was moderately cognitive impaired.

Based on observation, interviews, facility policy review, and record reviews, the facility failed to prevent an injury to Resident #1 by not following the proper procedures for the use of a full body mechanical lift that required two (2) persons to operate. Resident #1 sustained a fall from the lift, received a hematoma to the back of her head, three (3) skin tears to her hand, arm and elbow and had to have medical care in the emergency room (ER). This was for one (1) of three (3) residents that required a full body mechanical lift for all transfers reviewed. The facility had implemented corrective actions as of 10/21/24, prior to the State Agency (SA) entrance on 1/6/25, therefore the deficiency is determined to be Past Non-Compliance. Findings Include: The facility undated policy titled: Accidents and Supervision read: The resident environment will remain free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. Record review of the Modified Lifting Policy, effective date 1/1/2023 signed by Certified Nursing Assistant (CNA) #1 on 10/16/23 revealed, .I understand that whenever I use a lift on a resident, NO EXCEPTION, there MUST be a hands-on assist at all times. This assures that two employees are safety aware, are caring for the resident and the resident's safety and that I am a responsible person, making good sound choices to the best of my ability. I will always ask for assistance when using the lift . Record review of the facility investigation revealed Upon investigation, it is stated by CNA1 that resident was up on lift with CNA1 in room, by herself, transferring RESIDENT from recliner to bed. RESIDENT was in the lift seat with all 4 straps attached to the lift and closure pins in place and snapped down, per CNA1 statement. CNA1 stated per statement, RESIDENT just slipped out of the left side of lift sling, hitting RESIDENT's head on the floor. Per CNA1 statement, RESIDENT did have a pillow to back in the lift sling . Record review of the Emergency Department dated 10/20/24 revealed: Chief Complaint Patient presents with Fall, hematoma on back of head. Patient is an [AGE] year-old white female that fell at the (name of facility) reportedly out of a chair. Sustaining injury to head, skin tears to left wrist, left elbow, left ankle Patient has severe dementia and Parkinson's Disease. Patients follow commands and stated: I hate being here. Patient is on Aspirin. Resident had x-rays in the ER of: Computed Tomography (CT) Cervical Spine Without Contrast; CT Head without Contrast with findings including a small scalp hematoma/contusion posteriorly on the left. Resident #1 also underwent x-ray left ankle; x-ray Chest 1 view; x-ray Left Elbow; x-ray Pelvis Routine AP; x-ray Wrist Complete Left. Final impression sprain of left ankle, and acute cervical myofascial strain. Skin tears on the forearm and dorsal (back) of left hand closed with Derma Bond skin adhesive. An interview on 01/06/25 at 9:00 AM, with the Director of Nursing (DON) revealed that on 10/20/24 she received a call at approximately 4:45 PM from the Licensed Practical Nurse (LPN) #1 to report that a resident had fallen and hit her head and was sent out to the ER for evaluation. At that time the reason for the fall had not been determined, so the DON gave instructions to LPN #1 to begin the investigation and to get statements from all staff as to what had occurred. The DON stated that on 10/20/24 at approximately 7:00 PM she received another call that Certified Nursing Assistant (CNA) #1 had confirmed that she had used the full body mechanical lift without obtaining assistance from another person. CNA #1 told LPN #1 that she thought she could transfer Resident #1 alone without any assistance. DON told LPN #1 to send CNA #1 home until the investigation could be completed. DON stated that she was surprised that CNA #1 had not followed the policies and procedures of the facility because she had been employed at the facility for several years and had attended numerous in-services on the proper use of the full body mechanical lifts. DON stated that after the investigation was completed and all statements were obtained confirming that CNA #1 had misused the full body mechanical lift by not getting help with the transfer of Resident #1 and had caused injury to her, the facility terminated CNA #1 immediately. Interview by telephone on 01/06/25 at 9:45 AM, with CNA #1 revealed that she used the full body mechanical lift alone and did not seek another staff member to assist her with the transfer of Resident #1. CNA #1 stated that she had worked at the facility for five (5) years and had been educated to use at least two (2) people to assist with the full body mechanical lifts during resident transfers. She stated that as soon as Resident #1 fell from the lift she went and got the two (2) LPN's, LPN #1 and LPN #2 to come assist with resident who was on the floor. The nurses assessed Resident #1 on the floor and found that she had blood on her arm due to some skin tears and her ankle was swollen and there was hematoma found on the back of Resident #1's head. The three (3) assisted to lift Resident #1 with the full body mechanical lift, back to her bed. She stated that she could not remember all the details of the incident because it had happened so long ago in October 2024. Interviews on 01/06/25 at 10:30 AM with CNA #2, CNA #3 and CNA #4 all working on the unit with other residents, revealed that they always use the full body mechanical lift with the specified residents. They stated that all the full body mechanical lift residents were housed in rooms next to each other and that it only took them a few minutes with each resident to transfer them with the lift. They stated that the three (3) of them team up and go from room to room assisting with the transfers each morning and when needed. All three CNA 's confirmed that they had been in-serviced numerous times about the use of lifts and that they require two people for transfers. Interview and observation on 01/06/25 at 10:40 AM, with Resident #1 revealed that she was sitting in a chair in her room and answered yes when her name was called but was unable to have a conversation due to severe dementia. Interview on 01/06/25 at 10:50 AM, with LPN #3 who is the Staff Development nurse revealed that she had trained all CNAs and had watched them each give return demonstrations of the use of all lifts. LPN #3 stated that CNA #1 had been working at the facility for at least five (5) years and had gone through her CNA training at the facility. LPN #3 stated that CNA #1 had been trained on the facility policy and procedures for all lift usages. She stated that she conducts annual training and the representative from the lift company comes and gives an in-service on the use of full-body mechanical lifts at least once per year. The Staff Development nurse (LPN #3) provided a list that was posted and laminated that was hung on the lifts, that documented which resident had what type of lift and sling size and the residents room number. Interview on 01/06/2025 at 11:10 AM, with LPN #1 revealed that on 10/20/24, she was sitting at the nursing station just a few feet away from Resident #1's room and she heard someone yell out help, please I need help. LPN #1 stated that she was the first one to respond and when she entered the room of Resident #1 there was only one person with Resident #1 and that was CNA #1. Resident #1 was lying on the floor, and she was not moving or speaking, nor did she make any complaints or express pain. LPN #1 immediately began to run her fingers through the hair of Resident #1 and across her head. LPN #1 stated that she found Resident #1 to have approximately a three (3) inch hematoma on the back of her head and a significant amount of blood coming from her arm and a swollen ankle. Resident #1 was assisted to her bed from the floor by the three (3) staff and again she was reassessed after they got her in her bed. LPN #1 stated that the hematoma on Resident #1's head was most concerning, and she obtained an order to have her sent out to the ER for evaluation. The ambulance got to the facility within minutes of contact. LPN #1 stated that the DON instructed her to get statements from all staff working on that hall and to send CNA #1 home after she gave her written statement. LPN #1 stated that she really hated that CNA#1 had not obtained help with the lift. LPN #1 stated that CNA #1 said, I thought I could do it by myself when she asked her how the resident fell from the lift. LPN #1 stated that the unit was not short staffed on 10/20/24 and there was plenty of staff available to properly use the full body mechanical lifts for the few residents that required them. An interview on 01/06/25 at 11:50 AM, with Registered Nurse (RN) #1 revealed she received Resident #1 back into the facility from the ER at approximately 8:00 PM on 10/20/24. She stated that Resident #1 had three (3) skin tears that had been closed with Derma Bond (surgical glue) in the ER and had been wrapped with a bandage. RN #1 stated that there was plenty of staff working on 10/20/24 and there were no shortages of staff on that day. The interview on 01/06/25 at 7:00 PM, with LPN #2 revealed that she was the second nurse on the unit on 10/20/24 and had arrived in the room of Resident #1. She stated that she assisted in the assessment of Resident #1 after she fell from the lift and stated that CNA #1 had not properly used the full body lift while transferring Resident #1. Resident #1 fell from the lift to the floor and had to be sent out to the ER for evaluation because of her injuries. CNA #1 stated that she thought she could use the lift alone and she had not asked for assistance. LPN #2 stated that Resident #1 had a large hematoma to the back of her head that was the main concern for sending her out to the ER, and she also had blood on her arm from three (3) rather significant skin tears that would not stop bleeding. Resident #1 also had a swollen ankle. Record review of the facility's investigation report signed by the facility DON and dated 10/21/2024 read: At this time, it is the decision of DON, Assistant Director of Nursing (ADON), and Administrator that CNA #1 is liable for her actions and therefore terminated for Violation of Facility Rules and Lifting Immobile Resident without Proper Assistance leading to Resident Neglect/Abuse and Substandard Care. Nurses were also in serviced on mechanical lift incidents being reportable, immediately and having to be fully investigated. Record review of the handwritten statement of CNA #1 signed and dated 10/20/24 revealed, I did not ask for assist from a CNA or nurse when using the total lift when transfer a resident. Signed by CNA #1 dated 10/20/24 at 9:15 PM. Record review of the Admission Record of Resident #1 documented that she was admitted to the facility on [DATE] with diagnoses that included, Parkinsonism; Mood Disorder; Dementia; Depression; Osteoarthritis; and Muscle Weakness. Record Review of Resident #1's Minimum Data Set (MDS) Section C: Cognitive Patterns dated 11/27/24 revealed a Brief Interview for Mental Status should not be conducted because the resident is rarely/never understood and cognitive skills for daily decision making were severely impaired. Record review of the facility in-services after the incident and the investigation records revealed that the facility had corrected all deficiencies created by the fall of the resident from the improperly used lift. CNA #1 acted alone, and she admitted that she knew better and had been thoroughly trained as to the procedures for using the lifts. The facility also reviewed their policies with no changes made to the policies and conducted a Quality Assurance (QA) meeting on Monday 10/21/24 as well as conducted a thorough investigation. The State Agency (SA) reviewed the QA meeting held on 10/21/24, the lift in services that began on 10/20/24 and reviewed the documentation that the facility terminated CNA #1 on 10/21/24. The facility continues to monitor fall and accidents throughout the next eight (8) weeks through their QA program and meetings. The deficient practice had been corrected on 10/21/24 prior to the State Agency (SA) entering the facility on 01/06/2025 and determined to be Past Non-Compliance.

Based on interviews, facility policy review, and record review, the facility did not follow the plan of care for using a full body lift while transferring Resident #1 which caused her to fall from the full body lift and hit her head on the floor. Resident #1 had to be transported to the emergency room (ER) and received medical care for three (3) skin tears and a large hematoma to the back of her head. Resident #1 was one (1) three (3) residents care planned for the use of a full body mechanical lift for all transfers reviewed. The facility had implemented corrective actions as of 10/21/24, prior to the State Agency (SA) entrance on 1/6/25, therefore the deficiency is determined to be Past Non-Compliance. Findings include: The facility policy and procedure titled: Develop/Implement Comprehensive Care Plan date revised [DATE] revealed: The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights and that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Record review of Resident #1's care plan with an onset of problem dated 12/29/2023 revealed: Requires extensive to dependent assistance x (times) 2 (two) with ADL's (Activities of Daily Living) including dressing, eating, hygiene, bathing, and toileting. Transfer Using the Full Body Lift x 2 Assist. Record review of the facility investigation revealed Upon investigation, it is stated by CNA1 that resident was up on lift with CNA1 in room, by herself, transferring RESIDENT from recliner to bed. RESIDENT was in the lift seat with all 4 straps attached to the lift and closure pins in place and snapped down, per CNA1 statement. CNA1 stated per statement, RESIDENT just slipped out of the left side of lift sling, hitting RESIDENT's head on the floor. Per CNA1 statement, RESIDENT did have a pillow to back in the lift sling . Record review of the Emergency Department dated 10/20/24 revealed: Chief Complaint Patient presents with Fall, hematoma on back of head. Patient is an [AGE] year-old white female that fell at the (name of facility) reportedly out of a chair sustaining injury to head, skin tears to left wrist, left elbow, left ankle. Patient has severe dementia and Parkinson's Disease. Patients follow commands and stated: I hate being here. Patient is on Aspirin. Resident had x-rays in the ER of: Computed Tomography (CT) Cervical Spine Without Contrast; CT Head without Contrast with findings including a small scalp hematoma/contusion posteriorly on the left. Resident #1 also underwent x-ray left ankle; x-ray Chest 1 view; x-ray Left Elbow; x-ray Pelvis Routine AP; x-ray Wrist Complete Left. Final impression sprain of left ankle, and acute cervical myofascial strain. Skin tears on the forearm and dorsal (back) of left hand closed with Derma Bond skin adhesive. Interview on 01/06/25 at 9:00 A.M. with the Director of Nursing (DON) confirmed that Resident #1 was assessed for the full body lift and that it required the use of two people, and that CNA #1 did not follow the resident's care plan. Interview by telephone on 01/06/25 at 9:45 AM with Certified Nursing Assistant (CNA #1) revealed that she used the full body mechanical lift alone and did not seek another staff to assist with the transfer of Resident #1. CNA #1 stated that she had worked at the facility for five (5) years and had been in-serviced on the use of the full body lift and knew the care plan said that she needed to utilize two people for the lift. CNA #1 stated, Yes, I had been educated to use at least two (2) people to assist with the full body mechanical lifts during resident transfers. But, I have used them alone with no problem. CNA #1 stated that she had attended many in-service training courses on using the full body mechanical lift with at least two (2) people to assist. Interview on 01/06/25 at 10:50 AM, with the Licensed Practical Nurse (LPN) #3 who is the Staff Development Nurse, stated that CNA #1 did not follow the care plan that had been in place for Resident #1. CNA #1 operated the full body mechanical lift alone and she gave a written statement that she had not asked anyone to help her transfer Resident #1 on 10/20/24. CNA #1 was terminated for not following the policy and procedure for the two (2) people assisting with full body mechanical lifts which caused an injury to the resident. The interview on 01/06/25 at 2:20 PM, with the DON revealed that the CNA's had access to the care plans of all residents and that they would take report at the beginning of the shift to know who had changes in conditions and treatments etc. The CNAs were responsible for documenting that the care plans were followed on each resident that they were assigned to care for on each shift. The DON stated that also, the full body mechanical lifts had a laminated list posted on the lifts as to how the residents were lifted and what size sling each needed. Record review of the Admission Record of Resident #1 revealed that she was admitted to the facility on [DATE] with diagnoses that included Parkinsonism; Mood Disorder; Dementia; Depression; Osteoarthritis; and Muscle Weakness. Record review of Resident #1's Minimum Data Set (MDS) Section C: Cognitive Patterns dated 11/27/24 revealed a Brief Interview for Mental Status should not be conducted because the resident is rarely/never understood and cognitive skills for daily decision making were severely impaired. Record review of the facility in-services after the incident and the investigation records revealed that the facility had corrected all deficiencies created by the fall of the resident from the improperly used lift. CNA #1 acted alone, and she admitted that she knew better and had been thoroughly trained as to the procedures for using the lifts. The facility also reviewed their policies with no changes made to the policies and conducted a QA meeting on Monday 10/21/24 as well as conducted a thorough investigation. The State Agency (SA) reviewed the Quality Assurance (QA) meeting held on 10/21/24, the lift in services that began on 10/20/24 and reviewed the documentation that the facility terminated CNA #1 on 10/21/24. The facility continues to monitor fall and accidents throughout the next eight (8) weeks through their QA program and meetings. The deficient practice had been corrected on 10/21/24 prior to the State Agency (SA) entering the facility on 01/06/2025 and determined to be Past Non-Compliance

Based on staff interview, record review and facility policy review, the facility failed to monitor a resident receiving anticoagulant medication for signs of bruising and bleeding for one (1) of five (5) residents reviewed for unnecessary medication. Resident #27 Findings Include: Record review of the facility policy titled Medication Monitoring with a revision date of 8/13/2023 revealed under, Policy: This facility takes a collaborative, systematic approach to medication management, including the monitoring of medications for efficacy and adverse consequences. Record review of the May 2024 Physician Orders for Resident #27 revealed an order dated 12/16/2020, Eliquis (blood thinner) 2.5 MG (milligrams) by mouth twice a day R/T (related to) circulation. Record review of the Physician Orders and the Medication Administration Record (MAR) revealed there was not a monitoring tool for staff to monitor for signs of bruising and bleeding with the anticoagulant (blood thinner) medication Eliquis. An interview with Licensed Practical Nurse (LPN) #1 on 5/7/2024 at 1:40 PM revealed she considered anticoagulant medication to be a high-risk drug that should be monitored for adverse outcomes. She confirmed the facility did not have a monitoring task implemented on the Medication Administration Record (MAR) for Resident #27 for bruising or signs of bleeding. An interview with the Assistant Director of Nursing (ADON) on 5/7/2024 at 2:02 PM confirmed the facility did not have a system in place to trigger the nurses to monitor for the potential outcomes associated with the use of blood thinners. Record review of the Face Sheet revealed the facility admitted Resident #27 on 12/16/2020 with medical diagnoses that included schizophrenia and unspecified dementia.

Based on observation, staff interview, and facility policy review the facility failed to provide residents with a safe environment, as evidenced by various spray bottles and cans of chemical disinfectant, cleaning, and insecticide sprays, found unsecured on two hanging shelves on the B hallway for one (1) of three (3) days of survey. Findings include: Review of the facility policy titled, Storage of Chemicals, undated, revealed, Policy: The facility ensures the quality and safety of our residents through accepted storage practices. Procedure: 1. Chemicals are stored in a storage area, designated only for chemicals that can be locked. 2. Chemicals are safely stored for the protection of others by placing in locked carts while on halls during housekeeping procedures . On 5/06/24 at 10:40 AM, observation during the initial tour revealed on the B-Hall two (2) wooden shelves hanging approximately six (6) feet up on the right side of the wall. Shelf #1 had three chemical spray bottles: Cleaner/ Disinfectant, deodorizer, and fungicide. A label with HALT Danger on the bottles was noted. Shelf #2 revealed a can of chemical crawling insecticide spray and four chemical sprays labeled with HALT Danger. An interview on 5/06/24 at 10:50 AM, Housekeeper #1 confirmed the items were used to sanitize and clean and one was also an insecticide spray. She revealed we used those when we had COVID-19 and they have always stayed up on the wall in the hallway. During an observation and interview on 5/06/24 at 11:00 AM, the Environmental Manager revealed we keep the supplies up there so the staff can spray the equipment off. He confirmed that the chemical supplies were accessible to anyone and that residents could access the shelf with the chemicals on it. Observation and interview on 5/06/24 at 11:05 AM, the Administrator (ADM) confirmed the unsecured chemicals could be an accident hazard and should be kept locked up and away from the residents and visitors. Record review of the accident and incident log for the last year revealed there were no incidents related to chemicals being left unsecure.

