Every finding on record at MS Care Center of Greenville

Based on resident and staff interviews, record reviews, and facility policy reviews, the facility failed to honor a resident's rights to make her own healthcare decisions for end-of-life care for one (1) of 24 residents reviewed for advanced directives. Resident #3 Findings include: Record review of the facility policy titled, Advance Directives with a revision date of 9/2022 revealed The resident has the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Facility will inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment at the resident's option and to formulate an Advanced Directive. Record review of the Physician Statement of Status of Mental Capacity of Resident dated 1/23/24 revealed that the physician checked Competent, revealing that the resident was able to make her own decisions. Record review of the DNR (Do Not Resuscitate)/Full Code Request and Consent form dated 1/23/24 revealed Resident #3 had not signed her consent form and that it was signed by a family member. In an interview on 2/04/25 at 3:00 PM, Resident #3 revealed she could make her own decisions, and when she was admitted to the facility, no one talked with her about her end-of-life wishes. She revealed her niece had already signed all the paperwork and she did not sign her own Advance Directive. She stated, I had my legs cut off, not my brain, and revealed no one had gone over the paperwork with her. An interview on 2/04/25 at 3:31 PM, with the Admission Nurse revealed that she met with the family and had the paperwork signed prior to the resident's admission. She revealed that their physician also sees the resident prior to admission and deems the resident competent or non-competent in determining whether they can sign their own paperwork. She revealed Resident #3 was deemed competent; however, the niece signed the Advance Directive instead of the resident. She revealed that Resident #3 was able to make her own decisions and should have been given the opportunity to make her own decisions regarding her Advance Directive. An interview on 2/05/25 at 9:40 AM, the Administrator revealed that if a resident is able and competent to sign their own advance directive, the facility should go over the paperwork with the resident and allow them to sign. Record review of the Admission Record revealed Resident #3 was admitted to the facility on [DATE] with medical diagnoses that included Hypertensive Heart Disease with Heart Failure, Cerebral Infarction, Acquired absence of right leg below the knee, and Acquired absence of left leg above the knee. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/6/25, revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #3 was cognitively intact.

Based on staff interview, record review, and facility policy review, the facility failed to accurately complete Section A of the Minimum Data Set (MDS) for a resident with a serious mental illness (SMI) for one (1) of 21 MDS reviewed. Resident #23 Findings Include: Review of the facility policy titled Accuracy of Assessments unrevised revealed, The facility must ensure the assessment represents accurately the resident's status during the observation/look back period. The assessment must be reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline. Record review of the Preadmission Screening and Resident Review (PASRR) Summary of Findings Report dated 11/02/16 revealed under, Mental Health: The individual meets criteria for having a diagnosis of mental illness as defined by PASRR. Also revealed under, Axis I primary a diagnosis of Schizophrenia, paranoid type and under, Axis I secondary a diagnosis of Psychotic disorder. Record review of the Annual MDS with an Assessment Reference Date (ARD) of 4/18/24, revealed under, section A1500, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? No was marked. An interview with the MDS Nurse on 2/04/25 at 3:10 PM confirmed, Resident #23 had a SMI and revealed the MDS was not coded correctly. She explained that she kept a list of the residents that had a Level II but must have overlooked it. The MDS Nurse revealed the purpose of having an accurate assessment was for the staff to provide the best possible care for the residents. An interview with the Administrator on 2/5/25 at 11:36 AM, revealed her expectations were for the MDS to be checked and submitted accurately, so the residents get the best quality of care for mental health. Record review of the Admission Record revealed the facility admitted Resident #23 on 10/12/16 with medical diagnoses that included Paranoid Schizophrenia, Unspecified Psychosis and Hallucinations.

Based on resident and staff interview, record review and facility policy review the facility failed to report an allegation of abuse when a resident reported that a Certified Nursing Assistant (CNA) balled up her fist, placed her knuckles into the resident's thigh and twisted for one (1) of eight (8) residents reviewed for abuse. Resident #1. Findings include: Record review of the facility policy, titled Freedom from Abuse, Neglect and Exploitation revealed, It is the policy of the facility to provide services based on the following requirement .Reporting of Alleged Violations .The facility will ensure that all alleged violations involving abuse .are reported immediately, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . to the Administrator of the facility and State Survey Agency, Adult Protective Services and local law enforcement in accordance with state law . A record review of the facility Resident Incident Report for Resident #1, dated 5/26/24 and completed by Licensed Practical Nurse (LPN) #1, revealed that on 5/26/24, Resident #1 reported that CNA #2, who changed her on the previous shift balled up her fist and placed her knuckles into her thigh and twisted, and pointed at her left thigh. A record review of a witness statement from CNA #1, dated and timed 5/26/24 at 1:10 AM, revealed that Resident #1 told her that on 5/26/24 at 10:30 PM, the CNA took her knuckle and pushed it into the back of her left thigh. In an interview with Resident #1 on 6/3/24 at 2:06 PM, stated that she could not remember the day but when CNA #2 was turning her to clean her up it felt like she was pushing her in the thigh with her fist. During a telephone interview with LPN #1 on 6/3/24 at 2:45 PM, she confirmed that on 5/26/25 around 1:15 AM, CNA #1 informed her that Resident #1 stated that on the previous shift CNA #2 balled up her fist and placed her knuckles into her thigh and twisted. LPN #1 stated that she followed-up with Resident #1 and the resident verified that CNA #2 balled up her fist, placed her knuckles into her thigh and twisted. She stated that she was concerned about the report from the resident and notified the on-call Registered Nurse (RN) because it was an allegation of abuse. In an interview with RN #1 on 6/3/24 at 3:15 PM, she verified that she was the on-call RN on 5/26/24. She stated she received notification from LPN #1 on 5/26/24, of Resident #1's allegation of CNA #2 balling up her fist, placing her knuckles into her thigh and twisting. She stated that on 5/26/24 at 6:00 AM, Resident #1 told her that CNA #2 had come into the room to clean her up and asked her to grab the rail and hold herself. Resident #1 then told RN #1 that she felt CNA #2's fist smash into her left thigh. RN #1 stated that she notified the Administrator and Director of Nursing (DON) immediately because Resident #1's statement was an allegation of abuse. On 6/3/24 at 3:25 PM, during an interview with the DON, she verified that she received a report of Resident #1's allegation from RN #1 on 5/26/24. She stated that the facility did not report Resident #1's complaint of CNA #2 balling up her fist, placing her knuckles into her thigh and twisting because the resident has a history of making false accusations and on completion of their investigation, they could not validate the incident occurred. The DON agreed that Resident #1's complaint should have been considered an allegation of abuse and should have been reported as such. In an interview with the Administrator on 6/3/24 at 4:30 PM, she stated that Resident #1's complaint was not reported because they did not feel it was an allegation of abuse. A record review of the Face Sheet for Resident #1 revealed that the facility admitted the resident on 1/23/2017 with a diagnosis of Flaccid Hemiplegia affecting left non-dominant side. A record review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #1 was cognitively intact.

Based on observations, staff interview, record review and facility policy review the facility failed to implement a care plan for shaving for Resident #26, failed to develop a care plan for maintaining a PICC (peripherally inserted central catheter) line for Resident #62, and failed to implement a care plan for fluid restriction for Resident #69. This was for three (3) of 19 care plans reviewed. Findings include: Review of the facility policy titled Develop/Implement Comprehensive Care Plan with a revision date of September 2022 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 timeframe's to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required . 4. The resident's goals for admission and desired outcomes Resident #26 Record review revealed the resident had a care plan with problem onset date of 9/24/2015, Requires assistance with ADL's (Activities of Daily Living) due to DX (diagnoses) of Parkinson, Decreased Muscle Strength, Impaired Mobility, and Decreased Bed Mobility .Approaches .Assist with ADL's as needed . An observation of Resident #26 on 07/17/23 at 11:39 AM revealed she was sitting up in her wheelchair in the day room with a patch of white hair on both sides of her chin that is approximately 1/4 inch wide and approximately 1/4 inch long. An interview on 7/20/23 at 8:30 AM, with the Administrator and the Corporate Administrator confirmed that the residents Activities of Daily Living (ADL) care plan was not being implemented since the resident had hair on her chin and needed to be shaved. Record review of Resident #26's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia without Behavioral Disturbance. Record review of Resident #26's Minimum Data Set (MDS) with an Assessment Reference Date (ARD)of 5/29/23 revealed in Section G that the resident required total dependence with bathing and in Section C a Brief Interview for Mental Status (BIMS) score of three (3), which indicates the resident is severely cognitively impaired. 47874 Record review of Resident #62's Care Plans revealed a care plan was not developed for the PICC line maintenance. An interview with Registered Nurse (RN) #2 on 7/20/23 at 8:35 AM, confirmed that Resident #62 did not have a care plan for PICC line care. She stated, No ma'am, it's not in there; That's what I'm working on now. She revealed the purpose of developing and implementing a care plan was to make sure that the care was done and individualized to that resident. Record review of Resident #62's Electronic Medication Administration Record (eMAR) revealed an order dated 6/21/23 to flush the PICC line in the left arm with 10 cubic centimeters (CC) of normal saline (NS) before and after each antibiotic. Record review of the Face Sheet revealed Resident #62 was admitted to the facility on [DATE] with medical diagnoses that included Benign Prostatic Hyperplasia, Unspecified Systolic Congestive Heart Failure and Unspecified Atrial Fibrillation. Resident #69 Record review of Resident #69's care plan dated 7/13/23 revealed under intervention, 1200 cc (cubic centimeters) fluid restriction. Dietary to provide 720 cc. Nursing to provide 480 cc with med pass. On 7/18/23 at 4:45 PM, an interview with the DON confirmed that the facility did not monitor or document Resident #69's fluid intake on the Medication Administration Record (MAR) or Activities of Daily Living (ADL's) record. An interview with RN #2 on 7/19/23 at 2:10 PM, revealed the purpose of the care plan was to tell staff what the problem was with the resident and how to address it. She confirmed that staff did not follow the fluid restriction care plan for Resident #69. She stated, They wouldn't know the resident was on a fluid restriction. An interview with the DON on 7/19/23 at 2:30 PM confirmed that Resident #69's care plan was not followed for the fluid restriction and acknowledged that it should have been. An interview with the Assistant Director of Nursing (ADON) on 7/20/23 at 8:40 AM, revealed the purpose of the care plan was to determine what kind of care the resident was to receive. She confirmed that by not developing or implementing the care plan, the facility may fail to provide the care that was needed. Record review of the Face Sheet for Resident #69 revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Systolic Congestive Heart Failure, Hypokalemia, and Major Depressive Disorder.