Based on observation, resident and staff interview, and facility policy review, the facility failed to provide an appropriately sized wheelchair for one (1) of fifty-three residents residing in the facility during the survey. Resident #37 Findings Include: Review of the facility policy titled Resident Rights Policy with a revision date of 9/2022 revealed under, Reasonable Accommodations of Needs/Preferences: The resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. An observation and interview with Resident #37 on 5/6/2024 at 10:57 AM, revealed she was sitting in a wheelchair and slightly slouched forward. There was not enough seating space and the residents' hips, and outer thighs were tight against the edges of the wheelchair. The resident voiced that her wheelchair was too small. An observation and interview with the Director of Nursing (DON) on 5/7/2024 at 10:54 AM, confirmed Resident #37's wheelchair was too small. She revealed the family brought the wheelchair into the facility on admission, but the resident had gained weight and the wheelchair no longer fit the resident's size. She confirmed the resident should have an appropriately sized chair to ensure comfort and prevent skin concerns. Record review of the Facesheet revealed the facility admitted Resident #37 on 10/3/2023 with medical diagnoses that included Morbid obesity, Chronic pain, and Unspecified dementia.

Based on observations, staff interviews, record reviews, facility policy review and Center for Medicare and Medicaid Services (CMS) Quality Safety and Oversight (QSO) Memo review, the facility failed to prevent the likelihood of the spread of COVID-19 as evidenced by failure of ensuring all staff were fully vaccinated or received an exemption for 2 (two) of 89 employee records reviewed. Findings Include Review of the facility policy titled COVID-19 Vaccination with a revision date of November 2021 revealed under Policy Interpretation and Implementation .This facility requires all employees to receive the COVID-19 vaccination per federal regulations by required deadlines unless exemption status is provided. This vaccination policy applies to all facility staff , regardless of clinical responsibility or resident contract, including employees, licensed practitioners, students, trainees, volunteers, and individuals who provide care, treatment, or other services for the facility and/or Residents, under contract or other arrangement (such as hospice, therapy, mental health professionals, portable x-ray suppliers and consultants). An interview on 12/5/22 at 1:15 PM with the Infection Preventionist revealed she is aware that all staff should be fully vaccinated against COVID-19 or have an approved exemption and she is aware she has two staff members that have never went back and got their second dose of COVID-19. She revealed the facility has had no COVID-19 positive resident's or staff in the last four weeks and everyone continues to wear a mask. She revealed she is responsible for keeping up with the staff's vaccinations and making sure they are fully vaccinated or have an approved exemption. She revealed that the two staff members that have not completed their COVID-19 vaccinations or requested an exemption have been encouraged to be compliant but have been allowed to continue to work. An interview on 12/7/22 at 1:10 PM with the Administrator confirmed that she is aware of the regulation that all staff should be fully vaccinated or have a granted exemption. She revealed she was not aware that she had any employees that were still lacking their second dose of the COVID-19 vaccination. An interview on 12/7/22 at 2:45 PM with the Director of Nurses (DON) confirmed she is aware that two staff members have not received their second dose of the COVID-19 vaccination. She revealed that the Infection Preventionist was responsible for keeping up with the staff vaccinations and making sure they were compliant. She revealed that having staff that were not fully vaccinated with no exemption could pose a threat to the facility for possibly bringing COVID-19 into the building. An interview on 12/7/22 at 2:55 PM with Certified Nursing Assistant (CNA) #1 revealed she was hired in October 2022, and she received her first COVID-19 vaccination sometime around the end of October 2022. She confirmed that she has continued to work at the facility full time as a CNA and that the DON has told her she needs to get her second dose, but she was never given a deadline or told she could not work if she did not get it. An interview on 12/7/22 at 3:10 PM with CNA #2 revealed she has worked at the facility full time since 2012 and received her first COVID-19 vaccine in 11/2021. She revealed she feels like she had a severe allergic reaction to the first dose and has been wanting to get a medical exemption. She revealed she has been to several doctors and has not received one yet. She revealed that no one gave her a deadline for getting it taken care of, but they have told her today that she cannot come back to work until she gets her second dose of the covid vaccination. An interview on 12/7/22 at 3:40 PM with Staff Development confirmed that all staff are supposed to be fully vaccinated against COVID-19 or have a granted exemption in order to continue working at the facility. She confirmed that CNA #1 and CNA #2 have continued to work at the facility with CNA #1's last day to work being 12/04/22 and CNA #2's last day to work being 12/06/22. An interview on 12/7/22 at 4:00 PM with the Administrator confirmed that she realized that two staff members have not received their second COVID-19 vaccination or an approved exemption. She confirmed that all staff should have already had their second vaccination or exemption taken care of, but they continue to wear mask and follow precautions to prevent the spread of infection. Review of the facility COVID-19 Staff Vaccination Status for Providers revealed that CNA#1 and CNA#2 were not fully vaccinated and did not have a granted exemption. Review of CNA #1's vaccination record revealed she received one dose of a multi-dose COVID-19 vaccination on 10/18/22. Review of CNA #2's vaccination record revealed she received one dose of a multi-dose COVID-19 vaccination on 11/12/21. Review of CNA #1 and #2's time sheets from the past two weeks confirmed they have worked at the facility full time. This review revealed CNA #1's last day to work was 12/04/22 And CNA #'2's last day to work was 12/06/22. Review of the CMS-QSO Memo dated 01/14/22 with a reference number of QSO-22-09-ALL revealed under, Vaccination Enforcement-Surveying for Compliance Within 60 days after the issuance of this memorandum, if the facility demonstrates that: Policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; and 100% of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple-dose vaccine series), or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is compliant under the rule.

Based on record reviews, staff and Resident Represent (RR) interviews, and facility policy and procedure reviews, the facility failed to manage Res #1's pain after returning to the facility from her first right hip surgery on 06/04/2022 at 3:00 PM. The facility failed to obtain pain medications for Res #1 after she voiced pain and after the family's request for pain medications of [MEDICATION(S)] to be given to Res #1. Res #1 yelled out and screamed in pain through the night of 06/04/2022 and the facility failed to acquire methods of pain management for Res #1's verbalized pain. Res #1 sustained a second fall and a left fractured hip on 06/04/2022 at approximately 10:00 PM requiring a second hip surgery. Res #1 was one (1) of six (6) residents reviewed for pain. On 06/02/2022, Resident #1 had an unwitnessed fall resulting in a right hip fracture which required hospitalization for surgical repair. On 06/04/2022, Resident #1 returned to the facility post hip repair. Resident #1 complained of pain and the facility failed to obtain pain medication and provide pain management treatment resulting in the resident becoming increasingly distressed and agitated. Resident #1 sustained a second fall at approximately 10:00 PM on 06/04/2022 and suffered severe and avoidable pain until transferred to the hospital on 06/05/2022 for unresolved pain. While at the hospital it was discovered the resident had a left hip fracture that resulted in surgical repair. The facility's failure to effectively manage Resident #1's pain after a right hip surgery and after an additional fall on 06/04/2022 when Resident #1 returned to the facility post hospitalization for hip surgery. This situation caused Resident #1 serious harm, serious injury or serious impairment. This placed other residents in a situation that was likely to cause serious harm, serious injury, serious impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 06/04/2022 when the facility failed to assess and treat Resident #1's pain and notify the necessary parties of Resident #1's fall and pain. The facility Administrator was notified of the IJ and SQC on 08/03/2022 at 4:00 PM. The facility provide a Past Non-Compliance Corrective Action Plan in which the facility alleged all corrective actions were completed to remove the IJ and SQC on 06/16/2022, and the IJ and SQC was removed on 06/16/2022. The State Agency (SA) determined the IJ and SQC was removed on 06/16/22, prior to the SA's entrance on 08/01/2022 and was Past Non-Compliance (PNC). Findings include: Review of the facility policy and procedure titled Pain Management dated 1/20/2021 revised 6/10/2022 revealed: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The facility will utilize a systematic approach for recognition, assessment, treatment, and monitoring of pain. Record review of the undated facility policy titled Change In Resident Medical Status revealed: A change in medical status is defined as any physical, psychological, and/or medical deviation as compared to the resident's status as noted in the initial assessment. These changes may include fall and/or injury, fever, refusal to eat after 24-hour period, confusion,or other change in mental behavior. These changes must be noted in a) Clinical Record, b) Care Plan if significant, c) Accident/Incident Report (if due to fall or injury) . A facility must immediately inform the resident, the physician, responsible party when there is: 1. A need to alter treatment 2. An accident involving the resident which results in injury and has the potential for requiring physician intervention. 3. A significant change in the resident's physical, mental or psychological status. 4. A decision to transfer or discharge the resident from the facility. If the physician is unable to be reached for resident condition change requiring alterative treatment, you should do the following: 1. Notify the Medical Director. If unable to reach, 2. Call the ambulance and transfer to hospital. Interview with the facility Administrator (ADM) on 08/01/2022 at 12:00 PM, revealed that the facility had received resident (Res #1) back to the facility on Saturday 06/04/2022 at approximately 3:00 P.M. from the hospital where Res #1 had had a pin placed surgically to her right hip because of a fall in the facility on Thursday 06/02/2022. At the time of the first fall on Thursday 06/02/2022, Res #1 was able to relay to the facility that she had fallen in her room as she was attempting to toilet herself. On Thursday 06/02/2022 Res #1 was independently ambulatory with the assistance of a cane and was continent of bowel and bladder. Res #1 was able to relay to the facility staff how she had fallen. Resident was found on the floor of the bathroom with a cut to her eye and pain to her right hip. On Thursday 06/02/2022, Res #1 was transported via ambulance to the local hospital. Hospital x-rayed Res #1 and found her to have a fractured right hip and placed 10 stitches to the cut on her eye. The local hospital transferred Res #1 to the orthopedic unit in another town approximately 50 miles from the facility via ambulance to obtain surgery to the right fractured hip. On Friday 06/03/2022, Res #1 had surgery to her right hip and a pin was placed to the hip. On Saturday 06/04/2022, at approximately 3:00 PM Res #1 arrived back to the facility via ambulance accompanied by her daughter. Registered Nurse (RN) #2 told the daughter that the hospital had not sent any orders for pain medications only Tylenol as needed (PRN) for pain. The daughter told RN#2 that Res #1 was voicing pain and needed to have some pain medications ordered. The ADM stated that RN #2 called the hospital and the nurse at the hospital told her that the family had requested no pain medications for Res #1 because it made her loopy. RN #2 called the facility Medical Director (MD) to obtain a verbal order from for [MEDICATION(S)] pain medication per the request of the daughter, who was at the facility with Res #1. RN #2 called the pharmacy and gave the verbal order for [MEDICATION(S)] pain medication and the pharmacy told her that they would call back with the approval and would deliver the medications if approved. RN #2 left the facility at 5:00 PM on Saturday 06/04/2022 and passed on the information to the other nurses at the facility. Later, in the evening of Saturday 06/04/2022 at approximately 7:15 PM, the pharmacy called the facility back and told the 7:00 PM - 7:00 AM Licensed Practical Nurse (LPN #1) that they were not allowed to fill a prescription with a verbal order for pain medications ([MEDICATION(S)]) and that a hard copy with a physician's signature was required for all pain medications. LPN #1 did not attempt to obtain the required physician's signature, did not contact/notify the facility physician, did not notify/report to the family, did not call/notify the facility DON and did not notify/call the ADM that the medications were not available, as per facility policy and procedure for notifying. The ADM stated that the facility had a local pharmacy and a back-up pharmacy for obtaining medications. The facility policy is that if a hard copy with a physician's signature is needed or that a medication needs to be obtained, the nurse was supposed to have called the ADM and the DON and they would obtain the hard copy and go pick the medications up and deliver them to the facility. No one contacted the ADM or the DON per facility policy. The staff at the facility reported to the ADM on Friday 06/10/2022 that Res #1 expressed pain and had periods of yelling out in pain with restlessness and confusion throughout the night of Saturday 06/04/2022 and early morning of Sunday 06/05/2022. None of the behaviors of Res #1 were documented, reported, and/or assessed by the facility staff on Saturday 06/04/2022 and 06/05/2022, after a night of pain and restlessness and no pain medications. On 06/05/2022 at approximately 10:00 AM Res #1 was transferred to the local hospital, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADM reported that she received a call from the daughter of Res #1 inquiring about a second fall that had resulted in a second fracture to the opposite (left) hip. The ADM reported that during the first interviews with the evening staff (RN #1, LPN #2, and the CNA's) they all reported that they had no knowledge of a second fall of Res #1 on the evening of Saturday 06/04/2022. There were no documented reports of a fall for Res #1 on Saturday 06/04/2022. Interview with the Director of Nursing (DON) on 08/01/2022 at 12:45 PM, revealed that the nursing staff on 06/04/2022-06/05/2022 had not followed the facility's policies and procedures for assessing falls, documenting falls, using lifts, notifying of change in conditions, and had not obtained the treatments and medications needed by Res #1. The nursing staff had neglected to manage Res 1's pain. Interview with the Resident Representative (RR) on 08/01/2022 at 3:00 PM, stated that she accompanied her mother upon re-entering the facility on 06/04/2022 at approximately 3:00 PM and after approximately 30 minutes of being back in the facility Res #1 began to complain of pain. RR went to the nursing station and asked if they could give Res #1 some pain medications and was it possible to get her some [MEDICATION(S)] because that seemed to agree with her better and ease her pain. Nurse told RR that she would call and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RR assumed that the pain meds would be given to Res #1 when they arrived. RR stated that her mother was not hollering out and was not restless when she was with her in her room. Upon the arrival of her brother the RR left and went home leaving her brother there with Res #1. No one at the facility notified her or any member of her family that Res #1 had been without pain meds, and no one notified them of any change in Res #1's condition on 06/04/2022. RR stated that her brother had reported to her that Res #1 was voicing pain while he was at the facility with Res #1 up until approximately 8:00 PM when he left the facility. RR stated that she was told by the facility nurse that the hospital had not given them orders as to the treatment and medication needed for Res #1. The RR stated that she assumed that the facility was obtaining the orders for Res #1's pain medication and treatment orders. RR stated that on Sunday morning, 06/05/2022, her brother arrived at the facility at approximately 8:00 AM to sit with Res #1 and found that his mother was in uncontrolled pain and Res #1 was sitting in a recliner in her room alone calling out in pain. Brother was told by the nurse that they put Res #1 in the recliner because she had been trying to get out of bed and she was in pain. Staff told brother that Res #1 was more relaxed and calmer in the recliner and was refusing to stay in bed. RR and brother were concerned about Res #1 being out of bed and sitting up in a chair on her newly pinned right hip. Nurse told brother that they had called the facility physician and had obtained an order to transfer Res #1 to the local hospital for uncontrolled pain. Nurse told brother that the pain medication never arrived, and that Res #1 had been without pain medications since arriving back to the facility. The family accompanied Res #1 to the hospital emergency room (ER) on 06/05/2022 at approximately 10:00 AM. RR stated that on Thursday 06/09/2022 the Physical Therapist (PT) went to assess Res #1 at the hospital and found Res #1 to be in pain and unable to receive PT services, therefore the PT asked that Res #1 have x-rays and that is when they found the left hip to be fractured and in need of a second surgery. In an interview with CNA #1 on 08/02/2022 at 12:30 PM, reported she had been assigned as the CNA for Res #1 on 06/04/2022. CNA #1 stated that Res #1 had been agitated most all night and did yell out in pain. Interview with the facility Medical Director (MD) on 08/03/2022 at 8:45 AM, revealed that he had been called on 06/04/2022 by the facility nurse and was asked for a pain medication for Res #1 and he gave a verbal order for pain medication of [MEDICATION(S)] but had never been contacted that the pharmacy would not accept a verbal order for pain medications. MD stated that he would have expected the staff to have called him and informed him of what was going on with Res #1, but they never called him back with a report and never asked for a transfer of Res #1 to the hospital for pain control. MD stated that the nurses should have contacted him when they were unable to get the pain medication for Res #1. MD stated that Res #1 should never have had to endure pain. MD stated that on the morning of 06/05/2022, he received a call from the nurse that Res #1's medication had not been delivered as ordered and that Res #1 had uncontrolled pain. MD stated that he told the nurse to send Res #1 out immediately to the ER for uncontrolled pain. MD stated that the hospital should not have sent Res #1 back to the facility without pain medications and without orders for treatment. But that once Res #1 arrived back to the facility the nurses should have obtained orders for treatment from the hospital. The MD stated that he had not been the surgeon and had no idea what the hospital wanted the facility to do for Res #1 once she arrived back to the facility. That was why he told the nurse to send Res #1 to the ER for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] #1 fell in her room on 06/04/2022 she should have been sent out to the ER for evaluation. The MD stated that he was made aware on 06/10/2022 that Res #1 had a second fall in the facility. The MD stated that the QA committee met, and they reviewed all their policies and procedures and that they were all in place and were established prior to the fall of Res #1 and the staff just chose not to follow the facility policies and procedures. In an interview with RN #2 on 08/04/2022 at 5:30 PM, revealed that she worked from 6:00 AM to 5:00 PM on Saturday 06/04/2022 and she received Res #1 at approximately 3:00 PM from the hospital. RN #2 stated that she ordered the [MEDICATION(S)] for Res #1 and left the facility at 5:00 PM with the impression that the pharmacy was delivering the pain medications. RN #2 stated that Res #1 did not complain of pain or holler out prior to 5:00 PM on 06/04/2022. RN #2 stated that the family was with Res #1, and she was calm and relaxed upon entering the facility from the hospital. RN #2 stated that LPN #1 had told her on 06/05/2022 that Res #1 had yelled out and hollered all during the night. RN #2 discovered that the pain medications for Res #1 had not been obtained and she immediately called the MD and got orders to have Res #1 sent to the local hospital for uncontrolled pain. RN #2 stated that she had not received any report that Res #1 had fallen in the facility on 06/04/2022. Record review of a Departmental Note dated 06/04/2022 at 4:24 PM, revealed Resident complained of pain to right hip, resident's daughter at bedside and requested that resident have some [MEDICATION(S)], the resident took some while she was in the hospital and it seemed help, (Formal Name of MD) notified, new order received for [MEDICATION(S)] 5-325 MG (milligrams) tablet, give 1 (one) tablet by mouth every 6 (six) hours as needed for pain X (times) 3 (three) days. Signed by RN #2. Record review of the June 2022 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . signed prescription and Tylenol 1000 MG (milligrams) (give 2 (two) X 500 MG) by mouth every eight hours PRN pain (not to exceed 3 GM (grams) daily) There was no documentation that this medication was administered. There was no pain scale on the MAR. Record review of Res. #1's medical record revealed no pain assessment was completed 06/04/2022 and 06/05/2022. Record review of Res #1's Face Sheet revealed that Res #1 had been admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed an undated hand-written statement signed by (RN #1) that read: On 6-4-22 I was working with an agency nurse and one of our residents was screaming and hollering. We asked had she had any pain medication, other nurses stated family did not want her to have any. I tried to give her a Tylenol resident stated, no that's poison. Record review of the handwritten dated statement with LPN #1 and signed by LPN #1 and dated by LPN #1 on 6/10/2022 with her address and phone number revealed: 8:00 PM Saturday -Standing on side of bed-CNA helped to get her back in bed. 7:49 Son asked to stay with resident but (LPN #1) did not know the policy and would have to ask. He never mentioned it again and I did not find out what policy was. (Res #1) was standing on side of bed and we assisted her back to bed. I left room and another employee said (Res #1) was lying on floor. Near wall on right side. I asked (Res #1) what happened, and she said, I tried to walk and fell my hip is broke. Assessed her on floor and manually picked her up. 3 others (RN #1) helped to the bed. Did not c/o (complain of) pain. Did not document. Did not call anyone. 9:51 I asked (RN #1) about incident report. She said it was too long, don't worry about it. I went and got my food and went to room to sit with her. Resident complained of pain, and I went and got 2 Tylenol, but she only took one. One is enough, I guess I got to die someway. I tried to get her to take another one, but she would not take it. I sat with her to monitor pain. Pain level 8-9. At 7AM Sunday 6/5/22 I gave report to (RN #2) stating that I tried to give her Tylenol for pain, but she wouldn't take it. Is there a standing order for Ibuprofen. At this time, she took 2 Ibuprofen at 6:50 AM. Never reported fall. (RN #1) came in room we were just talking I told her (Res #1) will not take the Tylenol for pain and that what shall I do to try to make her take medicine because I knew she had to be in pain. (RN #1) came around the bed and said with hand motion to mouth zip it. I would not say a thing you assess her there were no bruises. Record review of the 06/10/2022 signed handwritten statement of RN #3 revealed: Resident (Res #1) returned to facility from hospital via Ambulance accompany by her daughter. (RN #2) did a full body assessment and vital signs. Weight done with full body lift. Daughter asks if mother could have something for pain after assessment and repositioning. Resident was not complaining of pain at this time. I took Tylenol to room. Daughter asks if she could have [MEDICATION(S)]. Explained to daughter that she did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 said she would call MD and see if she could get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol given as ordered. MD gave the order for [MEDICATION(S)]. Order sent to (Pharmacy). (Pharmacy) called later and said they needed a hard copy before they could send the [MEDICATION(S)]. Notified on coming nurse (LPN #1) that (Pharmacy) had called back and was not going to send the [MEDICATION(S)] without a hard copy. Resident had not complained of pain. Sunday June 5, 2022, received resident sitting up in recliner in room. Resident was trying to get out of recliner and was complaining of pain. Notified (RN #2) about the pain and she was in the process of trying to get her pain medicine. Parked medicine cart across from resident room to keep an eye on her while I gave medication. Son came to visit. He wanted to know why resident was in recliner and not in bed. Explained to him that she had been trying to get up out of bed and for her safety she was in the recliner. After son was in the room with her, I pushed cart on down the hall and continue to give medicine. Record review of the signed handwritten statement of (RN #2) dated 06/10/2022 revealed: I returned to work Sunday June 5th at approximately 5:45 A.M. I received resident (Res #1) lying in bed awake no complaints of pain at that time. She wanted to know what I was doing. I explained that I was getting her vital signs. When I exited her room, (LPN #1) said that she was glad resident was quiet because she had been hollering and trying to get up throughout the night. I asked her if she had given her a pain pill, (LPN #1) said that it did not come, pharmacy could not send it without a prescription hard copy. She said they had called back Saturday evening. (LPN #1) said she had tried giving resident Tylenol, but resident kept saying that they were trying to kill her with that medicine, so she would only take one Tylenol. I asked her if she may try to give her something else now since she was quiet. I continued to make my rounds. At approximately 7AM, CNA #5 came to nurse station and asked me to come to residents' room because she was trying to get up. Received resident sitting on edge of bed. Resident would not allow staff to assist her with lying back down, she kept trying to get up. Staff assisted resident to recliner. Resident appeared more relaxed/comfortable once placed in recliner. She did not try to get back up at that present time. Resident was not yelling/screaming prior to me exiting her room. (RN #3) later came in nurses' station and said that resident needed something for pain. I told her that I was in the process of getting it. I called pharmacy, they asked for reference number and said that they would have the on-call pharmacist to give me a call. After a while and no return call, I called MD (facility physician). He voiced that he was unable to get an actual prescription at this time and to send resident out to the ER. Resident's son was at bedside, and I explained that we were going to send resident out to the ER. I had previously talked to him and explained that we had gotten resident up to recliner because she was trying to get up from bed unassisted. He inquired about her not having pain medication. I told him that the nurse at the hospital said that the family did not want her to have any strong pain medicine because it made her loopy, he dropped his head and stated, we were talking about the [MEDICATION(S)]. I explained that if you all weren't specific then the hospital nurse thought they meant all strong pain meds and that I'm sure it was a miscommunication between them and the hospital. Resident was transferred to ER for evaluation. Record review revealed a handwritten statement dated 6/10/22 and signed by (CNA #6) that read: First time we transferred her she did not voice much pain. The second time she hollered as if she was in greater pain. She was coming out of the chair (8:30-9:00) CNA #13, RN #3, and myself pulled her up in chair. She was kicking legs as if nothing had happened to her (as if she hadn't fallen) at that point she was calling out in pain. Pain level was high (10). I did not go back into the room when I walked out resident was screaming, y'all gonna pay for that. Record review revealed a handwritten statement dated 6/10/22 and signed by (CNA #9) along with her address and phone number, the statement revealed: Came in work on 6-4-22 at 11:00 PM. I heard her as soon as I walked in the door. Screaming, and I walk down there to see what was going on and the nurse was in there with her sitting in the chair and she continued all night. About 6:AM that morning I saw the agency nurse. Record review revealed a handwritten statement dated 6/16/2022 signed by (CNA #10) that revealed: I first witnessed the resident when I noticed the (LPN #1) nurse was sitting at the bedside . After talking with the nurse, she asked me to sit for a short moment while she stepped out of the room . Later in the shift, the resident began hollering out loudly and could be heard when passing the room. The nurse again asked me to sit with the resident again while she stepped out. The older nurse (RN#1) also working came in the room with me and the resident. We all observed the resident, which the resident when questioned stated she was in pain. RN #1 suggested the resident needed something for pain. The resident had her mouth open and was crying out to RN #1. LPN #1 returned and both nurses were at the bedside. Record review revealed a handwritten statement signed by three (3) Certified Nursing Assistants (CNA's) (CNA #13); (CNA #5); and (CNA #6). The statement was dated 6/10/22 and revealed: RN #2 came in room she is sitting on side of bed. I asked (RN #2) if we should put her in recliner she said yes, and I called for (CNA #6) and (CNA #13) helped as (RN #2) cannot lift. I got under an arm (CNA #6) got one arm (CNA #13) supported both legs and we manually transported her to chair. She was hollering in pain. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 08/01/2022: Corrective Action Plan IJ-Residents will be assessed, and medications, treatments, and services will be obtained for residents experiencing a change in their condition and/or experiencing pain, the facility will notify the family, the physician, the DON, and the facility administrative staff-Corrective Actions: 1- The facility conducted a thorough investigation and obtained statements from all staff in the facility and determined that an incident had occurred on 06/04/2022 at approximately 10:00 P.M. of a second fall that resulted in a second left hip fracture to Res #1 that went unreported until 06/10/2022. The facility reported the incident to the family of Res #1 on 06/10/2022. 2-The facility conducted an Emergency Quality Assurance Committee meeting on 06/10/2022 with the Medical Director, DON, ADM, SSD, and QA staff all present. The QA committee reviewed all the facility policies and procedures for obtaining MD orders, delivery of medications, Pharmacy procedures and Abuse and Neglect; Using Lifts; Notifications of MD and family and DON and ADM; Care Plans; and Accident Prevention. The facility conducted three (3) additional QA Committee meetings from 06/10/2022-06/16/2022, with the fourth (4th) conducted on 06/16/2022. 3-100% audit of all Incident and Accidents and Falls that had occurred in the facility since January 2022 have been evaluated, reassessed, and reviewed by the QA Committee and Administration of the facility. 4-The facility contacted/reported to the MS State Department of Health, The MS Attorney General's Office; Area Ombudsman, and the MS Board of Nursing, on 06/10/2022 as soon as the unreported fall with a second left hip fracture was reported to the facility. 5-On 06/10/2022 100% Room to Room resident reviews were conducted along with interviews with all residents to assess them for safety and quality of care. All residents were checked for physical and emotional well-being by SSD, DON, and Nursing Staff with no negative findings and no harm was identified. 6-On 06/10/2022 all staff were mandated to attend in-service training on Lifts; Reporting; Assessing Residents; Obtaining Medication Orders; Notifying of Resident Change; Abuse/Neglect; Falls; and Ethics. 7-On 06/10/2022 all staff that worked 7:00 AM-7:00 PM and 7:00 PM- 7:00 A.M. on 06/04/2022 and 06/05/2022 were issued one on one counseling and write ups of discipline were placed in their personnel records. Three (3) staff, RN #1; LPN #1; and CNA #1 were terminated for failure to report an incident and fall for Res #1 and for not following the facility policies and procedures. 8-Resident #1 was transferred to the hospital located approximately 50 miles away for a second left hip surgery on 06/10/2022. Resident #1 was reassessed upon readmission to the facility and new measures put in to place to protect Res #1 from future falls and injuries. Res #1 had pain medications at the facility upon readmission to the facility after the second hip surgery. 9-Facility alleges the relieving of the immediacy of the Immediate Jeopardy (IJ) on 06/16/2022 and Past Non-Compliance. The SA validations of the Facility's Removal Plan/Corrective Action Plans Past Non-Compliance (PNC) were completed by interviews, policy and procedure reviews, record reviews, and observations on 08/01/2022 at 12:00 P.M. - 08/03/2022 at 6:00 P.M. with all staff in the building and via telephone interviews with staff that were terminated or scheduled to work at the facility. The SA validated through record review and observations that the facility had completed their Corrective Actions and had Removed the IJ prior to the SA entering the facility. The Past Non-Compliance was validated and the IJ removed on 06/16/2022. 1- The SA validated through record reviews and interviews from 08/03/2022-08/03/2022 that the facility had conducted a thorough investigation and obtained statements from all staff in the facility and determined that an incident had occurred on 06/04/2022 at approximately 10:00 P.M. of a second fall that resulted in a second left hip fracture to Res #1 that went unreported until 06/10/2022. The SA validated through family (RP) interviews that the facility had reported the incident to the family of Res #1 on 06/10/2022. 2- The SA validated through record reviews and interviews conducted during the complaint investigation on 08/01/2022- 08/03/2022 that the facility had conducted an Emergency Quality Assurance Committee meeting on 06/10/2022 with the Medical Director, DON, ADM, SSD, and QA staff all present. The QA committee reviewed all the facility policies and procedures for obtaining MD orders, delivery of medications, Pharmacy procedures and Abuse and Neglect; Using Lifts; Notifications of MD and family and DON and ADM; Care Plans; and Accident Prevention. The facility provided documentation and interviews that they had conducted three (3) additional QA Committee meetings from 06/10/2022-06/16/2022, with the fourth (4th) conducted on 06/16/2022. 3- The SA validated through interviews and documentation reviews that the facility had conducted 100% audit of all Incident and Accidents and Falls that had occurred in the facility since January 2022 have been evaluated, reassessed, and reviewed by the QA Committee and Administration of the facility. 4- The SA validated through record review and interviews on 08/01/2022 - 08/03/2022 that the facility contacted/reported to the MS State Department of Health, The MS Attorney General's Office; Area Ombudsman, and the MS Board of Nursing, on 06/10/2022 as soon as the unreported fall with a second left hip fracture was reported to the facility. 5- The SA validated through interviews, observations, and record reviews that on 06/10/2022, 100% Room to Room resident reviews were conducted along with interviews with all residents to assess them for safety and quality of care. All residents were checked for physical and emotional well-being by the facility's SSD, DON, and Nursing Staff with no negative findings and no harm was identified. 6- The SA validated through staff and family (RP) interviews and record reviews that on 06/10/2022 all staff were mandated [TRUNCATED]