Based on observation, staff interview, resident interview, record review and facility policy review the facility failed to flush a residents PICC (peripherally inserted central catheter) line for (1) one of (7) seven residents reviewed during medication observations. Resident #62. Findings include: Review of the facility policy titled Central Venous Catheter Procedures PICC/Central Venous Line Dressing and Caps (needleless connector) Change and Care policy revealed under, Policies and Guidelines . Flush PICC line every 12 hours or as ordered by physician . An observation and interview on 7/19/23 at 10:56 AM, with Resident #62 revealed a PICC line to his left upper arm with a dressing intact. Resident #62 revealed he went to the doctor recently and the device was flushed, but they do not flush it here at the facility. Record review of the July 2023 Medication Administration Record (MAR) for Resident #62 revealed an order dated 6/21/23, Normal Saline Flush 1 ML (milliliter) SYR (syringe) flush PICC (peripherally inserted central catheter) line left arm with 10 cc (cubic centimeters) normal saline before and after each antibiotic with a stop date of 7/04/23. Record review of the Physician Orders for the month of July 2023 revealed an order dated 6/22/23, PICC (peripherally inserted central catheter) line left arm sterile dressing change every 7 days: Sterile gloves clean gloves; mask; 4x4's; alcohol swabs occlusive dressing; Barrier for sterile field; An interview with the Assistant Director of Nursing (ADON) on 7/19/23 at 11:00 AM, revealed the resident was recently sent to the hospital for a blood transfusion. She revealed the Nurse Practitioner (NP) was waiting to see if the resident would require any further blood work or transfusions before removing the PICC line and she revealed that the resident had a follow-up appointment with the urologist on 7/17/23 and the NP wanted to leave the PICC line in place until that appointment. An interview with the ADON on 7/19/23 at 1:15 PM, revealed she was not aware that Resident #62's PICC line was not being flushed. She stated, We were flushing it. She revealed that the resident was receiving antibiotics for a UTI (urinary tract infection) and the PICC line flush order must have stopped when the antibiotic was completed on 7/04/23. She confirmed that they should be flushing it every day to maintain patency and prevent occlusion. An interview with the Director of Nursing (DON) on 7/19/23 at 1:30 PM, revealed she was not aware that Resident #62's PICC line was not being flushed every day. She stated, The order was entered with a stop date for when the IV antibiotic was completed. She revealed the NP wanted the line left in until he followed up with the Urologist. An interview with the NP on 7/19/23 at 1:45 PM, revealed the PICC line should still be flushed, and she stated, Yes, I didn't know that it wasn't, I can re-order that. She confirmed that flushing the PICC line could prevent the line from occluding. An interview with the DON on 7/19/23 at 2:00 PM, confirmed that Resident #62 should have an order to flush his PICC line and confirmed that by not doing this, the line could clot off. Record review of the Face Sheet revealed Resident #62 was admitted to the facility on [DATE] with medical diagnoses that included Benign Prostatic Hyperplasia, Unspecified Systolic Congestive Heart Failure and Unspecified Atrial Fibrillation. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/5/23 revealed under section C a Brief Interview for Mental Status (BIMS) score of 12, indicating resident #62 is moderately cognitively impaired.

Based on observations, staff interview, resident interview, record review and facility policy review the facility failed to shave a resident that was dependent on staff for bathing and personal hygiene for one (1) of 74 residents reviewed during initial tour. Resident #26 Findings Include: Review of the facility policy titled Mississippi Care Center-ADL (Activities of Daily Living) Care Provided for Dependent Residents with a review date of 09/22 revealed, Residents who are unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . An observation on 07/17/23 at 11:39 AM, revealed Resident #26 sitting up in her wheelchair in the day room with a patch of white hair on both sides of her chin that is approximately 1/4 inch wide and approximately 1/4 inch long. An interview and observation on 7/18/23 at 12:45 PM, with Certified Nurse Assistant (CNA) #2 revealed that Resident #26 is in an A bed and those baths are performed on Monday-Wednesday and Friday's. She stated that all personal hygiene care goes along with the resident's baths to include shaving. During an observation of Resident #26, CNA #2 confirmed that Resident #26 had hair on her chin and when the CNA asked the resident if she wanted it shaved off , the resident stated, If it's there then it needs to be off, I did not even know it was there CNA #2 confirmed that she should have been shaved and she would take care of it. An interview on 7/18/23 at 1:10 PM, with the Director of Nurses (DON) confirmed that female residents need to be shaved of facial hair when they have their baths unless the resident refuses. Record review of Resident #26's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia without Behavioral Disturbance. Record review of Resident #26's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/29/23 revealed in Section G that the resident required total dependence with bathing and in Section C a Brief Interview for Mental Status (BIMS) score of 3, which indicates the resident is severely cognitively impaired.

Based on observation, resident and staff interview, record review and facility policy review the facility failed to provide appropriate incontinent care treatment to prevent the potential for infection for one (1) of four (4) residents observed for care observations. Resident #21. Findings include: A review of the facility policy titled Incontinence, revised September 2022, revealed based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. The Policy Explanation and Compliance Guidelines revealed: Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. An interview on 07/17/23 at 11:13 AM, with Resident #21 revealed she doesn't feel like they clean her good. On 7/19/23 at 8:02 AM, an observation of Resident #21's incontinent care with Certified Nursing Assistant (CNA) #1 revealed that she did not change gloves after setting up the wash basin. CNA #1 wet a bath cloth, wiped across the resident's lower abdomen and groin areas. She then placed the contaminated bath cloth back in the clean water basin and wiped more than one area with the same area of the bath cloth. An interview on 07/19/23 at 09:45 AM, with Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 regarding the incontinent care process, LPN #1 stated that the staff should clean with a different area of the bath cloth from top to bottom with one swipe with each different location. RN #1 stated that CNA #1 should have used two basins. An interview on 07/19/23 at 10:00 AM, with CNA #1 regarding incontinent care confirmed that she put the dirty bath cloth back into clean water and contaminated the clean water and she should not wipe more than once with the same area of the bath cloth. An interview on 7/20/23 at 9:50 AM, with the Director of Nursing (DON) confirmed staff does annual competency check offs but the staff does get nervous. A review of facility in-service records revealed that CNA #1 attended an in-service on incontinent care on 01/30/23 and successfully performed skills check off for incontinent care on 07/20/22. A review of the facility Face Sheet for Resident #21 revealed she was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus, Intracerebral Hemorrhage, and Needs assistance with personal care. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #21 was cognitively intact.