Based on observation, record reviews, staff interviews, Resident Representative (RR) interview, and facility policy and procedure reviews, the facility failed to ensure Resident (Res) #1 was free of accidents as evidenced by an unwitnessed fall with major injury that occurred on 06/04/2022 after re-admission to the facility following surgery to repair a right [CONDITION(S)]. The staff utilized improper manual lifting techniques when transferring Res #1 from the floor after the fall on 06/04/2022 and failed to document, assess Res. #1 and report to the oncoming shift and administration that the fall had occurred. Res #1 was one (1) of six (6) residents reviewed for accidents/hazards and supervision. On 06/04/2022, Resident #1 had an unwitnessed fall resulting in a right [CONDITION(S)] which required hospitalization for surgical repair. On 06/04/2022, Resident #1 returned to the facility post hip repair. Resident #1 complained of pain and the facility failed to obtain pain medication and provide pain management treatment. The facility failed to provide adequate supervision of Resident #1, who was distressed, agitated, and disoriented and sustained a second fall. The facility nursing staff failed to notify the physician, family, and facility management of the second fall resulting in a delay in treatment and causing Resident #1 to suffer severe and avoidable pain until transferred to the hospital on June 5, 2022, for unresolved pain. While at the hospital it was discovered the resident had a left [CONDITION(S)] that resulted in surgical repair. The facility's failure to supervise Resident #1 causing Resident #1 to fall from bed and sustained a second fractured hip. This situation that has caused Resident #1 serious harm, injury and impairment. This placed other residents in a situation that was likely to cause serious harm, serious injury, serious impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 06/04/2022 when the facility failed to notify the necessary parties of Resident #1's fall and pain. The facility Administrator was notified of the IJ and SQC on 8/3/22 at 4:00 PM and provided the IJ Template. The facility provide a Past Non-Compliance Corrective Action Plan in which the facility alleged all corrective actions were completed to remove the IJ and SQC on 06/16/2022, and the IJ was removed on 06/16/2022. The State Agency (SA) determined the IJ was removed on 06/16/2022, prior to the SA's entrance on 08/01/2022 and was Past Non-Compliance (PNC). Findings include: Review of the facility policy titled Accident / Incident Reporting dated, 01/04, revealed 1. All accidents including residents . will be reported to the Charge Nurse and to the appropriate department head immediately when it occurs, to be evaluated . If there is a fall, the nurse, Certified Nursing Assistant (CNA), or other first responders, completes Form AD-040 and returns it to the Administrator and Director of Nurse (DON) for further investigation and follow-up . Outcomes must be included in this report. Description by Witnesses must be completed using Form AD-031. Witness' statements must accompany all reports. 7. Information regarding accidents/incidents that involve a resident will be recorded in the resident's medical record in the nurses' notes. The attending physician and the responsible party will be notified of the accident /incident according to state guidelines . Record review of the facility policy and procedure Modified Lifting Policy date 01/04, revealed (Formal Name of Facility) will provide a safe work environment for resident care areas by providing the use of safety materials equipment and training designed to prevent personnel and resident injury .Purpose .Mechanical resident lifts are a key component in this effort. Failure to utilize a mechanical resident lift when the use of this equipment is indicated in resident care plan could result in a disciplinary action up to and including termination of employment . On 08/01/2022 at 12:00 PM, an interview with the facility Administrator (ADM) revealed that the facility had received Res #1 back to the facility on Saturday 06/04/2022 at approximately 3:00 PM from the hospital where Res #1 had had a pin placed surgically to her right hip as a result of a fall in the facility on Thursday 06/02/2022. At the time of the first fall on Thursday 06/02/2022, Res #1 was able to relay to the facility that she had fallen in her room as she was attempting to toilet herself. On Thursday 06/02/2022 Res #1 was independently ambulatory with the assistance of a cane and was continent of bowel and bladder. Res #1 was able to relay to the facility staff how she had fallen. Resident was found on the floor of the bathroom with a cut to her eye and pain to her right hip. On Thursday 06/02/2022 Res #1 was transported via ambulance to the local hospital. Hospital x-rayed Res #1 and found her to have a fractured right hip and placed 10 stitches to the cut on her eye. The local hospital transferred Res #1 to the orthopedic unit in another town approximately 50 miles from the facility via ambulance in order to obtain surgery to the right fractured hip. On Friday 06/03/2022 Res #1 had surgery to her right hip and a pin was placed to the hip. On Saturday 06/04/2022 at approximately 3:00 PM, Res #1 arrived back to the facility via ambulance accompanied by her daughter. Later, the daughter inquired about the pain medications for Res #1. The nurse Registered Nurse (RN) #2 told the daughter that the hospital had not sent any orders for pain medications only Tylenol as needed (PRN) for pain. The daughter told RN#2 that Res #1 was voicing pain and needed to have some pain medications ordered. The ADM stated that RN #2 called the hospital and the nurse at the hospital told her that the family had requested no pain medications for Res #1 because it made her loopy. RN #2 called the facility Medical Director (MD) to obtain a verbal order from for [MEDICATION(S)] pain medication per the request of the daughter. RN #2 called the pharmacy and gave the verbal order for [MEDICATION(S)] pain medication and the pharmacy told her that they would call back with the approval and would deliver the medications if approved. RN #2 left the facility at 5:00 PM on Saturday 06/04/2022 and passed on the information to the other nurses at the facility. Later, in the evening of Saturday 06/04/2022 at approximately 7:15 PM, the pharmacy called the facility back and told the 7:00 PM. - 7:00 AM Licensed Practical Nurse (LPN) #1 that they were not allowed to fill a prescription with a verbal order for pain medications ([MEDICATION(S)]) and that a hard copy with a physician's signature was required for all pain medications. LPN #1 did not attempt to obtain the required physician's signature, did not contact or notify the facility physician, did not notify/report to the family, did not call/notify the facility Director of Nursing (DON) and did not notify/call the ADM that the medications were not available, as per facility policy and procedure for notifying. The ADM stated that the facility had a local pharmacy and a back-up pharmacy for obtaining medications. The facility policy is that if a hard copy with a physician's signature is needed or that a medication needs to be obtained, the nurse was supposed to have called the ADM and the DON and they would obtain the hard copy and go pick the medications up and deliver them to the facility. No one contacted the ADM or the DON per facility policy. The staff at the facility reported to the ADM on Friday 06/10/2022 that Res #1 expressed pain and had periods of yelling out in pain with restlessness and confusion throughout the night of Saturday 06/04/2022 and early morning of Sunday 06/05/2022. None of the behaviors of Res #1 were documented, reported, and/or assessed by the facility staff on Saturday 06/04/2022 and 06/05/2022. After a night of pain and restlessness and no pain medications, on 06/05/2022 at approximately 10:00 AM, Res #1 was transferred to the local hospital, with a diagnosis of uncontrolled pain. The administrative staff at the facility had not been notified that Res #1 had fallen in her room on the evening of Saturday 06/04/2022, until Friday 06/10/2022 during interviews with staff. The ADM reported that she received a call from the daughter of Res #1 inquiring about a second fall that had resulted in a second fracture to the opposite (left) hip. The ADM reported that during the first interviews with the evening staff (RN #1, LPN #2, and the CNA's) they all reported that they had no knowledge of a second fall of Res #1 on the evening of Saturday 06/04/2022. There were no documented reports of a fall for Res #1 on Saturday 06/04/2022. On Friday 06/10/2022 CNA #2 reported to the facility Social Service Designee (SSD) that there had been a second facility fall for Res #1 in her room on 06/04/2022 and she had helped to manually pick Res #1 up and place her back in her bed, along with the RN #1, LPN #1, and CNA #1. The four (4) nursing staff picked Res #1 up off the floor manually and placed her back in her bed after she was found on the floor by the facility laundry worker. The ADM stated that the method of lifting that was reported by CNA #2 was not in accordance with the facility policy and procedure. The ADM stated that the facility policy and procedure for lifting a resident up from the floor after a fall was to obtain the full body lift and get them off the floor with the lift and place back in the bed for assessments by the nurse. The ADM stated that none of the facility policies and procedures for notifying, falls/accidents, reporting and assessments had been followed by the staff on Saturday 06/04/2022 during the evening shift. As soon as the ADM had received the report on 06/10/2022 that the staff had not told the truth, about the fall of Res #1, the ADM obtained the hall security camera video and saw the incident of the staff running to Res #1's room at approximately 10:00 PM. The hall camera activity had been identified by the facility ADM and the DON and the video confirmed the incident had occurred on 06/04/2022 at 2155 (9:55 PM) and the staff had responded to Res #1's room. The ADM stated that she had saved the video for her records. The ADM then called all the staff back in and obtained handwritten statements from all staff involved. She stated that RN #1 and LPN #1 were both terminated, and all other staff received counseling with a write up placed in their personnel records. All facility staff were in-serviced on Lifts, Notifying/Reporting; Incidents and Accidents; Pain Management; Obtaining MD and Pharmacy Orders; Visitors Policy; Abuse/Neglect; and Assessments. The facility began working on the investigation and conducted a Quality Assurance (QA) Meeting; reviewed the facility policies and procedures; and in-serviced all the facility staff. The facility ADM stated that the facility staff did not follow the policies and procedures of the facility and that an Immediate Jeopardy (IJ) had existed prior to the State Agency (SA) entering the facility on 08/01/2022. The ADM stated that they immediately on 06/10/2022 assessed all residents in the building and did a complete audit of 100% of all incidents and accidents that had occurred since January 2022. They interviewed all residents that were interviewable on 06/10/2022 and none heard or saw anything with Res #1 on 06/04/2022. The ADM stated that the facility had reported the incident to the Attorney General's Office, the Mississippi State Board of Nursing and to the SA on 06/10/2022. The facility ADM stated that the facility had completed the removal of the (IJ) on 06/16/2022. The ADM had all the investigation materials and the IJ removal documentation in a binder and presented the completed information to the surveyor on 08/01/2022 at 12:45 PM. On 08/01/2022 at 12:45 PM, an interview with the Director of Nursing (DON) revealed that on Saturday 06/04/2022 no facility staff contacted her that Res #1 had been transferred back to the facility. She did not know that Res #1 was back in the facility on 06/04/2022, until she got to work on Monday 06/06/2022. DON confirmed that she had not been given any reports that Res #1 had no pain medications and/or no orders for pain medications and she had no idea that Res #1 had had a second fall in the facility on Saturday 06/04/2022. The DON stated that there was no documentation of a fall for Res #1 in the facility for 06/04/2022. DON stated that the facility had begun in-serving and investigating immediately on 06/10/2022 when it was discovered that Res #1 had fallen a second time in the facility on 06/04/2022. DON stated that the nursing staff on 06/04/2022-06/05/2022 had not followed the facility's policies and procedures for assessing falls, documenting falls, using lifts, notifying of change in conditions, and had not obtained the treatments and medications needed by Res #1. Observation of Resident #1 on 08/01/2022 at 1:00 PM revealed that Res #1 was in her room on A-hall reclined with feet up in a recliner in her room sleeping soundly. There was an alarm attached to her chair. Resident did not awaken. There was no roommate in Res #1 room. Res #1's room was the first door on the left on A-Hall near to the nursing station. Resident was neatly dressed in season appropriate clothing. There was a wing backed padded wheelchair parked in her room. On 08/01/2022 at 3:00 PM, an interview with the Resident Representative (RR), Res. #1's daughter, revealed that she had been staying with her mother at the hospital after a fall in the facility on 06/02/2022 in which Res #1 received a fractured right hip and a cut with stitches to her eye. The RR stated that Res #1 had surgery at the hospital on Friday 06/03/2022 and had been given strong pain medication such as [MEDICATION(S)] while at the hospital. The family had not left Res #1 unattended in the hospital from 6/2/22-6/4/22 RR stated that her brother came to the facility at approximately 6:00 P.M. on 06/04/2022. The RR stated that she accompanied her mother upon re-entering the facility on 06/04/2022 at approximately 3:00 PM and after approximately 30 minutes of being back in the facility Res #1 began to complain of pain. She went to the nursing station and asked if they could give Res #1 some pain medications and was it possible to get her some [MEDICATION(S)] because that seemed to agree with her better and ease her pain. Nurse told RR that she would call and get an order for pain meds because the hospital had not sent any orders with her for pain medications. She assumed that the pain meds would be given to Res #1 when they arrived. The RR stated that her mother was not hollering out and was not restless when she was with her in her room. Upon the arrival of her brother the RR left and went home leaving her brother there with Res #1. No one at the facility notified her or any member of her family that Res #1 had been without pain meds, and no one notified them of any change in Res #1's condition on 06/04/2022. The RR stated that her brother had reported to her that Res #1 was voicing pain while he was at the facility with Res #1 up until approximately 8:00 P.M. when he left. The RR stated that she was told by the facility nurse that the hospital had not given them orders as to the treatment and medication needed for Res #1. The RR stated that she assumed that the facility was obtaining the orders for Res #1's pain medication and treatment orders. She stated that on Sunday morning 06/05/2022 her brother arrived at the facility at approximately 8:00 AM to sit with Res #1 and found that his mother was in uncontrolled pain and Res #1 was sitting in a recliner in her room alone calling out in pain. Her brother was told by the nurse that they put Res #1 in the recliner because she had been trying to get out of bed and she was in pain. Staff told her brother that Res #1 was more relaxed and calm in the recliner and was refusing to stay in bed. RR and brother were concerned about Res #1 being out of bed and sitting up in a chair on her newly pinned right hip. The nurse told her brother that they had called the facility physician and had obtained an order to transfer Res #1 to the local hospital for uncontrolled pain. The nurse told brother that the pain medication never arrived, and that Res #1 had been without pain medications since arriving back to the facility. The family accompanied Res #1 to the hospital emergency room (ER) on 06/05/2022 at approximately 10:00 AM. RR stated that on Thursday 06/09/2022 the Physical Therapist (PT) went to assess Res #1 at the hospital and found Res #1 to be in pain and unable to receive PT services, therefore the PT asked that Res #1 have x-rays and that is when they found the left hip to be fractured and the resident was in need of a second surgery. RR and her family had been with Res #1 and knew that she had not had an injury in the hospital, but the only time they had not stayed with Res #1 was at the nursing home. The hospital physician told the family that a second fall or injury had to have occurred after Res #1 was returned to the facility. RR called the nursing home administrator and told her what had been told to them by the hospital physician. The facility administrator stated to the RR that there were no reported falls for Res #1 on 06/04/2022-06/05/2022. RR stated that later on 06/10/2022 she expressed her anger to the facility Social Services Designee (SSD) and that it was not long after that she received a phone call from the facility administrator telling her that they had discovered that an unreported fall had occurred on 06/04/2022 and that the staff had been disciplined and the nurses terminated. RR stated that her brother did not want Res #1 returned to the facility because they had neglected her and had lied and withheld the fall report. RR stated that Res #1 has now got a bed alarm and a wheelchair alarm in place to signal that she is trying to get up. The RR stated that none of those fall prevention measures were in place for Res #1 on 06/04/2022 when she returned from her first surgery. The RR stated that since the falls that Res #1 had greatly declined and was no longer independently ambulatory with a cane and now she was incontinent of bowel and bladder. RR stated that Res #1 was mentally more confused, and her cognitive status had declined since having the falls. The RR stated that they hope this type of incidents will not ever occur to another resident because it could have been avoided if the nursing staff had done their job and watched out more closely for the resident. Observation on 08/01/2022 at 3:50 P.M. revealed Res #1 sitting with a group of several residents in the front lobby of the facility near the entrance door. Res #1 was sitting in a reclined wing back wheel chair that was padded and was in the reclined position. She presented as quiet and relaxed. When asked questions Res #1 answered with incomplete sentences and salad phrases. When asked how she felt today Res #1 stated waiting on Saturday. Res #1 was not interviewable on 08/01/2022. Res #1 was oriented to self. Res #1 did not present as being in any distress. Her affect was sad and flat. In 08/01/2022 at 4:00 PM, during an interview with CNA #3 she stated that she was working the 3:00-11:00 PM shift on 06/04/2022. CNA #3 stated that Res #1 was calm and relaxed and was not yelling out while her family was with her in her room. CNA #3 stated that after Res #1's family left the facility at approximately 7:30-8:00 PM, Res #1 progressively became more restless and more verbal. CNA #3 passed by Res #1's room at approximately 6:30 P.M. and Res #1 was in her bed and appeared agitated and she was talking out of her head I would say she was out of it. Res #1 was hollering out things like what y'all doing? Res #1 was yelling and was trying to get out of her bed. At about 7:00 P.M. was when LPN #1 came to work on Bhall and she was the nurse for Res #1. There was also CNA #1 that was assigned to work with Res #1 from 3:00 PM to 11:00 PM on 06/04/2022. CNA #3 stated that Res #1 fell out of her bed and on to the floor at approximately 7:30-8:00 PM, shortly after her family had left the facility. CNA #3 was standing out in the hall in front of Res #1's door talking to a housekeeping/laundry staff when they saw Res #1 on the floor. Laundry worker called out for help. CNA #3 stated that CNA #1, CNA #2 and RN #1 (nurse supervisor) and LPN #1 went into Res #1's room at approximately 8:00 P.M. and lifted Res #1 from the floor to the bed. CNA #3 stated that after the fall of Res #1 the LPN #1 said that she was going to go and sit in the room with Res #1 to try and keep her in the bed. CNA #3 stated that Res #1 yelled out and hollered off and on the remainder of her shift. CNA #3 stated that she left the facility at 11:00 PM on 06/04/2022. CNA #3 stated that the CNAs were required to document all changes and all incidents that their assigned residents have during their shift. CNA #3 stated that she had no idea that none of the staff had not reported the fall and she had no idea that Res #1 had no treatment orders. CNA #3 stated that it had always been the policy of the facility to use a full body lift to pick a resident up off the floor after a fall. CNA #3 stated that by not using a lift to pick up a resident that it may cause more unnecessary injury. CNA #3 stated that she was aware that the staff did not follow the facility's policies and procedures for the use of a full body lift after a fall to the floor for Res #1. She only learned on 06/10/2022 that it was not reported and documented. CNA #3 stated that she had attended numerous in-services after the incidents with Res #1. CNA #3 stated that they were in-serviced on the proper use of lifts; falls; reporting/notifying; documenting incidents; assessments; visiting, and ethics. On 08/02/2022 at 12:30 PM, an interview with (CNA #1) she stated that she had worked in the facility on the 7 AM-7PM shift since March of 2022 (approximately 4-5 months). CNA #1 stated that she had been terminated from the facility as a result of the fall of Res #1 on 06/04/2022. CNA #1 confirmed she had been assigned as the CNA for Res #1 on 06/04/2022. CNA #1 stated that she had worked with Res #1 several times during her contract at the facility and she had knowledge of Res #1's surgery on 06/03/2022. CNA #1 stated that a laundry worker called out to the nurse that Res #1 was on the floor and the nurses ran to Res #1's room prior to CNA #1. When CNA #1 got to Res #1's room she saw RN #1, LPN #1 and CNA #2 in the room with Res #1 who was on the floor. RN #1 told them all to assist her in manually picking up Res #1 and putting her back in bed. CNA #1 stated that they all followed the directions of their supervisor. CNA #1 stated that she did not document the fall and did not complete an incident report. CNA #1 stated that Res #1 had been agitated most all night and did yell out in pain. CNA #1 stated that after Res #1 was found on the floor of her room the LPN #1 sat with Res #1 in her room the rest of the night. CNA #1 stated that she had been terminated from the facility for failure to report and document the incident, but no one had asked her to document. The nurse supervisor RN #1 was at the scene of Res #1's fall and was advising them on what to do. CNA #1 assumed that the RN #1 and LPN #1 completed the reporting and documenting. CNA #1 stated that she had been trained that the facility policy was to use a full body lift to pick up a resident from the floor. CNA #1 stated that even though she knew the facility policy for lifting, she also followed the directions of her supervisor (RN #1). CNA #1 stated that she had attended all the in-services for reporting, lifting; documenting, and visiting prior to her termination. On 08/02/2022 at 1:10 PM, an interview with the facility Social Services Designee (SSD) revealed that she had been the SSD since 1990 and had been a CNA. SSD stated that prior to Res #1's first fall on 06/02/2022, Res #1 walked about the facility with a cane and was able to toilet herself and care for most of her own Activities of Daily Living (ADL's) with some supervision from staff. SSD stated that since the falls and surgeries Res #1 had declined and was no longer independent of her ADL's. SSD stated that the facility staff had all attended in-services for supervision of residents; reporting; falls; incident reports; lifts; and abuse and neglect. On 08/02/2022 at 1:20 PM, an interview with CNA #2 revealed that on 06/04/2022 she was working 3:00 PM to 11:00 PM. CNA #2 stated that she helped RN #1, LPN #1 and CNA #1 to pick up Res #1 manually and put her back in the bed from the floor. CNA #2 stated that the incident happened so long ago that the details were now fuzzy to her, and she was unable to recall who all was working as CNA's that night of 06/04/2022. To the best of her memory, she thought that the laundry worker might have been the one that saw Res #1 on the floor and reported it to the nurses. I think (name of HK) said she's on the floor and the nurses and me went running to her room. I don't know where CNA #1 was but she came in later and helped to pick Res #1 up off the floor and get her in the bed. The RN #1 told us to manually pick Res #1 up and put her in the bed. We did what we were supposed to do and followed the supervisor's instructions. We had all been taught that you never manually pick a resident up from the floor. CNA #2 stated that the fall of Res #1 had occurred at approximately 8:30 P.M. on 06/04/2022. CNA #2 stated that yes we could hear her hollering out wanting to get up and out of the bed. We went on our lunch break shortly after that and Res #1 was keeping up some noise. LPN #1 went in and sat with Res #1. I did not document the fall and I did not report the fall because she was not my assigned resident and I assumed that her CNA and the nurse supervisor would have done all of that. I think it was three (3) or maybe four (4) of us CNAs along with the nurse supervisor (RN #1) and LPN #1 that manually picked Res #1 up off the floor and put her back in her bed. All the facility staff has had to attend in-services and give written statements after the incident with Res #1 on 06/04/2022. Nobody asked me anything about the incident until about a week after it happened. We should have used a full body lift to put Res #1 back in her bed after she was found on the floor. During an interview and video observation on 08/02/2022 at 3:30 PM, with the ADM she confirmed that she had the video of the staff running in to Res #1's room at about 10:00 P.M. on 06/04/2022. ADM stated that she, the DON and the cooperate staff had all viewed the video numerous times and they had identified that the first persons to enter the room of Res #1 was CNA #2 and CNA #3. The RN #1 nurse supervisor was the third person to run down the hall and enter the room of Res #1 at approximately 10:00 PM. The ADM confirmed that she had the video saved on her computer and she invited the surveyor to view the video as she narrated the events and identified each staff member that entered Res #1's room. The ADM confirmed that Res #1 did not have a roommate on 06/04/2022 and was alone in her room. The observation of the facility video revealed that the facility staff were rushing to Res #1's room that was located on Hall B on the left-hand side of the hall at about the first or second room behind the nursing station. The ADM identified each of the staff as we watched the video of them running to get to Res #1's room. The time and date on the video were 06/04/2022 at 2155 (military time for 9:55 P.M.). The video showed RN #1 running to Res #1's room and she entered through the door. A few seconds afterwards, LPN #1 ran to Res #1's room. LPN #1 was the last person to enter Res #1's room. After a few minutes RN #1 came out of Res #1's room and returned to the nursing station. LPN #1 came out of Res #1's room and went to the nursing station and got her backpack and some other items and went back to Res #1's room. The ADM gave the surveyor a written statement that she had saved the video of the events of 06/04/2022 to her computer in her office because the video does not automatically safe after a certain length of time and that she was fortunate to have been able to secure the video in a timely manner prior to it being erased. The ADM stated that through watching the video they were able to see the time of the events and who had knowledge of the events. That was how they knew who to interview because the staff had denied the event when first questioned by the ADM on 06/10/2022. ADM stated that they did not follow the facility's policies and procedures. ADM confirmed that all the staff had had one on one counseling and had received write-ups placed in their personnel records. ADM provided copies of all the discipline and counseling sessions that were completed prior to 06/16/2022. The ADM confirmed that all the staff knew better. The ADM confirmed and provided copies of the in-services that the staff had to attend prior to reporting for work on 06/10/2022-06/13/2022. The ADM stated that the IJ removal plan was completed on 06/16/2022. The ADM provided a timeline of the corrective actions that the facility completed on 06/16/2022. On 08/03/2022 at 8:45 AM, an interview with the Medical Director (MD) revealed that he had been called on 06/04/2022 by the facility nurse and was asked for a pain medication for Res #1 and he gave a verbal order for pain medication of [MEDICATION(S)] but had never been contacted that the pharmacy would not accept a verbal order for pain medications. MD stated that he would have expected the staff to have called him and informed him of what was going on with Res #1, but they never called him back with a report and never asked for a transfer of Res #1 to the hospital for pain control. MD stated that the nurses should have contacted him when they were unable to get the pain medication for Res #1. MD stated that Res #1 should never have had to endure pain. MD stated that on the morning of 06/05/2022 he received a call from the nurse that Res #1's medication had not been delivered as ordered and that Res #1 had uncontrolled pain. MD stated that he told the nurse to send Res #1 out immediately to the ER for uncontrolled pain. MD stated that the hospital should not have sent Res #1 back to the facility without pain medications and without orders for treatment. But that once Res #1 arrived back to the facility the nurses should have obtained orders for treatment from the hospital. MD stated that he had not been the surgeon and had no idea what the hospital wanted the facility to do for Res #1 once she arrived back to the facility. That was why he told the nurse to send Res #1 to the ER for treatment of pain. MD stated that no one at the facility had contacted him to tell him that Res #1 had fallen a second time at the facility on 06/04/2022. MD stated that immediately after Res #1 fell in her room on 06/04/2022 she should have been sent out to the ER for evaluation. The MD stated that he was made aware on 06/10/2022 that Res #1 had a second fall in the facility. MD stated that the Quality Assurance (QA) committee met, and they reviewed all their policies and procedures and that they were all in place and were established prior to the fall of Res #1, the staff choose not to follow the facility policies and procedures. On 08/03/2022 at 9:00 AM, in an interview RN #1 stated that she had no idea that the LPN #1 had not notified the facility administration that Res #1 had fallen nor that LPN #1 had not documented the fall. RN #1 stated that she asked LPN #1 if she was an RN and she said yes. RN #1 stated that LPN #1 was an agency nurse, and she did not know her prior to that evening. RN #1 stated that LPN #1 did not wear a name tag and she did not know her name and did not know she was an LPN. RN #1 stated that LPN #1 was the nurse on the B Hall and RN #1 was the nurse for the A hall. RN #1 stated that she did not learn until after the incident that she (RN #1) was the nurse supervisor, she thought LPN #1 was the nurse supervisor. RN #1 stated that she had served as [TRUNCATED]