Based on observations, resident and staff interview, record review and facility policy review the facility failed to follow a physician prescribed fluid restriction for (1) one of (4) four residents on dialysis. Resident #69 Findings include: Review of the facility policy titled Fluid Restriction policy dated 12/13/2018 revealed, Fluid restriction orders will be carried out as ordered by the physician by the nursing and dietary departments 2. Fluids ordered for the resident will be divided between the Nursing and Dietary departments. 3. Fluids determined to be used by Dietary will be sent out on the meal tray. 4. All fluids given by the aides will be recorded in the resident's room on a fluid intake form. 5. Fluids determined to be used by nursing will be divided between their medication passes. 6. Fluids given by the nurses on medication passes are to be recorded on the eMAR (electronic medication administration record). 7. Fluid intake sheet will be totaled, and a 24-hour total entered on the eTAR (electronic treatment administration record). An observation and interview with Resident #69 on 7/18/23 3:15 PM, revealed that he did not have a water pitcher in his room. The resident revealed that he goes by his fluid restriction. He stated, Pretty much, I drink only what they bring me. Record review of the July 2023 Physician Orders revealed an order dated 6/06/23, 1200 cc (cubic centimeter) fluid restriction R/T (related to) ESRD (End Stage Renal Disease) Record review of the July 2023 Medication Administration Record (MAR) revealed Resident #69 did not have an order listed for fluid restriction or a monitoring tool to track fluid intake within a 24-hour period. An interview with the Director of Nursing (DON) on 7/18/23 at 4:15 PM, revealed that the aides would know not to give Resident #69 any fluids because he doesn't have a water pitcher in his room. An interview on 7/18/23 at 4:30 PM with Medical Records revealed that Resident #69's fluid restriction was not added on the Activities of Daily Living (ADL) task for the aides to document. An interview with the DON on 7/18/23 at 4:45 PM, confirmed that the facility did not monitor or document Resident #69's fluid intake on the MAR or ADL's. She confirmed that this should have been done, and that this could cause the resident to be in fluid volume overload. She also confirmed that they did not provide a breakdown of the total number of fluids that the resident should receive between nursing and the dietary department in a 24 -hour period. She stated, No, we didn't do it. An interview with Certified Nurse Aide (CNA) #3 on 7/19/23 at 8:00 AM, revealed she was able to identify if a resident was on a fluid restriction because the resident will not have a water pitcher in their room. She stated, The fluid restriction will be on their meal slip. She revealed that Resident #69 does go by his ordered fluid restriction. She stated, He may ask for 1/2 (one-half) cup of coffee in the mornings, and we have to check with the nurse before getting it. An interview with Registered Nurse (RN) #2 on 7/19/23 at 2:10 PM, revealed Resident #69 did not have an order for a fluid restriction on the MAR or ADL. She stated, They (the staff) wouldn't know the resident was on a fluid restriction because it's not on there (the ADL or MAR). An observation of Resident #69's Medical Record with the Minimum Data Set (MDS) on 7/20/23 at 9:15 AM, confirmed that the resident did not have a fluid restriction task on the ADL's. Record review of the Face Sheet for Resident #69 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Systolic Congestive Heart Failure, Hypokalemia, Gastro-Esophageal Reflux Disease Without Esophagitis, and ESRD. Record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 7/07/23 revealed under section C a Brief Interview for Mental Status (BIMS) score of 99, indicating Resident #69 was unable to complete the BIMS.

Based on observation, resident and staff interviews, record review, and facility policy review the facility failed to post an oxygen in use sign outside the door and to label oxygen tubing and a humidifier bottle for one (1) of four (4) residents reviewed that were receiving oxygen. Resident #21. Findings include: Record review of a procedure Nursing Department Infection Control undated, revealed .Respiratory Equipment: .Oxygen tubing .When not in use, store the mask/cannula in a plastic bag labeled with the resident's name and date . An observation on 07/17/23 at 11:11 AM, revealed, Resident #21's oxygen tubing and humidifier bottle were not labeled and dated. The cannula was laying on the floor underneath the overbed table. No oxygen in use signage was on the door. An observation and interview on 07/19/23 at 8:16 AM, with the Director of Nursing (DON) confirmed, Resident #21's oxygen tubing was laying on the floor and the oxygen tubing and humidifier water bottle was not labeled. The DON stated that the procedure should be to change tubing every seven days and that tubing should be labeled with time, date and initials. The DON stated that the water bottle on the concentrator should be changed every thirty days and should be labeled with time, date, and initials. The DON stated that the tubing should be stored in a plastic bag when not in use and should not be laying on the floor to prevent infection. The DON confirmed that there was not an oxygen sign on the door. A record review of the Physician Orders dated 07/17/23 revealed Oxygen at two (2) liters per minute by nasal cannula as needed. An observation and interview with Resident #21 on 07/19/23 at 04:30 PM, revealed the oxygen tubing and humidifier bottle remained unlabeled and the tubing was laying on the floor. Resident #21 stated she doesn't use it all the time, just when she thinks she needs it. A review of the facility Face Sheet revealed Resident #21 was admitted to the facility on [DATE] with diagnoses that included Congestive Heart Failure, Human Immunodeficiency Virus, Essential Hypertension and Cough. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #21 was cognitively intact.