Based on observations, interviews, record reviews, and facility policy and procedure reviews, the facility failed to ensure Resident #1 was free from neglect when she returned to the facility following right hip surgery and suffered a second fall in the facility which resulted in a second left hip fracture. Res #1 was calling out in pain and the nursing staff neglected to obtain pain medications, to assess and treat Res #1's pain and report a fall. Res #1 was one (1) of six (6) residents reviewed for neglect. On 06/02/2022, Resident #1 had an unwitnessed fall resulting in a right hip fracture which required hospitalization for surgical repair. On 06/04/2022, Resident #1 returned to the facility post hip repair. Resident #1 complained of pain and the facility neglected to obtain pain medication and provide pain management treatment resulting in the resident becoming increasingly distressed and agitated. Resident #1, who was distressed, agitated, and disoriented sustained a second fall. The facility nursing staff failed to notify the physician, family, and facility management of the second fall resulting in a delay in treatment and causing Resident #1 to suffer severe and avoidable pain until transferred to the hospital on 06/05/2022, for unresolved pain. While at the hospital it was discovered the resident had a left hip fracture that resulted in surgical repair. The facility's failure to notify the physician, facility administration, and the Resident Representative of a second fall and neglected to address Resident #1's pain has caused Resident #1 serious harm, injury, and impairment. This placed other residents in a situation that was likely to cause serious harm, serious injury, serious impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 06/04/2022 when the facility failed to assess and treat Resident #1's pain and notify the necessary parties of Resident #1's fall and pain. The facility Administrator was notified of the IJ and SQC on 08/03/2022 at 4:00 PM. The facility provide a Past Non-Compliance Corrective Action Plan in which the facility alleged all corrective actions were completed to remove the IJ and SQC on 06/16/2022, and the IJ and SQC was removed on 06/16/2022. The State Agency (SA) determined the IJ and SQC was removed on 6/16/22, prior to the SA's entrance on 08/01/2022 and was Past Non-Compliance (PNC). Findings include: Review of the facility policy titled: Freedom from Abuse, Neglect, and Exploitation F600-F610 dated revised November 2016. The policy revealed Neglect is a failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. During an interview on 08/01/2022 at 12:00 PM, with the facility Administrator (ADM) revealed that the facility had received Resident #1 (Res) back to the facility on Saturday 06/04/2022 at approximately 3:00 PM, from the hospital where Res #1 had had a pin placed surgically to her right hip as a result of a fall in the facility on Thursday 06/02/2022. At the time of the first fall on Thursday 06/02/2022, Res #1 was able to relay to the facility that she had fallen in her room as she was attempting to toilet herself. On Thursday 06/02/2022, Res #1 was independently ambulatory with the assistance of a cane and was continent of bowel and bladder. Res #1 was able to relay to the facility staff how she had fallen. The resident was found on the floor of the bathroom with a cut to her eye and pain to her right hip. On Thursday 06/02/2022, Res #1 was transported via ambulance to the local hospital. X-ray found her to have a fractured right hip and placed 10 stitches to the cut on her eye. The local hospital transferred Res #1 to the orthopedic unit in another town approximately 50 miles from the facility via ambulance in order to obtain surgery to the right fractured hip. On Friday 06/03/2022, Res #1 had surgery to her right hip and a pin was placed to the hip. On Saturday 06/04/2022, at approximately 3:00 PM, Res #1 arrived back to the facility via ambulance accompanied by her daughter. Later, the daughter inquired about the pain medications for Res #1. Registered Nurse (RN) #2 told the daughter that the hospital had not sent any orders for pain medications, only Tylenol as needed (PRN). The daughter told RN#2 that Res #1 was voicing pain and needed to have some pain medications ordered. The ADM stated that RN #2 called the hospital and the nurse at the hospital told her that the family had requested no pain medications for Res #1 because it made her loopy. RN #2 called the facility Medical Director (MD) to obtain a verbal order for [MEDICATION(S)] pain medication per the request of the daughter, who was at the facility with Res #1. RN #2 called the pharmacy and gave the verbal order for [MEDICATION(S)] pain medication and the pharmacy told her that they would call back with the approval and would deliver the medications if approved. RN #2 left the facility at 5:00 PM on Saturday 06/04/2022 and passed on the information to the other nurses at the facility. Later, in the evening of Saturday 06/04/2022 at approximately 7:15 PM, the pharmacy called the facility back and told the 7:00 PM - 7:00 AM nurse, Licensed Practical Nurse (LPN) #1, that they were not allowed to fill a prescription with a verbal order for pain medications ([MEDICATION(S)]) and that a hard copy with a physician's signature was required for all pain medications. LPN #1 did not attempt to obtain the required physician's signature, did not contact/notify the facility physician, did not notify/report to the family, did not call/notify the facility Director of Nursing (DON) and did not notify/call the ADM that the medications were not available, as per facility policy and procedure for notifying. The ADM stated that the facility had a local pharmacy and a back-up pharmacy for obtaining medications. The facility policy is that if a hard copy with a physician's signature is needed or that a medication needs to be obtained, the nurse was supposed to have called the ADM and the DON and they would obtain the hard copy and go pick the medications up and deliver them to the facility. No one contacted the ADM or the DON per facility policy. The staff at the facility reported to the ADM on Friday 06/10/2022 that Res #1 expressed pain and had periods of yelling out in pain with restlessness and confusion throughout the night of Saturday 06/04/2022 and early morning of Sunday 06/05/2022. None of the behaviors of Res #1 were documented, reported, and/or assessed by the facility staff on Saturday 06/04/2022 and 06/05/2022. After a night of pain and restlessness and no pain medications, on 06/05/2022 at approximately 10:00 AM, Res #1 was transferred to the local hospital, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADM reported that she received a call from the daughter of Res #1 inquiring about a second fall that had resulted in a second fracture to the opposite (left) side/hip. The ADM reported that during the first interviews with the evening staff, RN #1, LPN #2, and the Certified Nursing Assistants (CNA) all reported that they had no knowledge of a second fall of Res #1 on the evening of Saturday 06/04/2022. There were no documented reports of a fall for Res #1 on Saturday 06/04/2022. Later on, Friday 06/10/2022 CNA #2 reported to the facility Social Service Designee (SSD) that there had been a second facility fall for Res #1 in her room on 06/04/2022 and she had helped to manually pick Res #1 up and place her back in her bed, along with the RN #1, LPN #1, and CNA #1. The four (4) nursing staff picked Res #1 up off the floor manually and placed her back in her bed after she was found on the floor by the facility laundry worker. The ADM stated that the methods that were reported by CNA #2 were not in accordance with the facility policy and procedure. The ADM stated that the facility policy and procedure for lifting a resident up from the floor after a fall was to obtain the full body lift and get them off the floor with the lift and place back in the bed for assessment by the nurse. The ADM stated that none of the facility policies and procedures for notifying, falls/accidents, reporting and assessments had been followed by the staff on Saturday 06/04/2022 during the evening shift. As soon as the ADM had received the report on 06/10/2022 that the staff had not told the truth about the fall of Res #1, the ADM obtained the hall security camera video and saw the incident of the staff running to Res #1's room at approximately 10:00 PM. The hall camera activity had been identified by the facility ADM and the DON and the video confirmed the incident had occurred on 06/04/2022 at 9:55 PM and the staff had responded to Res #1's room. The ADM stated that she had saved the video for her records. The ADM then called all the staff back in and obtained handwritten statements from all staff involved. The ADM stated that RN #1 and LPN #1 were both terminated, and all other staff received counseling with a write up placed in their personnel records. All facility staff were in-serviced on Lifts, Notifying/Reporting; Incidents and Accidents; Pain Management; Obtaining MD and Pharmacy Orders; Visitors Policy; Abuse/Neglect; and Assessments. The facility began working on the investigation and conducted a Quality Assurance (QA) Meeting; reviewed the facility policies and procedures; and in-serviced all the facility staff. The facility ADM stated that they admit that the facility staff did not follow the policies and procedures of the facility and that an Immediate Jeopardy (IJ) had existed prior to the State Agency (SA) entering the facility on 08/01/2022. The ADM stated that they immediately on 06/10/2022 assessed all residents in the building and did a complete audit of 100% of all incidents and accidents that had occurred since January 2022. They interviewed all residents that were interviewable on 06/10/2022 and none heard or saw anything with Res #1 on 06/04/2022. The ADM stated that RN #1 was the weekend nurse supervisor and had been employed at the facility since 2016. The LPN #1 was an agency nurse/employee that had worked several weekends at the facility. This was not her first time working on 7:00 PM to 7:00 AM. The ADM stated that the facility had reported the incident to the Attorney General's Office, the MS State Board of Nursing and to the State Agency on 06/10/2022. The facility ADM stated that the facility had completed the removal of the (IJ) on 06/16/2022. During an interview with the DON on 08/01/2022 at 12:45 PM, revealed that she had been contacted by the hospital on the evening of 06/03/2022 that Res #1 had had surgery to her right hip and a pin had been put in the right hip. The hospital asked the DON if the facility planned on allowing Res #1 to return to the facility after discharge from the hospital and the DON stated of course. The DON stated that the hospital did not give any information, nor did she ask for any information, she was merely asked if the facility was willing to accept Res #1 back upon hospital discharge. DON stated that on Saturday 06/04/2022 that no facility staff contacted her that Res #1 had been transferred back to the facility. DON stated that she did not know that Res #1 was back in the facility on 06/04/2022, until she got to work on Monday 06/06/2022. The DON confirmed that she had not been given any reports that Res #1 had no pain medications and/or no orders for pain medications and she had no idea that Res #1 had had a second fall in the facility on Saturday 06/04/2022. She stated that there was no documentation of a fall for Res #1 in the facility for 06/04/2022. The DON stated that the facility had begun in-serving and investigating immediately on 06/10/2022 when it was discovered that Res #1 had fallen a second time in the facility on 06/04/2022. She stated that the LPN #1 and RN #1 were both terminated. The DON stated that the nursing staff on 06/04/2022-06/05/2022 had not followed the facility's policies and procedures for assessing falls, documenting falls, using lifts, notifying of change in conditions, and had not obtained the treatments and medications needed by Res #1. The nursing staff had neglected to manage Res 1's pain. Observation of Resident #1 on 08/01/2022 at 1:00 PM, revealed that Res #1 was in her room on A-hall reclined with feet up in a recliner sleeping soundly. There was an alarm attached to her chair. Resident did not awaken. There was a wing backed padded wheelchair parked in her room. An interview on 08/01/2022 at 3:00 P.M. with Res. #1's daughter, Resident Representative (RR), revealed that she had been staying with her mother at the hospital after a fall in the facility on 06/02/2022 in which Res #1 received a fractured right hip and a cut with stitches to her eye. RR stated that Res #1 had surgery on Friday 06/03/2022 and had been given strong pain medication such as [MEDICATION(S)] while at the hospital. The family had not left Res #1 unattended in the hospital from 06/02/2022-06/04/2022. She stated that she accompanied her mother upon re-entering the facility on 06/04/2022 at approximately 3:00 PM and after approximately 30 minutes of being back in the facility Res #1 began to complain of pain. RR went to the nursing station and asked if they could give Res #1 some pain medications and was it possible to get her some [MEDICATION(S)] because that seemed to agree with her better and ease her pain. The nurse told the RR that she would call and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RR assumed that the pain meds would be given to Res #1 when they arrived. She stated that her mother was not hollering out and was not restless when she was with her in her room. Upon the arrival of her brother the RR left and went home leaving her brother there with Res #1. No one at the facility notified her or any member of her family that Res #1 had been without pain meds, and no one notified them of any change in Res #1's condition on 06/04/2022. The RR stated that her brother had reported to her that Res #1 was voicing pain while he was at the facility with Res #1 up until approximately 8:00 PM when he left the facility. The RR stated that she was told by the facility nurse that the hospital had not given them orders as to the treatment and medication needed for Res #1. The RR stated that she assumed that the facility was obtaining the orders for Res #1's pain medication and treatment orders. The RR stated that on Sunday morning 06/05/2022 her brother arrived at the facility at approximately 8:00 AM to sit with Res #1 and found that his mother was in uncontrolled pain and Res #1 was sitting in a recliner in her room alone calling out in pain. Her brother was told by the nurse that they put Res #1 in the recliner because she had been trying to get out of bed and she was in pain. Staff told her brother that Res #1 was more relaxed and calmer in the recliner and was refusing to stay in bed. The RR and her brother were concerned about Res #1 being out of bed and sitting up in a chair on her newly pinned right hip. The nurse told her brother that they had called the facility physician and had obtained an order to transfer Res #1 to the local hospital for uncontrolled pain. The nurse told him that the pain medication never arrived, and that Res #1 had been without pain medications since arriving back to the facility. The family accompanied Res #1 to the hospital emergency room (ER) on 06/05/2022 at approximately 10:00 AM. The RR stated that on Thursday 06/09/2022 the Physical Therapist (PT) went to assess Res #1 at the hospital and found Res #1 to be in pain and unable to receive PT services, therefore the PT asked that Res #1 have x-rays and that is when they found the left hip to be fractured and the resident in need of a second surgery. The RR and her family had been with Res #1 and knew that she had not had an injury in the hospital, but the only time they had not been with Res #1 was at the nursing home. The hospital physician told the family that a second fall or injury had to have occurred after Res #1 was returned to the facility. RR called the nursing home Administrator and told her what had been told to them by the hospital physician. The facility Administrator stated to the RR that there were no reported falls for Res #1 on 06/04/2022-06/05/2022. The RR stated that later on 06/10/2022 she expressed her anger to the facility Social Services Designee (SSD). The RR stated that it was not long after that she received a phone call from the facility Administrator telling her that they had discovered that an unreported fall had occurred on 06/04/2022 and that the staff had been disciplined and the nurses terminated. The RR stated that her brother did not want Res #1 returned to the facility because they had neglected her and had lied and withheld the fall report. The RR stated that since the falls that Res #1 had greatly declined and was no longer independently ambulatory with a cane and now she was incontinent of bowel and bladder. RR stated that Res #1 was mentally more confused, and her cognitive status had declined since having the falls. The RR stated that they hope this type of incident will not ever occur to another resident because it could have been avoided if the nursing staff had done their job and watched out more closely for the resident. Observation on 08/01/2022 at 3:50 P.M. revealed Res #1 sitting with a group of several residents in the front lobby of the facility near the entrance door. Res #1 was sitting in a reclined wing back wheelchair that was padded and was in the reclined position. She presented as quiet and relaxed. When asked questions Res #1 answered with incomplete sentences and word salad phrases. When asked how she felt today Res #1 stated waiting on Saturday. Res #1 was not interviewable on 08/01/2022. During an interview with CNA #3 on 08/01/2022 at 4:00 PM, she stated that she was working the 3:00-11:00 PM shift on 06/04/2022. CNA #3 stated that Res #1 was calm and relaxed and was not yelling out while her family was with her in her room. CNA #3 stated that after Res #1's family left the facility at approximately 7:30-8:00 PM, Res #1 progressively became more restless and more verbal. Res #1 was hollering out things like what y'all doing? Res #1 was yelling and was trying to get out of her bed. At about 7:00 PM was when the agency nurse (LPN #1) came to work on the Bhall and she was the nurse for Res #1. There was also an agency (CNA #1) that was assigned to work with Res #1 from 3:00 PM to 11:00 PM on 06/04/2022. CNA #3 stated that Res #1 fell out of her bed and on to the floor at approximately 7:30-8:00 PM, shortly after her family had left the facility. CNA #3 was standing out in the hall in front of Res #1's door talking to a housekeeping/laundry staff when they saw Res #1 on the floor. The laundry worker called out for help. CNA #3 stated that CNA #1, CNA #2, RN #1 nurse supervisor and LPN #1 went into Res #1's room at approximately 8:00 PM and lifted Res #1 from the floor to the bed. CNA #3 stated that after the fall of Res #1 LPN #1 said that she was going to go and sit in the room with Res #1 to try and keep her in the bed. CNA #3 stated that Res #1 yelled out and hollered off and on the remainder of her shift. CNA #3 stated that she left the facility at 11:00 PM on 06/04/2022. CNA #3 stated that the CNAs were required to document all changes and all incidents that their assigned residents have during their shift. CNA #3 stated that she had no idea that none of the staff had not reported the fall and she had no idea that Res #1 had no treatment orders. CNA #3 stated that it had always been the policy of the facility to use a full body lift to pick a resident up off the floor after a fall. CNA #3 stated that by not using a lift to pick up a resident that it may cause more unnecessary injury. CNA #3 stated that she was aware that the staff did not follow the facility's policies and procedures for the use of a full body lift after a fall to the floor for Res #1 but only learned on 06/10/2022 that it was not reported and documented. CNA #3 stated that the entire facility staff had attended numerous in-services after the incidents with Res #1. CNA #3 stated that they were in-serviced on the proper use of lifts; falls; reporting/notifying; documenting incidents; assessments; visiting, and ethics. During an interview on 08/02/2022 at 12:30 PM, with CNA #1 she stated that she had been terminated from the facility as a result of the fall of Res #1 on 06/04/2022. CNA #1 confirmed that she had been assigned as the CNA for Res #1 on 06/04/2022. CNA #1 stated that she had worked with Res #1 several times during her contract at the facility and she had knowledge of Res #1's surgery on 06/03/2022. CNA #1 stated that a laundry worker called out to the nurse that Res #1 was on the floor. When CNA #1 got to Res #1's room she saw RN #1, LPN #1 and CNA #2 in the room with Res #1 who was on the floor. RN #1 told them all to assist her in manually picking up Res #1 and putting her back in bed. CNA #1 stated that they all followed the directions of their supervisor. CNA #1 stated that she did not document the fall and did not complete an incident report. CNA #1 stated that Res #1 had been agitated most all night and did yell out in pain. CNA #1 stated that she had been terminated from the facility for failure to report and document the incident, but no one had asked her to document. The nurse supervisor RN #1 was at the scene of Res #1's fall and was advising them on what to do. CNA #1 stated that she had been trained that the facility policy was to use a full body lift to pick up a resident from the floor. CNA #1 stated that even though she knew the facility policy for lifting, she also followed the directions of her supervisor RN #1. CNA #1 stated that she had attended all the in-services for reporting, lifting; documenting, and visiting prior to her termination. During an interview on 08/02/2022 at 1:10 PM, with the facility Social Services Designee (SSD) revealed that prior to Res #1's first fall on 06/02/2022, Res #1 walked about the facility with a cane and was able to toilet herself and care for most of her own Activities of Daily Living (ADLs) with some supervision from staff. The SSD stated that since the falls and surgeries Res #1 had declined and was no longer independent of her ADLs. SSD stated that she attended in-services for supervision of residents; reporting; falls; incident reports; lifts; and abuse and neglect. During an interview on 08/02/2022 at 1:20 PM with CNA #2 revealed that on 06/04/2022 she was working 3:00 PM to 11:00 PM. CNA #2 stated that she helped RN #1, LPN #1 and CNA #1 to pick up Res #1 manually and put her back in the bed from the floor. CNA #2 stated that the incident happened so long ago that the details were now fuzzy to her, and she was unable to recall who all was working as CNAs that night of 06/04/2022. To the best of her memory, she thought that the laundry worker might have been the one that saw Res #1 on the floor and reported it to the nurses. I think (name of HK) said she's on the floor and the nurses and me went running to her room. The RN #1 told us to manually pick Res #1 up and put her in the bed. We did what we were supposed to do and followed the supervisor's instructions. We had all been taught that you never manually pick a resident up from the floor. CNA #2 stated that the fall of Res #1 had occurred at approximately 8:30 P.M. on 06/04/2022. CNA #2 stated that yes we could hear her hollering out wanting to get up and out of the bed. We went on our lunch break shortly after that and Res #1 was keeping up some noise. (LPN #1) went in and sat with Res #1. I did not document the fall and I did not report the fall because she was not my assigned resident and I assumed that her CNA and the nurse supervisor would have done all of that. I think it was three (3) or maybe four (4) of us CNA's along with the nurse supervisor (RN #1) and LPN #1 that manually picked Res #1 up off the floor and put her back in her bed. Nobody asked me anything about the incident until about a week after it happened. We should have used a full body lift to put Res #1 back in her bed after she was found on the floor. During an interview and video observation on 08/02/2022 at 3:30 PM, with the ADM she confirmed that she had the video of the staff running in to Res #1's room at about 10:00 PM on 06/04/2022. The time and date on the video was 06/04/2022 at 2155 (military time for 9:55 PM). The ADM stated that she, the DON and the cooperate staff had all viewed the video numerous times and they had identified that the first persons to enter the room of Res #1 was CNA #2 and CNA #3. The RN #1 nurse supervisor was the third person to run down the hall and enter the room of Res #1 at approximately 10:00 PM. The ADM confirmed that she had the video saved on her computer and she invited the surveyor to view the video as she narrated the events and identified each staff member that entered Res #1's room. ADM confirmed that Res #1 did not have a roommate on 06/04/2022 and was alone in her room. The observation of the facility video revealed that the facility staff were rushing to Res #1's room that was located on Hall B on the left-hand side of the hall at about the first or second room behind the nursing station. The ADM identified each of the staff as we watched the video of them running to get to Res #1's room. The video showed RN #1 running to Res #1's room and she entered through the door. In a few seconds afterwards, the LPN #1 ran to Res #1's room and was the last person to enter Res #1's room. After a few minutes RN #1 came out of Res #1's room and returned to the nursing station. LPN #1 came out of Res #1's room and went to the nursing station and got her backpack and some other items and went back to Res #1's room. The ADM stated that through watching the video they were able to see the time of the events and who had knowledge of the events. That was how they knew who to interview because the staff had denied the event when first questioned by the ADM on 06/10/2022. The ADM confirmed that the staff did not do the right thing for Res #1 and that they did not follow the facility's policies and procedures. The ADM confirmed that all the staff involved had had one on one counseling and had received write-ups placed in their personnel records. ADM provided copies of all the discipline and counseling sessions that were completed prior to 06/16/2022. The ADM confirmed that all the staff knew better. The ADM confirmed and provided copies of the in-services that the staff had to attend prior to reporting for work on 06/10/2022-06/13/2022. The ADM stated that all corrective actions were completed on 06/16/2022 and provided a timeline of the corrective actions that the facility completed on 06/16/2022. During an interview on 08/03/2022 at 8:45 AM, with the facility Medical Director (MD) revealed that he had been called on 06/04/2022 by the facility nurse and was asked for a pain medication for Res #1. He gave a verbal order for pain medication of [MEDICATION(S)] but had never been contacted that the pharmacy would not accept a verbal order for pain medications. The MD stated that he would have expected the staff to have called him and informed him of what was going on with Res #1 but they never called him back with a report and never asked for a transfer of Res #1 to the hospital for pain control. The MD stated that the nurses should have contacted him when they were unable to get the pain medication for Res #1. MD stated that Res #1 should never have had to endure pain. MD stated that on the morning of 06/05/2022 he received a call from the nurse that Res #1's medication had not been delivered as ordered and that Res #1 had uncontrolled pain. MD stated that he told the nurse to send Res #1 out immediately to the ER for uncontrolled pain. MD stated that the hospital should not have sent Res #1 back to the facility without pain medications and without orders for treatment. He said that once Res #1 arrived back to the facility the nurses should have obtained orders for treatment from the hospital. MD stated that he had not been the surgeon and had no idea what the hospital wanted the facility to do for Res #1 once she arrived back to the facility. That was why he told the nurse to send Res #1 to the ER for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The MD stated that immediately after Res #1 fell in her room on 06/04/2022 she should have been sent out to the ER for evaluation. The MD stated that he was made aware on 06/10/2022 that Res #1 had a second fall in the facility. The MD stated that the Quality Assurance (QA) committee met and they reviewed all their policies and procedures and that they were all in place and were established prior to the fall of Res #1. The staff choose not to follow the facility policies and procedures. During an interview with RN #1 on 08/03/2022 at 9:00 AM, revealed RN #1 had no idea that the LPN #1 had not notified the facility administration that Res #1 had fallen. RN #1 stated that she had no idea that LPN #1 had not documented the fall. RN #1 stated that she asked LPN #1 if she was an RN and she said yes. RN #1 stated that LPN #1 was an agency nurse, and she did not know her prior to that evening. RN #1 stated that LPN #1 did not wear a name tag and she did not know her name and did not know she was an LPN. RN #1 stated that LPN #1 was the nurse on the B Hall and RN #1 was the nurse for the A hall. RN #1 stated that she did not learn until after the incident that she (RN #1) was the nurse supervisor, she thought LPN #1 was the nurse supervisor. RN #1 stated that she had served as the nurse supervisor for the 7 PM -7 AM shift at the facility. RN #1 stated that she along with three (3) other CNAs had manually picked up Res #1 and put her back in her bed. RN #1 stated that the facility policy was to use a full body lift to get a resident up from the floor. RN #1 stated that she did not complete an incident and accident report for Res #1. RN #1 stated that Res #1 hollered and yelled out during the night. RN #1 stated that hollering and yelling out was not a new behavior for Res #1. Res #1 usually hollered out and yelled most nights prior to her right hip surgery. RN #1 stated that the facility terminated her for not following the facility's policies and procedures for falls and incidents and accidents. RN #1 stated that she did not assess Res #1 after she was found on the floor, she assumed that LPN #1 had assessed Res #1. RN #1 stated that LPN #1 had gone in Res #1's room and sat with her after the fall but that Res #1 continued to holler out and yell. During an interview on 08/04/2022 at 5:30 PM, with RN #2 revealed she worked from 6:00 AM to 5:00 PM on Saturday 06/04/2022 and she received Res #1 at approximately 3:00 PM from the hospital. RN #2 stated that Res #1 walked with the assistance of a cane prior to the right hip fracture. Res #1 was continent of bowel and bladder and was able to take herself to the toilet. She had no issues with hollering out at night prior to the fall on 06/02/2022. RN #2 stated that Res #1 had declined in her physical and mental status after the fall. RN #2 stated that she ordered the [MEDICATION(S)] for Res #1 and left the facility at 5:00 P.M. with the impression that the pharmacy was delivering the pain medications. RN #2 stated that Res #1 did not complain of pain or holler out prior to 5:00 PM on 06/04/2022. RN #2 stated that the family was with Res #1 and she was calm and relaxed upon entering the facility from the hospital. RN #2 stated that LPN #1 had told her on 06/05/2022 that Res #1 had yelled out and hollered all during the night. RN #2 discovered that the pain medications for [TRUNCATED]