Based on observations, staff interviews, record review and facility policy review the facility failed to prevent the possibility of infection as evidenced by failing to perform hand hygiene, provide a clean workspace, change gloves and keep oxygen tubing off the floor and in a plastic bag for one (1) of four (4) resident care observations. Resident #21 Findings include: A review of the facility policy titled Infection Control, revised September 2022, revealed: Staff involved in direct resident contact will perform hand hygiene (even if gloves are used). Hand hygiene is performed: After removing personal protective equipment (e.g., gloves, gown, facemask). Gloves changed and hand hygiene performed before moving from a contaminated body site to a clean body site during resident care. Oxygen tubing, when not in use, store the mask/cannula in a plastic bag labeled with the resident's name and date. An observation, on 07/17/23 at 11:11 AM, revealed Resident #21's oxygen tubing and humidifier bottle were not labeled and dated. The cannula was laying on the floor underneath the overbed table. , An observation and interview on 07/19/23 at 8:16 AM, with the Director of Nursing (DON) confirmed, Resident #21's oxygen tubing was laying on the floor. The DON stated that the tubing should be stored in a plastic bag when not in use and should not be laying on the floor to prevent infection. An observation on 07/19/23 at 08:24 AM, of incontinent care with Certified Nursing Assistant (CNA) #1 revealed, she set up a wash basin on the overbed table of Resident #21. There was an open container of juice, toothpaste, a comb, jewelry, and a contact case on the same table with the wash basin. CNA #1 did not change gloves after setting up the wash basin. CNA #1 wet a bath cloth and wiped across the resident's lower abdomen and groin areas and placed the contaminated bath cloth back in clean water basin and reused it. CNA #1 wiped more than once with the same area of the bath cloth and left the dirty bath cloth on the bed. CNA #1 positioned Resident #21 on her right side. CNA #1 then got a new bath cloth and did not change gloves. CNA #1 looked over resident #21's room for briefs touching items in drawers, touching furniture, the bed and the privacy curtain. CNA #1 then put on clean gloves without performing hand hygiene. CNA #1 then applied skin protectant, did not change gloves and then applied a clean brief to Resident #21. An interview on 07/19/23 at 09:45 AM, with Registered Nurse (RN)#1 and Licensed Practical Nurse (LPN) #1 regarding incontinent care process revealed, LPN #1 stated that gloves should be changed frequently, and staff's hands should be washed each time gloves are changed. LPN #1 stated that the staff should clean with a different area of the bath cloth from top to bottom with one swipe with each different location. RN #1 stated that CNA #1 should have used two wash basins. An interview on 07/19/23 at 10:00 AM, with CNA #1 confirmed she put the dirty bath cloth back into the clean water and contaminated the clean water. CNA #1 stated that there should not have been anything on the table with the basin and confirmed there was open apple juice and other items on the table. She stated that having the items on the table was an infection control problem. An interview on 7/20/23 at 9:50 AM, with the DON confirmed staff does annual competency check offs, but the staff does get nervous. Record review of the Face Sheet for Resident #21 revealed Resident #21 was admitted to the facility on [DATE] with diagnoses that included Congestive Heart Failure, Human Immunodeficiency Virus, Essential Hypertension and Cough. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #21 was cognitively intact.

Based on facility policy review, resident interview, staff interviews, and record reviews, the facility failed to respect a resident's rights, as evidenced by a staff member calling a resident boy for one (1) of six (6) residents reviewed. Resident #1 Findings include: Review of facility policy titled, Resident Rights Policy/F550 Resident Rights/Exercise of Rights, with a revised date of 9/2022, revealed Facility will ensure the resident has the right to a dignified existence . Facility will treat each resident with respect and dignity . The facility will protect and promote the rights of each resident . An interview with the Ombudsman on 3/28/23 at 08:30 AM, revealed she had been involved with Resident #1 regarding his complaint of being called a boy by the Registered Nurse (RN) Supervisor on 2/10/23 and she noted that Resident #1 was very upset by the incident. An observation and interview on 3/28/23 at 06:50 PM, with Resident #1 revealed he was called a boy by the RN Supervisor on 2/10/23. Residents #1 revealed he was getting off the second (2nd) floor elevator when the RN Supervisor asked him Where you going boy? Resident #1 noted he heard the RN Supervisor but did not respond. Resident #1 then revealed the RN Supervisor expressed You're on the wrong floor aren't you boy? Resident #1 stated that he responded after being called a boy the second time and cursed the RN Supervisor. He informed the RN Supervisor that he was a grown man and should be called Mr. or Sir. Resident #1 revealed he was very upset from being called a boy and did not feel as he was being respected by the RN Supervisor. An interview on 3/28/23 at 07:45 PM, with Social Services revealed she spoke with Resident #1 on 2/10/23 regarding the incident where the RN Supervisor called him a boy. She noted Resident #1 was noticeably upset and cursed often in his description of the incident. Social Services revealed Resident #1 was still upset about the incident on 2/12/23, as he continually expressed his feelings about it, and how it bothered him. An interview on 3/28/23 at 07:52 PM, with the RN Supervisor, confirmed he did call Resident #1 a boy on 2/10/23. He noted he patted Resident #1 on the shoulder and he said, You are on the wrong floor boy. He confirmed that Resident #1 became furious with him but could not remember everything Resident #1 said. He stated he did remember him expressing that he was a grown man and should not be called a boy. He also revealed that when Resident #1 became as mad as he did, he realized what he had done by calling Resident #1 a boy. He expressed that he had addressed Resident #1 incorrectly and should have called him Mr. An interview on 3/29/23 at 05:40 PM, with the Director of Nursing (DON) revealed that the RN Supervisor did report that he called Resident #1 a boy on 2/10/23 and confirmed that the RN Supervisor should have treated Resident #1 with dignity and respect by addressing him as Mr. or Sir. An interview on 3/29/23 at 06:35 PM, with the Former Administrator in Training (AIT) ,that was working at the facility during the time of the incident revealed that she did not feel that Resident #1's Resident Rights were violated because the RN Supervisor did not mean anything by calling Resident #1 a boy. She revealed it was done in a playful manner and was not intended to violate Resident #1. A telephone interview on 3/30/23 at 11:41 AM, with the Former Interim Administrator, that was working at the facility during the time of the incident confirmed that Resident #1's Resident Rights were violated by the RN Supervisor by calling Resident #1 a boy and not Mr. or Sir on 2/10/23. Record review of the Face Sheet for Resident #1 revealed an admitted [DATE] and diagnoses that included Acquired Absence of Limb, Unspecified, and Unspecified Sequelae of Cerebral Infarction. Record review of Section C of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/2023, for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 is cognitively intact.

Based on facility policy review, record review, resident interview, and staff interviews the facility failed to include a resident in the development of his person-centered Trauma Informed care plan for one (1) of seven (7) residents reviewed for care plans. Resident #1. Findings include: Review of the facility policy titled F553 Right To Participate In Planning Care, with a revision date of 9/2022, revealed, The right to participate in the development and implementation of their person-centered plan of care including but not limited to: a. The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions of the person-centered plan of care. b. The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. c. The right to be informed, in advance, of changes to the plan of care. Record review of the Care Plan for Resident #1 revealed Problem Onset: 2/10/2023 Resident stated he has a HX of trauma. Res. reported that he has encountered racism as a child and witnessed a Caucasian murder an African American which took an emotional effect on him. Certain words trigger flash backs. Example boy . Social to visit as needed. Engage in activities of choice. Speak with a Mental health Therapist to verbalize my feelings. Consult Psych as needed. An interview on 3/28/23 at 06:50 PM, with Resident #1 revealed he had not been spoken to by Social Services about a Trauma Informed care plan to show how they were going to help him work this through the incident. An interview on 3/28/23 at 07:45 PM, with Social Services revealed she did develop a Trauma Informed care plan for Resident #1 confirmed that she did not give him the opportunity to participate in the development of the care plan and confirmed that she did not inform him in advance of changes to his care plan. An interview on 3/29/23 at 06:35 PM, with the Former Administrator in Training (AIT) that was working at the facility during the time of the incident did not confirm that Resident #1 should have been allowed to be involved in the development of his Trauma Informed care plan. She noted that Resident #1 agreed to his full care plan on 2/14/23, with no complaints, when reviewed with him by the Care Plan Nurse and Social Services even though he was noted by Social Services to not have been involved in the development of it on 2/10/23. A telephone interview on 3/30/23 at 11:00 AM, with Social Services revealed she did not go to Resident #1's room with the Care Plan Nurse to discuss and review the Trauma Informed care plan and had only signed the staff sheet attached to Resident #1's care plan after the Care Plan Nurse informed her she had a care plan meeting with Resident #1. She noted she was not aware of the level of explanation Resident #1 was given regarding his Trauma Informed care plan. A telephone interview on 3/30/23 at 11:41 AM, with Former Interim Administrator, that was working at the facility during the time of the incident, confirmed Resident #1 should have been allowed to participate in the development of his Trauma Informed care plan, to enable him to have an adequate person-centered plan of care. An interview on 3/30/23 at 01:20 PM, with the Care Plan Nurse revealed she was not aware of the development of the Trauma Informed Care Plan for Resident #1 until she was preparing to have her care plan meeting on 2/14/23 with Resident #1. Record review of the Face Sheet for Resident #1 revealed an admitted [DATE] and diagnoses that included Benign Prostatic Hyperplasia Without Lower Urinary Tract, Acquired Absence of Limb, Unspecified, and Unspecified Sequelae of Cerebral Infarction. Record review of Section C of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/2023, for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 is cognitively intact.