Based on record review, staff interviews, family/Resident Representative (RR) interviews, and facility policy and procedure reviews, the facility failed to notify the physician, the facility administration, and the family/ RR on 06/04/2022 that Resident #1 was yelling out in pain and asking for pain medications after returning to the facility following right hip surgery. The facility failed to notify the DON, the facility administration, the physician, and the family/RR that Resident #1 had a second fall in the facility which resulted in a left hip fracture on 06/04/2022 at approximately 10:00 PM, after her return to the facility following surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/02/2022, Resident #1 had an unwitnessed fall resulting in a right hip fracture which required hospitalization for surgical repair. On 06/04/2022, Resident #1 returned to the facility post hip repair. Resident #1, who was distressed, agitated, and disoriented post hospital return sustained a second fall on 06/04/2022. The facility nursing staff failed to notify the physician, family, and facility management of the second fall resulting in a delay in treatment and causing Resident #1 to suffer severe and avoidable pain until transferred to the hospital on 06/05/2022, for unresolved pain. While at the hospital it was discovered the resident had a left hip fracture that resulted in surgical repair. The facility's failure to notify the physician, facility administration, and the RR caused a situation that has caused Resident #1 serious harm, serious injury and serious impairment and placed other residents at risk for serious harm, serious injury, serious impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) that began 06/04/2022 when the facility failed to notify the necessary parties of Resident #1's fall and pain. The facility Administrator was notified of the IJ on 08/03/2022 at 4:00 PM. The facility provide a Past Non-Compliance Corrective Action Plan in which the facility alleged all corrective actions were completed to remove the IJ on 06/16/2022, and the IJ was removed on 06/16/2022. The State Agency (SA) determined the IJ was removed on 06/16/2022, prior to the SA's entrance on 08/01/2022 and was Past Non-Compliance (PNC). Findings include: Record review of the undated facility policy titled Change In Resident Medical Status revealed: A change in medical status is defined as any physical, psychological, and/or medical deviation as compared to the resident's status as noted in the initial assessment. These changes may include: fall and/or injury, fever, refusal to eat after 24 hour period, confusion or other change in mental behavior. These changes must be noted in: a) Clinical Record, b) Care Plan if significant, c) Accident/Incident Report (if due to fall or injury) . A facility must immediately inform the resident, the physician, responsible party when there is: 1. A need to alter treatment 2. An accident involving the resident which results in injury and has the potential for requiring physician intervention. 3. A significant change in the resident's physical, mental or psychological status. 4. A decision to transfer or discharge the resident from the facility. If the physician is unable to be reached for resident condition change requiring alterative treatment, you should do the following: 1. Notify the Medical Director. If unable to reach, 2. Call the ambulance and transfer to hospital. Interview on 08/01/2022 at 12:00 PM, with the facility Administrator (ADM) revealed that the facility had received Resident #1 back to the facility on Saturday 06/04/2022 at approximately 3:00 PM from the hospital where Resident #1 had a pin placed surgically to her right hip as a result of a fall in the facility on Thursday 06/02/2022. At the time of the first fall on Thursday 06/02/2022, Resident #1 was able to relay to the facility staff that she had fallen in her room as she was attempting to toilet herself. On Thursday 06/02/2022, Resident #1 was independently ambulatory with the assistance of a cane and was continent of bowel and bladder. Resident #1 was found on the floor of the bathroom with a cut to her eye and pain to her right hip. On Thursday 06/02/2022, Resident #1 was transported via ambulance to the local hospital. The hospital x-rayed Resident #1 and found her to have a fractured right hip and placed 10 stitches to the cut on her eye. The local hospital transferred Resident #1 to the orthopedic unit in another town approximately 50 miles from the facility via ambulance in order to obtain surgery to the right fractured hip. On Friday 06/03/2022, Resident #1 had surgery to her right hip and a pin was placed to the hip. On Saturday 06/04/2022, at approximately 3:00 PM, Resident #1 arrived back to the facility via ambulance accompanied by her daughter. Later, the daughter inquired about the pain medications for Resident #1. Registered Nurse (RN) #2 told the daughter that the hospital had not sent any orders for pain medications, only Tylenol as needed (PRN) for pain. The daughter told (RN#2) that Resident #1 was voicing pain and needed to have some pain medications ordered. The ADM stated that RN #2 called the hospital nurse and was told that the family had requested no pain medications for Res #1 because it made her loopy. RN #2 called the facility physician to obtain a verbal order for [MEDICATION(S)] pain medication per the request of the daughter. RN #2 called the pharmacy and gave the verbal order for [MEDICATION(S)] pain medication and the pharmacy told her that they would call back with the approval and would deliver the medications if approved. RN #2 left the facility at 5:00 PM on Saturday 06/04/2022 and passed the information to the other nurses at the facility. Later, in the evening of Saturday 06/04/2022 at approximately 7:15 PM, the pharmacy called the facility and told the 7:00 PM to 7:00 AM nurse Licensed Practical Nurse (LPN) #1 that they were not allowed to fill a prescription with a verbal order for pain medications ([MEDICATION(S)]) and that a hard copy with a physician's signature was required for all pain medications. LPN #1 did not attempt to obtain the required physician's signature, did not contact/notify the facility physician, did not notify/report to the family, did not call/notify the facility DON or ADM that the medications were not available, as per facility policy and procedure for notifying. The ADM stated that the facility had a local pharmacy and a back-up pharmacy for obtaining medications. The staff at the facility reported to the ADM on Friday 06/10/2022, that Resident #1 expressed pain and had periods of yelling out in pain with restlessness and confusion throughout the night of Saturday 06/04/2022 and early morning of Sunday 06/05/2022. None of the behaviors of Resident #1 were documented, reported, and/or assessed by the facility staff on Saturday 06/04/2022 and 06/05/2022, after a night of pain and restlessness and no pain medications. On 06/05/2022 at approximately 10:00 AM, Resident #1 was transferred to the local hospital, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADM reported that she received a call from the daughter of Resident #1 inquiring about a second fall that had resulted in a second fracture to the opposite (left) side/hip. The ADM reported that during the first interviews with the evening staff (RN #1, LPN #2, and the Certified Nursing Assistants (CNA's) they all reported that they had no knowledge of a second fall of Resident #1 on the evening of Saturday 06/04/2022. There were no documented reports of a fall for Resident #1 on Saturday 06/04/2022. On Friday 06/10/2022, CNA #2 reported to the facility Social Service Designee (SSD) that there had been a second facility fall for Resident #1 in her room on 06/04/2022 and she had helped to manually pick Resident #1 up and place her back in her bed, along with the RN #1, LPN #1, and CNA #1.The ADM stated that none of the facility policies and procedures for notifying, falls/accidents, reporting and assessments had been followed by the staff on Saturday 06/04/2022 during the evening shift. As soon as the ADM had received the report on 06/10/2022 that the staff had not told the truth about the fall of Resident #1, the ADM obtained the hall security camera video and saw the incident of the staff running to Resident #1's room at approximately 10:00 PM. The hall camera activity had been identified by the facility ADM and the Director of Nurses (DON) and the video confirmed the incident had occurred on 06/04/2022 at 2155 (9:55 PM) and the staff had responded to Resident #1's room. The ADM stated that she had saved the video for her records. The ADM then called all the staff back in and obtained handwritten statements from all staff involved. The ADM stated that RN #1 and LPN #1 were both terminated, and all other staff received counseling with a write up placed in their personnel records. All facility staff were in-serviced on Lifts, Notifying/Reporting; Incidents and Accidents; Pain Management; Obtaining MD and Pharmacy Orders; Visitors Policy; Abuse/Neglect; and Assessments. The facility began working on the investigation and conducted a Quality Assurance (QA) meeting, reviewed the facility policies and procedures, and in-serviced all facility staff. The facility ADM stated that they admit that the facility staff did not follow the policies and procedures of the facility and that an Immediate Jeopardy (IJ) had existed prior to the State Agency (SA) entering the facility on 08/01/2022. The ADM stated that they immediately on 06/10/2022 assessed all residents in the building and did a complete audit of 100% of all incidents and accidents that had occurred since January 2022. They interviewed all residents that were interviewable on 06/10/2022 and none heard or saw anything with Resident #1 on 06/04/2022. The ADM stated that the facility had reported the incident to the Attorney General's Office and to the Mississippi (MS) State Board of Nursing and to the State Agency on 06/10/2022. The facility ADM stated that the facility had completed the removal of the (IJ) on 06/16/2022. Interview on 08/01/2022 at 12:45 PM, with the DON revealed that she did not know that Resident #1 was back in the facility on 06/04/2022, until she got to work on Monday 06/06/2022. The DON confirmed that she had not been given any reports that Resident #1 had no pain medications and/or no orders for pain medications and she had no idea that Resident #1 had had a second fall in the facility on Saturday 06/04/2022. The DON stated that there was no documentation of a fall for Resident #1 in the facility for 06/04/2022. The DON stated that the facility had begun in-serving and investigating immediately on 06/10/2022 when it was discovered that Resident #1 had fallen a second time in the facility on 06/04/2022. The DON stated that LPN #1 and RN #1 were both terminated. The DON confirmed that RN #1 was the nurse supervisor for the 7:00 PM to 7:00 AM shift for weekends. The DON stated that the nursing staff on 06/04/2022 to 06/05/2022 had not followed the facility's policies and procedures for notifying of change in conditions and had not obtained the treatments and medications needed by Resident #1. Interview on 08/01/2022 at 3:00 PM, with Resident #1's daughter who is her RR, revealed that she had been staying with her mother at the hospital after a fall in the facility on 06/02/2022 in which Resident #1 received a fractured right hip and a cut with stitches to her eye. The RR stated that Resident #1 had surgery at the hospital on Friday 06/03/2022 and had been given strong pain medication such as [MEDICATION(S)] while at the hospital. The RR stated that she accompanied her mother upon re-entering the facility on 06/04/2022 at approximately 3:00 PM and after approximately 30 minutes of being back in the facility Resident #1 began to complain of pain. The RR went to the nursing station and asked if they could give Resident #1 some pain medications and was it possible to get her some [MEDICATION(S)] because that seemed to agree with her better and ease her pain. LPN#1 told the RR that she would call and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RR assumed that the pain meds would be given to Resident #1 when they arrived. The RR stated that her mother was not hollering out and was not restless when she was with her in her room. Upon the arrival of her brother the RR left and went home leaving her brother there with Resident #1. No one at the facility notified her or any member of her family that Resident #1 had been without pain meds, and no one notified them of any change in Resident #1's condition on 06/04/2022. The RR stated that her brother had reported to her that Resident #1 was voicing pain while he was at the facility, up until approximately 8:00 PM, when he left the facility. The RR stated that she was told by the facility nurse that (Formal Name of Hospital) had not given them orders as to the treatment and medication needed for Resident #1. The RR stated that she assumed that the facility was obtaining the orders for Resident #1's pain medication and treatment orders. The RR stated that on Sunday morning 06/05/2022, her brother arrived at the facility at approximately 8:00 AM to sit with Resident #1 and found that his mother was in uncontrolled pain and Resident #1 was sitting in a recliner in her room alone calling out in pain. Her brother was told by the nurse that they put Res #1 in the recliner because she had been trying to get out of bed and she was in pain. Staff told her brother that Resident #1 was more relaxed and calmer in the recliner and was refusing to stay in bed. The RR and brother were concerned about Resident #1 being out of bed and sitting up in a chair on her newly pinned right hip. LPN #1 told her brother that they had called the facility physician and had obtained an order to transfer Resident #1 to the local hospital for uncontrolled pain. LPN #1 told her brother that the pain medication never arrived, and that Resident #1 had been without pain medications since arriving back to the facility. The family accompanied Resident #1 to the hospital emergency room (ER) on 06/05/2022 at approximately 10:00 AM. The RR stated that on Thursday 06/09/2022 the Physical Therapist (PT) went to assess Resident #1 at the hospital and found Resident #1 to be in pain and unable to receive PT services, therefore the PT asked that Resident #1 have x-rays and that is when they found the left hip to be fractured and in need of a second surgery. The RR and her family had been with Resident #1 and knew that she had not had an injury in the hospital, but the only time they had not stayed with Resident #1 was at the nursing home. The hospital physician told the family that a second fall or injury had to have occurred after Resident #1 was returned to the facility. The RR called the Nursing Home Administrator and told her what had been told to them by the hospital physician. The facility Administrator stated to the RR that there were no reported falls for Resident #1 on 06/04/2022 to 06/05/2022. The RR stated that on 06/10/2022 she expressed her anger to the facility SSD. The RR stated that it was not long after that she received a phone call from the facility Administrator telling her that they had discovered that an unreported fall had occurred on 06/04/2022 and that the staff had been disciplined and the nurses terminated. The RR stated that her brother did not want Resident #1 returned to the facility because they had neglected her and had lied and withheld the fall report. The RR stated that Resident #1 was mentally more confused, and her cognitive status had declined since having the falls. In an interview with CNA #3 on 08/01/2022 at 4:00 PM, she stated that she was working the 3:00 PM to 11:00 PM shift on 06/04/2022. CNA #3 stated that Resident #1 was calm and relaxed and was not yelling out while her family was with her in her room. CNA #3 stated that after Resident #1's family left the facility at approximately 7:30 PM to 8:00 PM, Resident #1 progressively became more restless and more verbal. CNA #3 stated that she had served Resident #1 her supper tray at approximately 5:20 PM and the son was in the room with Resident #1. When CNA #3 went in to Resident #1's room and her family was present Resident #1 did not appear in pain and did not voice pain. CNA #3 passed by Resident #1's room at approximately 6:30 PM and Resident #1 was in her bed and appeared agitated and she was talking out of her head. I would say she was out of it. Resident #1 was hollering out things like what y'all doing? Resident #1 was yelling and was trying to get out of her bed. At about 7:00 PM, was when the agency nurse (LPN #1) came to work that BHall and she was the nurse for Resident #1. There was also an agency (CNA #1) that was assigned to work with Resident #1 from 3:00 PM to 11:00 PM on 06/04/2022. CNA #3 stated that Resident #1 fell out of her bed and on to the floor at approximately 7:30 to 8:00 PM, shortly after her family had left the facility. CNA #3 was standing out in the hall in front of Resident #1's door talking to a housekeeping/laundry staff when they saw Resident #1 on the floor. The laundry worker called out for help. CNA #3 stated that CNA #1, CNA #2, RN #1 (Nurse Supervisor) and (LPN #1) went into Resident #1's room at approximately 8:00 PM and lifted Resident #1 from the floor to the bed. CNA #3 stated that after the fall of Resident #1, LPN #1 said that she was going to go and sit in the room with Resident #1 to try and keep her in the bed. CNA #3 stated that Resident #1 yelled out and hollered off and on the remainder of her shift. CNA #3 stated that the CNA 's was required to document all changes and all incidents that their assigned residents have during their shift. CNA #3 stated that she had no idea that none of the staff had not reported the fall. But only learned on 06/10/2022 that it was not reported and documented. CNA #3 stated that she assumed that the nurse supervisor (RN #1) had taken care of everything since she was the one that helped to get Resident #1 up after her fall. CNA #3 stated that the entire facility staff had attended numerous in-services after the incidents with Res #1. CNA #3 stated that they were in-serviced on the proper use of lifts; falls; reporting/notifying; documenting incidents; assessments; visiting, and ethics. In an interview on 08/01/2022 at 4:30 PM, with LPN #2 stated that she was not the assigned nurse for B-hall where Resident #1's room was located, but she was the assigned nurse for A-hall. LPN #2 stated that she worked the 7 AM to 7 PM shift as the A-Hall nurse. LPN #2 stated that she left the facility at 7:00 PM on 06/04/2022 and the family was still visiting with Resident #1 in her room. LPN #2 stated that the second shift nurse supervisor was RN #1. LPN #2 stated that the facility had required that all staff have in-service training after the incidents with Resident #1 on 06/04/2022 and they had been in-serviced on the policies and procedures of the facility, lifts, pharmacy orders, ethics, falls, reporting/notifying, and many others. LPN #2 stated that it had always been the facility policy and procedure to notify the doctor, the family, and the DON of all changes and all incidents. LPN #2 stated that the CNA's and the nurses all knew that a fall had to be assessed and an incident report was to have been completed. In an interview on 08/02/2022 at 12:30 PM, with CNA #1 stated that she had been terminated from the facility as a result of the fall of Res #1 on 06/04/2022. CNA #1 confirmed that she was an agency employee for the nursing company and had been assigned as the CAN for Resident #1 on 06/04/2022. CNA #1 stated that she had worked with Resident #1 several times during her contract at the facility and she had knowledge of Resident #1's surgery on 06/03/2022. CNA #1 stated that a laundry worker called out to the nurse that Resident #1 was on the floor and the nurses ran to Resident #1's room prior to CNA #1. When CNA #1 got to Resident #1's room she saw RN #1, LPN #1, and CNA #2 in the room with Resident #1 who was on the floor. RN #1 told them all to assist her in manually picking up Resident #1 and putting her back in bed. CNA #1 stated that they all followed the directions of their supervisor. CNA #1 stated that she did not document the fall and did not complete an incident report. CNA #1 stated that Resident #1 had been agitated most all night and did yell out in pain. CNA #1 stated that after Resident #1 was found on the floor of her room LPN #1 sat with Resident #1 in her room the rest of the night. CNA #1 stated that she had been terminated from the facility for failure to report and document the incident, but no one had asked her to document. The Nurse Supervisor (RN #1) was at the scene of Resident #1's fall and was advising them on what to do. CNA #1 assumed that RN #1 and LPN #1 completed the reporting and documenting. CNA #1 stated that she had attended all the in-services for reporting, lifting, documenting, and visiting prior to her termination. Interview on 08/02/2022 at 1:20 PM, with CNA #2 revealed that she was working the 3:00 PM to 11:00 PM shift. CNA #2 stated that she was not assigned to Resident #1 on 06/04/2022 that CNA #1 was assigned to Resident #1. CNA #2 stated that she helped RN #1 and LPN #1 and CNA #1 to pick up Res #1 manually and put her back in the bed from the floor. I did not document the fall and I did not report the fall because she was not my assigned resident and I assumed that her CNA and the nurse supervisor would have done all of that. All the facility staff had to attend in-services and give written statements after the incident with Resident #1 on 06/04/2022. In an interview and video observation on 08/02/2022 at 3:30 PM, with the ADM she confirmed that she had the video of the staff running in to Resident #1's room at about 10:00 PM on 06/04/2022. The ADM stated that she and the DON and the corporate staff had all viewed the video numerous times and they had identified that the first persons to enter the room of Resident #1 was CNA #2 and CNA #3. The Nurse Supervisor (RN#1) was the third person to run down the hall and enter the room of Resident #1 at approximately 10:00 PM. The ADM confirmed that Res #1 did not have a roommate on 06/04/2022 and was alone in her room. The observation of the facility video revealed that the facility staff were rushing to Resident #1's room that was located on Hall B. The ADM identified each of the staff as we watched the video of them running to get to Resident #1's room. The time and date on the video were 06/04/2022 at 2155 (military time for 9:55 PM). The video showed RN #1 running to Resident #1's room and she entered through the door. In a few seconds afterwards, LPN #1 ran to Resident #1's room. LPN #1 was the last person to enter Resident #1's room. After a few minutes RN #1 came out of Resident #1's room and returned to the nursing station. LPN #1 came out of Resident #1's room and went to the nursing station and got her backpack and some other items and went back to Resident #1's room. The ADM stated that through watching the video they were able to see the time of the events and who had knowledge of the events. By watching the video, they knew who to interview because the staff had denied the event when first questioned by the ADM on 06/10/2022. The ADM confirmed that all the staff had had one on one counseling and had received write-ups placed in their personnel records. The ADM confirmed that all the staff knew better. The ADM confirmed in-services that the staff had to attend prior to reporting for work on 06/10/2022 to 06/13/2022. The ADM stated that the IJ corrective action plan was completed on 06/16/2022. The ADM provided a timeline of the corrective actions that the facility completed on 06/16/2022. Interview on 08/03/2022 at 8:45 AM, with the facility Medical Director (MD) revealed that he had been called on 06/04/2022 by the facility nurse and was asked for a pain medication for Resident #1 and he gave a verbal order for pain medication of [MEDICATION(S)] but had never been contacted that the pharmacy would not accept a verbal order for pain medications. The MD stated that he would have expected the staff to have called him and informed him of what was going on with Resident #1, but they never called him back with a report and never asked for a transfer of Resident #1 to the hospital for pain control. The MD stated that the nurses should have contacted him when they were unable to get the pain medication for Resident #1 and Resident #1 should never have had to endure pain. The MD stated that on the morning of 06/05/2022 he received a call from the nurse that Resident #1's medication had not been delivered as ordered and that Resident #1 had uncontrolled pain. The MD stated that he told the nurse to send Resident #1 out immediately to the ER for uncontrolled pain. The MD stated that the hospital should not have sent Resident #1 back to the facility without pain medications and without orders for treatment. But that once Resident #1 arrived back to the facility the nurses should have obtained orders for treatment from the hospital. The MD stated that he had not been the surgeon and had no idea what the hospital wanted the facility to do for Resident #1 once she arrived back to the facility and that was why he told the nurse to send Resident #1 to the ER for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The MD stated that immediately after Resident #1 fell in her room on 06/04/2022 she should have been sent out to the ER for evaluation. The MD stated that he was made aware on 06/10/2022 that Resident #1 had a second fall in the facility. The MD stated that the Quality Assurance (QA) committee met, and they reviewed all their policies and procedures and that they were all in place and were established prior to the fall of Resident #1 and the staff choose not to follow the facility policies and procedures. Interview with RN #1 on 08/03/2022 at 9:00 AM, revealed that she had no idea that LPN #1 had not notified the facility administration that Resident #1 had fallen. RN #1 stated that she had no idea that LPN #1 had not documented the fall. RN #1 stated that she asked LPN #1 if she was an RN and she said Yes. RN #1 stated that LPN #1 was the nurse on the B Hall and RN #1 was the nurse for the A hall. RN #1 stated that she did not learn until after the incident that she (RN #1) was the Nurse Supervisor, she thought LPN #1 was the Nurse Supervisor. RN #1 stated that LPN #1 was an agency nurse, and she did not know her prior to that evening. RN #1 stated that she had served as the Nurse Supervisor for the 7 PM to 7 AM shift at the facility. RN #1 stated that she along with three other CNAs had manually picked up Resident #1 and put her back in her bed. RN #1 stated that she did not complete an incident and accident report for Resident #1. RN #1 stated that LPN #1 did not wear a name tag and she did not know her name and did not know she was an LPN. RN #1 stated that Resident #1 hollered and yelled out during the night. RN #1 stated that hollering and yelling out was not a new behavior for Resident #1. RN #1 stated that Resident #1 usually hollered out and yelled most nights prior to her right hip surgery. RN #1 stated that the facility terminated her for not following the facility's policies and procedures for falls and incidents and accidents. RN #1 stated that she did not assess Resident #1 after she was found on the floor. RN #1 assumed that LPN #1 had assessed Resident #1. RN #1 stated that LPN #1 had gone in Resident #1's room and sat with her after the fall but that Resident #1 continued to holler out and yell. In an interview on 08/04/2022 at 5:30 PM, with RN #2 revealed that RN #2 stated that she worked from 6:00 AM to 5:00 PM on Saturday 06/04/2022 and she received Resident #1 at approximately 3:00 PM from the hospital. RN #2 stated that she ordered the [MEDICATION(S)] for Resident #1 and left the facility at 5:00 PM with the impression that the pharmacy was delivering the pain medications. RN #2 stated that Resident #1 did not complain of pain or holler out prior to 5:00 PM on 06/04/2022. RN #2 stated that the family was with Resident #1, and she was calm and relaxed upon entering the facility from the hospital. RN #2 stated that LPN #1 had told her on 06/05/2022 that Resident #1 had yelled out and hollered all during the night. RN #2 discovered that the pain medications for Resident #1 had not been obtained and she immediately called the MD and got orders to have Resident #1 sent to the local hospital for uncontrolled pain. RN #2 stated that she had not received any report that Resident #1 had fallen in the facility on 06/04/2022. Record review of Resident #1's Face Sheet revealed that Resident #1 had been admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The daughter (RR) of Resident #1 was listed on the Face Sheet as the primary RR. Record review of the facility's investigation report on Friday 06/10/2022 revealed that handwritten statements had been obtained and the facility staff had admitted in the handwritten statements that Resident #1 was found on the floor of her bedroom and the facility staff had manually lifted Resident #1 from the floor to her bed on Saturday 06/04/2022 at approximately 10:00 PM under the directions and supervision of the Nurse Supervisor, (RN #1) and LPN #1. The facility staff documented in the handwritten statements that no staff had documented the incident and no staff had reported the incident to the facility or to the family. The staff documented in the handwritten statements that the facility's policies and procedures had not been followed for notifications. Record review of the hand written statement taken by the ADM from a telephone interview with RN #1 dated 06/10/2022 revealed: A employee hollered that Resident #1 was on floor. I was at nurse's station. I went in room. LPN #1 in room with 4 others and I went into see if they needed help. I helped to manually lift her off floor and onto the bed. LPN #1 assessed her on floor. LPN #2 told Resident #1's daughter that her brother could not stay with his mom. I told (Formal Name of LPN #1) she may want to call the DON. I told her to get all her stuff and sit with her Resident #1 the rest of night. LPN #1 asked me near 6 AM if she needed to send Resident #1 out and call the doctor. I did not tell her to send Resident #1 out. She needed to go to the ER. I thought LPN #1 was an RN and she should know what to do. Record review revealed an undated handwritten statement signed by (RN #1) that read On 6-4-22 I was working with an agency nurse and one of our residents was screaming and hollering. We asked had she had any pain medication, other nurses stated family did not want her to have any. I tried to give her a Tylenol resident stated no that's poison. We were called to room saying that resident was in floor, that wasn't witnessed. I was under the assumption the nurse was an RN because I had asked her before, and she had said yes. I told her to call the DON about it. I told her it looked like she would have to take all her stuff in the room due to her getting up. If I had known the agency nurse wasn't an RN, I would have handled the situation myself, and should have done that anyway. The undated handwritten statement was signed by RN #1 with her phone number and her address attached. Record review of the hand written dated 06/10/2022 statement and signed by LPN #1 with her address and phone number rev [TRUNCATED]