Cross Reference F699 Based on facility policy review, resident interview, facility staff interviews, and record review, the facility failed to resolve a grievance for a resident, for one (1) of six (6) residents reviewed for an unresolved grievance. Resident #1 Findings include: Review of the facility policy titled, F585 Grievances, with a revision date of 9/2022, revealed The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. The facility will make information on how to file a grievance or complaint available to the resident. Record review of the Grievance/Complaint dated 2/13/2023, for Resident #1, revealed Date of Grievance/Complaint 2/10/23 . Explanation/Nature of Complaint: Res. approached SW stating he needed to talk. SW invited Res. into a private location. (SW office). Res. stated he was on the second floor, about to get off the elevator when (RN Supervisor's Name Removed) stated to him Boy you on the wrong floor. Boy where are you going? Res. expressed that he did not like being called a boy because he is a grown man; Summary of the pertinent finding of conclusions: SW spoke with DON (DON's Name Removed) who stated (RN Supervisor's Name Removed) was only joking and did not mean anything by calling Res. a boy. (RN Supervisor's Name Removed) apologized to Res. immediately. However, Res. stated he did not hear (RN Supervisor's Name Removed) apologizing; Corrective Action Taken: DON in serviced (RN Supervisor's Name Removed), informing him that he can not refer to Res. by anything other than their preferred name or Mr. or Mrs. ADMINISTRATOR along with AIT and resident had a meeting. Res. informed staff on why he didn't like the word boy. Resident stated he did not like being called a boy d/t racism and witnessing the murder of an African American. Res. stated the word boy makes him have flashbacks. Staff was unaware of the traumatic experience Res. stated he encountered. Res. agreed to have a conversation with (RN Supervisor's Name Removed). (RN Supervisor's Name Removed) apologized again to (Resident #1's Name Removed) and they were able to shake hands; Date and discussion with resident of the findings: 2/10/23; Is this matter resolved?: Yes; Was a copy of written findings requested? No; Was a copy of written findings provided? No; Is further action necessary? No . 2/12/23-Res. informed SW that he does not desire d/c and that he had another plan. SW asked Res. did he need any assistance Res. stated Its my personal business. Record review of the Departmental Notes/Social Notes, for Resident #1 revealed 2/13/23 . Grievance verbalized by this Res. on 2/10/23 is currently being investigated. SW reported Grievance to Local Ombudsman, who was present today and she went and spoke with Res. Res. came back to this SW and stated his advocate told him that this SW was suppose to file a Grievance and that he has to sign it. SW informed Res. that the Grievance had been initiated but it was not complete. Res. requested a copy. SW printed a copy for Res. Res. reviewed the Grievance and stated This shit ain't right, He called me a boy twice. SW changed Nature of Complaint. Res then stated, That's some bullshit he did not apologize to me. SW deleted that [NAME] had apologized. SW informed Res. that this information was given and put in by this SW and the details of the grievance came from the DON. SW also explained that the Grievance process is not complete until the DON has added how she plans to address issue. Res. then stated She ain't got shit to do with this. SW informed Res. that the DON is responsible for addressing grievances that are filed towards her staff. On 3/28/23 at 08:30 AM, during an interview with the Ombudsman revealed she had been involved with Resident #1 regarding his complaint of being called a boy by the Registered Nurse (RN) Supervisor on 2/10/23. She noted that Resident #1 was very upset by the incident, and that he had revealed he did not feel the nursing facility would do anything about it since the RN Supervisor's Supervisor, the Director of Nursing (DON), was his fiance. She revealed Resident #1 told her being called a boy by a Caucasian male was very upsetting, she informed Resident #1 that he can be active in his grievance process. The Ombudsman told Resident #1 that he had the right to see what had been put in writing, by the nursing facility, regarding his grievance being resolved. She noted Resident #1 did meet with the Interim Administrator, and the RN Supervisor, but he informed the Ombudsman that he was still not satisfied with how the incident was being resolved. An interview on 3/28/23 at 06:50 PM, with Resident #1 revealed he was called a boy by the RN Supervisor on 2/10/23. Resident #1 revealed he was getting off the second (2nd) floor elevator when the RN Supervisor ask him Where you going boy? Resident #1 revealed he went to Social Services to talk with her on that same day to get help regarding the incident, was told by Social Services that she would write it down for him but he did not feel anything would be done about it since the DON is the RN Supervisor's fiance. Resident #1 expressed that he felt the DON should not be involved in the investigation, due to her relationship with the RN Supervisor. He noted he met with the two (2) lady bosses, the Interim Administrator and the Former Administrator in Training (AIT), and the RN Supervisor, on the Monday after the incident happened. Resident #1 discussed the conversation he had with the Ombudsman on 2/13/23, after meeting with the Interim Administrator and the RN Supervisor, about not being satisfied with the results of the meeting. He noted the Ombudsman informed him he could request a copy of his grievance form to see what was written on it. He revealed he went to Social Services, and she provided him with a copy of the grievance report and that Social Services had not discussed his grievance with him after he initially reported the incident with her. He shared that he was upset that the grievance report showed the DON was active in the investigation process and he was not satisfied with the information that had been recorded on the grievance report by Social Services. Resident #1 noted that none of the facility staff tried to tell him how the incident was going to be handled. An interview on 3/28/23 at 07:45 PM, with Social Services, revealed she spoke with Resident #1 on 2/10/23 regarding the incident where the RN Supervisor called him a boy and his wanting to be moved to another nursing facility. She revealed she started the grievance process and documented, on the grievance form, as she was provided information by the staff members involved in the investigation. She noted she was informed by the Interim Administrator of the meeting with Resident #1 on 2/13/23 and of the resolution between Resident #1 and the RN Supervisor. She confirmed she resolved the grievance and did not discuss it with Resident #1. An interview on 3/29/23 at 06:35 PM, with the Former AIT/Administrator confirmed that Resident #1 should have been talked to by Social Services before the grievance was resolved and Resident #1 should have been allowed to fully participate in the grievance process. A telephone interview on 3/30/23 at 11:41 AM, with Former Interim Administrator/Corporate Nurse, revealed she did not inform Social Services to resolve Resident #1's grievance on 2/13/23. She confirmed that Resident #1 should have been involved in his grievance process/resolution of his grievance, and has had an unresolved grievance since 2/10/23. Record review of the Face Sheet for Resident #1 revealed an admitted [DATE] and diagnoses of Benign Prostatic Hyperplasia Without Lower Urinary Tract, Essential (primary) Hypertension, Elevated Blood-Pressure Reading, Without Diagnosis of Hypertension, Other Sleep Disorder Not Due to a Substance or Known Physiological Condition, Acquired Absence of Limb, Unspecified, and Unspecified Sequelae of Cerebral Infarction. Record review of Section C of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 2/8/2023, for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 is cognitively intact.

Based on facility policy review, resident interview, staff interviews, and record review, the facility failed to implement a Trauma Informed Care Plan for a resident in need of trauma informed care for one (1) of six (6) residents reviewed for care plans. Resident #1 Findings include: Review of the facility policy titled, 656 Develop/Implement Comprehensive Care Plan, with a revised date of September 2022, revealed The facility will . implement a comprehensive person-centered care plan for each resident . that includes measurable objectives and timeframes to meet the resident's . mental and psychosocial need that are identified in the comprehensive assessment. Record review of the Care Plan for Resident #1 revealed Problem Onset: 2/10/2023 Resident stated he has a HX of trauma. Res. reported that he has encountered racism as a child and witnessed a Caucasian murder an African American which took an emotional effect on him. Certain words trigger flash backs. Example boy . Social to visit as needed. Engage in activities of choice. Speak with a Mental health Therapist to verbalize my feelings. Consult Psych as needed. An interview on 3/28/23 at 06:50 PM, with Resident #1 revealed he had not spoken with anyone regarding a Trauma Informed care plan and wanted help to work through the trauma so he would not get upset again. Resident #1 stated that no staff had come to check on him to see how he was making it since the incident, nor had anyone spoken to him about options to deal with the bad feelings that were brought back to his memory. An interview on 3/28/23 at 07:45 PM, with Social Services confirmed she did not implement the Trauma Informed care plan and had not referred Resident #1 to any mental health services for him to work through his feelings about the trauma. She revealed she had not visited Resident #1 as indicated on the Trauma Informed Care Plan and had not worked with the nursing staff to get a physician's order for a referral to a psychiatrist for Resident #1. She revealed she did inform the Activities Director that the activities department will have responsibilities listed to implement in the Trauma Informed Care Plan on 2/10/23. An interview on 3/29/23 at 02:20 PM, with the Activities Director revealed she was not aware that Resident #1 had a Trauma Informed care plan and had not assessed Resident #1 for additional activities to implement the activities intervention of the Trauma Informed care plan. The Activities Director revealed she did not talk with Social Services regarding a Trauma Informed care plan, that she was not aware of the traumatic incident with Resident #1 being called a boy by the RN Supervisor on 2/10/23, and that Social Services could have possibly spoken with the Assistant Activities Director. An interview on 3/29/23 at 02:30 PM with the Assistant Activities Director revealed she had not been informed that Resident #1 had a Trauma Informed care plan but did come across it in record review in the electronic health record (EHR) last week when she updated other residents' Activities care plan. She revealed she did not assess Resident #1 for additional options for activities to assist to occupy him related to the incident of him being called a boy by the RN Supervisor on 2/10/23. An interview on 3/29/23 at 05:40 PM, with the Director of Nursing (DON), revealed she was aware that Social Services developed a Trauma Informed care plan for Resident #1 on 2/10/23 and had not attempted to obtain an order for a psychiatrist consult for Resident #1. The DON confirmed Resident #1 should have been referred to psychiatry services due to the level of how upset he was regarding his recent trauma from being called a boy by the RN Supervisor on 2/10/23. An interview on 3/29/23 at 06:35 PM, with the Former AIT/Administrator confirmed that the Trauma Informed care plan should have been implemented for Resident #1. A telephone interview on 3/30/23 at 11:41 AM, with the Former Interim Administrator confirmed that Resident #1's Trauma Informed care plan should have been implemented to assist him to work through his recent trauma and to avoid the possibility of psychosocial harm. Record review of the Physician Orders List revealed there was no physician's order for a referral to mental health services for Resident #1. Record review of the Face Sheet for Resident #1 revealed an admitted [DATE] and diagnoses that included Acquired Absence of Limb, Unspecified, and Unspecified Sequelae of Cerebral Infarction. Record review of Section C of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/2023, for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 is cognitively intact.