Based on observation, staff interview, and facility policy review, the facility failed to provide storage for Resident #16's oxygen (O2) nasal cannula to prevent the possible spread of infection and/or contamination one (1) of four (4) resident's receiving oxygen therapy. Findings include: Review of the facility's Quality Assessment and Assurance Component policy, not dated, revealed: To use disposable tubing, masks, and cannulas for patients receiving oxygen therapy. This equipment is to be discarded as this procedure dictates. 11. When not in use, store the mask/cannula in a plastic bag clearly labeled with the resident's name and date. On 07/30/19 at 1:33 PM, an observation revealed Resident #16 lying in bed with his oxygen cannula on. No storage bag was noted in the room. When asked what he does with his tubing when he is not wearing it, he stated he just wraps it around the machine. Resident #16 stated he has not had a bag to put it in. On 07/31/19 at 3:30 PM, Resident #16 was observed asleep in bed. The resident was not wearing oxygen. The oxygen tubing was wrapped around the O2 concentrator, and not in a storage bag. On 07/31/19 at 4:30 PM, an observation with Registered Nurse (RN) #1 confirmed Resident #16's oxygen cannula was not in a bag. She confirmed the cannula should be in a bag to prevent contamination and possible infection. On 07/31/19 at 4:45 PM, an interview with the Director of Nursing (DON) revealed Resident #16's oxygen cannula should be stored in a bag to prevent possible infection.

Based on staff interview, record review and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for two (2) of 19 residents reviewed. The facility failed to accurately code Resident #28 regarding an anticoagulant medication, and Resident #45 for Urinary Tract Infections (UTIs). Findings include: Review of the facility's Accuracy of Assessments policy, dated (MONTH) (YEAR), revealed the facility must ensure the assessment represents accurately the resident's status during the observation/look back period. Resident #45 Review of the quarterly MDS, dated [DATE], revealed Resident #45 was on an anticoagulant medication for seven (7) days. Review of Resident #45's (MONTH) 2019 physician's orders [REDACTED]. Resident #45 did have orders for [MEDICATION NAME] 75 milligrams (mg) per tube daily for circulation and Aspirin 81 mg per tube daily for circulation. On 07/31/19 at 3:02 PM, an interview with the MDS Coordinator revealed she had several people working part time to assist her with MDSs, and she bet they coded Resident #45's [MEDICATION NAME] as an anticoagulant. The MDS Coordinator stated [MEDICATION NAME] is not an anticoagulant, and should not be coded as such. She stated accuracy of the MDS is important because it reflects the care the resident is receiving and should be correct. The MDS Coordinator stated she reviews all the MDSs and signs off on their completion. She stated she did not catch that it was incorrect. Resident #28 Review of the MDSs for Resident #28, dated 12/10/18 (Significant Change), 03/13/19 (Quarterly), and 06/05/19 (Quarterly), revealed she was coded as having a Urinary Tract Infection [MEDICAL CONDITION]. Review of the physician's orders [REDACTED]. On 07/31/19 at 3:59 PM, an interview with the Director of Nursing (DON) revealed Resident #28 had a UTI in (MONTH) (2018), but not (MONTH) or (MONTH) (2019). The DON stated the nurse completing the MDS did not uncheck the box for UTI. She stated she had a nurse on the floor completing MDSs and the Infection Control Nurse was assisting with MDSs. On 07/31/19 at 4:17 PM, an interview with Registered Nurse (RN) #1 revealed she had assisted with MDSs for about six (6) months, but has limited knowledge regarding completion of the MDSs.

Based on observation, staff interview, and record review, the facility failed to follow the Comprehensive Care Plan for storage of an Oxygen (O2) cannula, for one (1) of 19 care plans reviewed, Resident #16. Findings include: Review of the care plan for Resident #16 revealed a Problem, dated 12/06/18, of requiring use of oxygen PRN (as needed) SOB (shortness of breath). The Approaches included: Make sure oxygen tubing was stored properly when not in use. On 07/30/19 at 1:33 PM, an observation revealed Resident #16 lying in bed with an oxygen cannula on. No storage bag was noted in room. When Resident #16 was asked what he does with his tubing when he is not wearing it, he stated he just wraps it around the machine. He stated he has not had a bag to put it in. On 07/31/19 at 3:30 PM, an observation revealed Resident #16 asleep in bed. The resident was not wearing oxygen. The oxygen tubing was wrapped around the O2 concentrator and not in a storage bag. On 07/31/19 at 4:30 PM, an observation with Registered Nurse (RN) #1 confirmed the resident's oxygen cannula should be in a bag to prevent contamination and possible infection. On 07/31/19 at 4:45 PM, an interview with the Director of Nursing (DON) revealed Resident #16's oxygen cannula should be stored in a bag to prevent possible infection. She confirmed the care plan was not followed.

Based on interview, policy review and facility record review the facility failed to report an unexplained femur fracture for one (1) of six (6) residents reviewed, Resident #6. Findings include: Review of facility policy entitled Abuse, Neglect and Exploitation, with a revision date of 1/29/13, section V revealed: The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators: Physical injury of a resident, of unknown source. Section VII noted that anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected the staff should contact the State Agency to report and document actions taken in the medical record. The Administrator should follow up with government agencies to confirm report was received and to report the results of the investigation when final, as required by state agencies. Review of the facility investigation of an incident, involving Resident #6, revealed on 10/09/17 around 8:45 PM, a nurse was called to Resident #6's room. Two (2) Certified Nurse Assistants (CNA's) reported to the nurse that while preparing the resident for bed, the resident was striking out at staff and hit the bar on the total lift with her right forearm causing it to swing around and hit the resident on the right side of her head. The resident sustained [REDACTED]. The following day, 10/10/17, while bathing the resident, the CNA noted the resident's knee was swollen and painful to touch. Nurses evaluated the knee, called the physician and an order was given to X-ray the knee. The X-ray showed a femoral fracture. The physician ordered repeat X-rays from hip to knee. No further fractures were found. The facility investigated the incident and was unable to determine the exact cause of the fracture. Review of Resident #6's X-ray reports, dated 10/10/17, revealed a prior right total knee replacement with Osteopenia and an acute displaced [MEDICAL CONDITION] right femur with posterior and medial displacement of the distal fracture fragment. Interview with Registered Nurse (RN) #2 on 11/07/17 at 4:30 PM, revealed the facility investigated the incident with Resident #6's skin tear and bump to the head. RN #2 stated the fracture was found the next day. RN #2 stated they notified the Corporate Nurse and were advised that since they were unable to determine the cause of the fracture and the resident had [MEDICAL CONDITION], there was no need to report. Interview with the Director of Nurses (DON) on 11/8/17 at 9:45 AM, revealed Resident #6 did not complain of pain until the next day, after the incident on 10/9/17, and X-rays were obtained which revealed the fracture. The DON stated that the resident had [MEDICAL CONDITION] and both knees had been replaced. She stated that the fracture was adjacent to the artificial knee, which also showed Osteopenia on X-ray. The fracture could have happened at any time. The DON confirmed the facility investigated, but could not find out the exact cause of the fracture. Interview with the Administrator on 11/08/17 at 10:05 AM, revealed they interviewed staff and tried to figure out what happened with Resident #6 to cause the fracture, but was unable to find the cause. The Administrator stated they should have reported the fracture. Review of Resident #6's face sheet revealed the facility admitted the resident on 11/26/11. The resident's [DIAGNOSES REDACTED]. Review of the residents most recent full Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/01/17, revealed staff assessed Resident #6 with moderate cognitive impairment.

Based on observation, staff interview, facility policy review, and record review, the facility failed to ensure resident care equipment was cleaned and stored in a manner to prevent the possible spread of infection for one (1) of one (1) residents reviewed with a continuous positive airway pressure (CPAP) mask; the only resident in the facility with CPAP. (Resident #4) Findings include: Observations on 10/10/17, at 11:30 AM and 4:30 PM, revealed Resident #4's CPAP mask in the bed rails under the bed spread and not covered or bagged. Observations on 10/11/17 at 10:00 AM, at 12:30 PM and 3:30 PM, revealed Resident #4's un-bagged CPAP mask on the floor beside her bed. Observation on 10/12/17 at 10:45 AM, revealed Resident #4's CPAP mask on the nightstand not covered or bagged. Review of Resident #4's Physician order [REDACTED]. Review of Resident #4's Treatment Administration Record (TAR) for October 2017, revealed the CPAP mask to be put on at 8:00 PM and removed at 6:00 AM. Check marks and nurses initials in the 6:00 AM and 8:00 PM slots under the dates 10/01/17 through 10/11/17, indicated the mask was applied and removed on those dates. Further review of the TAR revealed a new entry on 10/12/17, to remove the CPAP mask at 6:00 AM daily and wipe the mask with a damp paper towel and allow to air dry. Interview with Assistant Director of Nurses (ADON) on 10/10/17 at 11:30 AM, revealed staff puts the CPAP mask on Resident #4 at night and takes it off in the morning, but sometimes the resident will take it off herself. The ADON stated there are orders to put the CPAP on and take it off on the TAR, but there are no orders for cleaning/storage that she was aware of. Interview with Registered Nurse (RN) #2, Infection Control Nurse, on 10/12/17 at 12:50 PM, revealed CPAP masks should be in a bag and should be cleaned daily. RN #2 stated the the nurse on duty when the CPAP mask is taken off is responsible for cleaning the mask. RN #2 stated that Resident #4 will take the mask off and put it where ever she wants but the nurses should clean and bag it. RN #2 stated that it was definitely an infection control issue if the mask is on the floor. Interview with Director of Nurses (DON) on 10/12/17 at 1:45 PM, revealed the facility did not have any specific policy for CPAP cleaning and storage. She stated that Resident #4's was the only CPAP in the facility and the CPAP mask should not be in the bed or on the floor, it should be bagged. The DON stated that Nurses are responsible for the cleaning and care of the CPAP equipment and it could cause infection if not cleaned or if left on the floor. Review of the facility's face sheet revealed the facility admitted Resident #4 on 08/31/10. Resident #4's [DIAGNOSES REDACTED]. Review of Resident #4's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/04/17, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderate cognitive impairment.

Based on observation, staff interview, facility policy review and record review the facility failed to develop a comprehensive care plan related to a resident's behavior of pulling out her hair, for one (1) of 14 care plans reviewed, Resident #3. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, with an implementation date of 01/05/17, revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan to meet a resident's medical, nursing, mental and psychosocial needs. The care plan will include an assessment of the resident's strengths and needs. The comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, and any specialized services the nursing facility will provide. The care plan will be reviewed and revised after each comprehensive and quarterly Minimum Data Set (MDS) assessment. Review of Resident #3's current Comprehensive Care Plan revealed no problems, goal or interventions related to the resident's behavior of pulling out her hair and putting it in her mouth. Review of Resident #3's Care Plan Conference Summary with a date of 08/23/17, revealed the resident's daughter was in agreement with her mother's plan of care. Resident is a [MEDICAL TREATMENT] patient- facility has received numerous complaints from nurses at [MEDICAL TREATMENT] unit that resident is disruptive. Her yelling out has begun to annoy others there for treatment. Resident's family was informed of her pulling out her hair and putting in in her mouth. Family agreed to hair being cut very short. Consent form was forwarded to resident's daughter to be signed. Also informed that referral has been sent to mental health consultant. Observation on 10/10/17 at 11:00 AM, revealed Resident #3 sitting in a reclining chair in her room. The hair on the right side of her head appeared much shorter than that on the left. There was a sock on the resident's right hand. Interview with Registered Nurse (RN) #1 on 10/10/17 at 11:00 AM, revealed Resident #3 had started pulling out her hair and putting it in her mouth. RN #1 stated the facility had gotten permission and cut the resident's hair very short but she still pulled at it. RN #1 stated the resident used to just pat herself on the head and this was a fairly new behavior. They put the sock on that hand to keep her from pulling out her hair. Interview with Licensed Practical Nurse (LPN) #1, Minimum Data Set (MDS) and Care Plan Nurse, on 10/12/17 at 11:00 AM, revealed she was aware that Resident #3 had been having some problems at [MEDICAL TREATMENT], hollering and disturbing other patients. LPN #1 stated the resident liked to be left alone. LPN #1 recalled hearing something about Resident #3 hitting herself in the head and pulling out her hair. LPN #1 stated this behavior should have been documented in the nurses notes and care planned. Interview with Director of Nurses (DON) on 10/12/17 at 1:45 PM, revealed some of the Certified Nurse Aids (CNA's) put the sock on Resident #3's hand in hopes of keeping her from pulling out her hair. She stated the resident can and does pull the sock off any time she wishes. The DON stated that Psychology services had been seeing her at the facility and regulating her medication to try to control these behaviors. The DON acknowledged there was no care plan or documented interventions for Resident #3's behavior of pulling out her hair. Review of the facility's face sheet revealed the facility admitted Resident #3 on 03/26/16. The resident's [DIAGNOSES REDACTED]. Review of Resident #3's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/16/17, revealed staff assessed the resident with moderate impairment with cognitive skills for daily decision making.

Based on staff interview, record review and facility policy review, the facility failed to update and revise a care plan for Resident #9 for behaviors after documented incidents. For one (1) of nine (9) care plans reviewed. Findings Include: Review of the facility's policy titled, Care Plan Development, dated May 2014, noted The care plan will be reviewed and revised as needed as the resident's care needs are updated throughout their stay. Record review revealed that the care plan titled, Verbally Abusive Behavior was developed on 05/18/16, and has not been revised or updated since that date. Record review revealed that on 10/26/16, Social Services had written a note that Resident #9 was Cursing and yelling. On 11/04/16, a Social Services note revealed resident was transported to a Geriatric Psychiatric facility and the resident stated, I need to get away from this place for a while. The care plan for Resident #9 was not updated to show the incident on 10/26/16, or the Geri-psych stay on 11/04/16. Interview with RN #3 on 1/5/17 at 6:00 PM, who completes the care plans, stated, I usually don't update the care plan regarding behaviors, the social worker does that, but if we update a care plan we would write it directly on the care plan. Interview with Social Services #1, on 01/05/17 at 6:15 PM, confirmed that she failed to update the care plan after the 10/26/16 incident and again failed to update the care plan after Resident #9 went to Geri-psych. Resident #9 was admitted to the facility on [DATE], with diagnosis, which included, [MEDICAL CONDITION] affecting left nondominant side, Major [MEDICAL CONDITION] and [MEDICAL CONDITION]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/4/16, revealed a Brief Interview for Mental Status (BIMS) revealed a score of 12, indicating moderate to full cognitive ability.

Based on staff interview, record review and facility policy review, the facility failed to prevent and protect a resident from physical abuse for one (1) of nine (9) residents reviewed. Resident #9 Findings Include: Review of the facility's policy titled, Standards of Conduct, with no date, noted, Employees are expected to conduct themselves in a manner that contributes to the quality and reliability of our services. The following conduct is prohibited and will subject the individual involved to disciplinary action, up to and including termination: Any form of resident abuse; Violation of Resident's Rights; Willful insubordination or failure or refusal to carry out job requirements and functions, or job requests from management; Inefficient, negligent or below standard performance. Review of the facility's policy titled, Abuse, with no date, noted, All residents of this facility have the right to be free from verbal, sexual, physical, or mental abuse. The facility must thoroughly investigate all alleged violations and document this investigation. The facility must ensure that results of all investigations are reported to the administrator or designated representative or to other officials in accordance with State Law. Review of the facility's investigation of an incident that occurred on 12/11/16, of abuse by Certified Nursing Assistant (CNA) #3, revealed that the CNA physically hit Resident #9 during an altercation in the hallway around 2:45 PM. Record review revealed that after the body audit was completed that Resident #9 had a red area to the left side of her neck with two (2) small abrasions. The facility report noted, After an investigation of the facts, the employee has been terminated per facility policy for violation of the resident as she slapped the resident as witnessed by two (2) CNA's and two (2) nurses. Record review of CNA #3's employee file revealed a Personnel Action form, dated 03/08/16 for Improper Conduct and Insubordination. The Director of Nursing (DON) counseled CNA #3 and described her as, Lips out, angry expression on face, arms folded, argumentative and defiant attitude. CNA #3 was informed, If she cannot take instruction from charge nurses, she cannot work here. Record review revealed that on 10/10/16, a resident filed a grievance against CNA #3 and documentation included, Spoke harshly to her and that she would rather urinate on self rather than let her (CNA #3) take her to the restroom. Records revealed that CNA #3 was cautioned about her tone of voice. Record review revealed that on 11/03/16 a Personnel Action form was completed on CNA #3 for Insubordination and Failure to Obey Orders. CNA #3 had been told that a resident had to use the restroom and she yelled, She better pee in the bed. Registered Nurse (RN) #1 heard the CNA #3 yell this statement, so the RN#1 asked if she would please put the resident on the bedpan and the CNA #3 still refused. RN#1 provided the care to the resident and notified the DON by phone and she instructed her to tell CNA #3 to clock out and go home. Records and interviews obtained later indicate that CNA #3 was suspended after this incident on 11/03/16, and then brought back to work after investigation. Interview on 01/05/17 at 11:00 AM through 11:55 AM, with the Administrator, DON and Assistant DON, recalled the incident that occurred on 12/11/16 between CNA#3 and Resident #9. The State Agency (SA) asked if there had been any prior incidents with CNA #3 and the DON stated, No, she was a good CNA, she had been here for years, we had never had any issues with her. The DON confirmed that her and her sister both worked at the facility and she felt like this resident did not like these girls from years ago when they lived by her. The DON confirmed that Resident #9 had just gotten back from Senior Care because she had been cussing staff. The DON confirmed that the incident happened around change of shift at 3:00 PM on a Sunday. She said that RN #2 called her and told her about the incident and told her that the CNA had left the building, so she (DON) called CNA #3 and told her that she would be suspended and she told me, I didn't do anything. The DON confirmed that the next morning, on Monday 12/12/16, they called CNA #3 into the facility and obtained a statement from her. We made the decision to terminate her after we obtained the interviews from the staff that witnessed her hit (Resident#9) on the left side of her face/neck area. The DON confirmed that she failed to review her prior write-up's and personnel action forms each time there was a new concern with CNA #3 and that the incidents on 10/10/16 and 11/3/16 were examples of abuse by CNA #3. The Administrator confirmed during this same interview that she was not made aware that there had been any prior concerns with CNA #3. The Administrator confirmed that the CNA should have been terminated after the last write-up on 11/03/16. The Administrator, DON and Assistant DON all confirmed that the 11/03/16 incident is an example of verbal abuse and neglect because she refused to care for a resident in need and then she yelled and told her to pee on the bed. The Administrator stated, I didn't know she had those (write-up), we usually don't do this. We have a zero tolerance for abuse and neglect. Interview and observation with Resident #9 on 01/05/17 at 12:15 PM, revealed the resident sitting in the front lobby in her wheelchair, alert, friendly, smiled often and laughed when she talked. Resident #9 was observed to have a contracted left arm that drew inward to her upper chest. Resident #9 recalled the incident that occurred on 12/11/16 (with CNA #3) and stated, She's got a smart mouth, trying to tell me what to do, I got tired of it. If you hit me, I'm going to hit you back too, so I grabbed her shirt and she hit me. They fired her. Interview with RN #2 on 01/05/17 at 3:35 PM, regarding the incident on 12/11/16, revealed she recalled that she was the charge nurse that day and it was almost time for the shift to end and the funeral home was here to pick up a body, so we had some of the resident's in the dining room and Resident #9 stated that she needed to go to the bathroom and got upset about it. RN #2 stated the next thing she knew, she heard a disturbance and when she looked up, she saw CNA #3 slapping Resident #9. RN #2 stated, I was shocked, I couldn't believe my eyes. RN #2 confirmed that she called the DON and the other nurse that day and tried to talk to CNA #3 but it was time for her to go home, so she left the building. Interview with CNA #2, on 01/05/17 at 4:55 PM, confirmed that she saw CNA #3 hit Resident #9 in the face on 12/11/16, and that Resident #9 had grabbed the CNA's shirt around her stomach area and that the resident was sitting in her wheelchair and the CNA was standing above the resident when she hit her. CNA #2 confirmed that she did not see the resident hit the CNA. An attempt was made and message left for CNA #3 on 1/5/17 at 3:50 PM, with no return call. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/4/16, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate to full cognitive ability.