Cross reference F585 Based on facility policy review, observations, resident interviews, staff interviews, and record reviews, the facility failed to provide trauma-informed care and failed to complete a trauma-informed care assessment properly for a resident experiencing trauma, as evidenced by a resident's behaviors related to a nursing facility staff member calling him a boy for one (1) of six (6) residents reviewed for trauma. Resident #1. Findings include: Review of the facility policy titled, F699 Trauma Informed Care, with a revision date of September 2022, revealed, .1. The facility will ensure that residents who are trauma survivors receive culturally-competent, trauma care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Collaboration - There is an emphasis on partnering between residents and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care. Trustworthiness and transparency - Efforts to establish a relationship based on trust, and clean and open communication between the staff and the resident. 4. Facility will use a multi-pronged approach to identifying a resident's history of trauma as well as his or her cultural preferences. This includes asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools . 8. Facility will provide cultural competencies to help staff communicate effectively with residents and their families and help provide care that is appropriate to the culture and the individual. Cultural competence refers to a person's ability to interact effectively with person of cultures different from his/her own. An interview on 3/28/23 at 08:30 AM, with the Ombudsman revealed she had been involved with Resident #1 regarding his complaint of being called a boy by the Registered Nurse (RN) Supervisor on 2/10/23. She noted that Resident #1 was very upset by the incident and that he had revealed he did not feel the nursing facility would do anything about it since the RN Supervisor's Supervisor was his fiance, the Director of Nursing (DON). She revealed Resident #1 told her being called a boy by a Caucasian male caused him to have flashbacks of traumatic racial events from his youth and he had witnessed a racially motivated homicide as a child. She noted Resident #1 met with the Interim Administrator, the Former Administrator in Training (AIT)/Administrator (that was working at the facility at the time of the incident), and the RN Supervisor on 2/13/23, but he informed the Ombudsman that he was still not satisfied with how the incident was being resolved. The Ombudsman revealed she met with the Interim Administrator, AIT, who is now the nursing facility's Administrator, the DON, and Social Services (SS), on 2/13/23, immediately after Resident #1's meeting, and was informed, by the Interim Administrator, that the situation had been calmed down, and that Resident #1 was satisfied with the results of the meeting with the Interim Administrator and RN Supervisor. An observation and interview on 3/28/23 at 06:50 PM, with Resident #1 revealed he was called a boy by the RN Supervisor on 2/10/23. Resident revealed he was getting off the second (2nd) floor elevator when the RN Supervisor asked him Where you going boy? Resident #1 noted he heard the RN Supervisor but did not respond. Resident #1 then revealed the RN Supervisor expressed You're on the wrong floor aren't you boy? Resident noted he responded after being called a boy the second (2nd) time, cursed the RN Supervisor as he informed him that he was a grown man, was old enough to be the RN Supervisor's father, and did not appreciate being called a boy. Resident #1 then revealed being called a boy was racist to him and it brought back horrible memories of racism from his childhood and when he was a younger adult. Resident #1 shared information of witnessing a racially motivated homicide when he was a child and was often called a boy by Caucasians in the 1960's to be degraded. Resident noted all those feelings came rushing back to him and made him feel that he was back in one of those degrading situations. State Agency (SA) observed Resident #1 became tearful and was angrily cursing when recounting the information of what he experienced when he was younger. Resident revealed he went to Social Services to talk with her on that same day to get help regarding the incident, was told by Social Services that she would write it down for him, but he did not feel anything would be done about it since the DON was the RN Supervisor's fiance. Resident #1 expressed that he felt the DON should not be involved in the investigation, due to her relationship with the RN Supervisor. He noted he met with the two (2) lady bosses, the AIT/, and the RN Supervisor, on the Monday after the incident happened, and the RN Supervisor apologized to him. He shared that he did accept the RN Supervisor's apology, shook his hand, but told the RN Supervisor that he did not believe his apology was sincere. Resident #1 discussed the conversation he had with the Ombudsman on 2/13/23, after meeting with the Interim Administrator, the Former AIT/Administrator, and the RN Supervisor, about not being satisfied with the results of the meeting. He revealed he went to Social Services, and she provided him with a copy of the grievance report and that Social Services had not discussed his grievance with him after he initially reported the incident to her. He shared that he was upset that the grievance report that showed the DON was active in the investigation process, and he was not satisfied with the information that had been recorded on the grievance report by Social Services. Resident #1 also revealed the meeting with the AIT, and RN Supervisor called with him after he had gotten upset and strongly expressed himself verbally, again, in the Social Services office after reading the information on the grievance form. Resident noted there were only Caucasian staff members in the meeting on 2/13/23, and he felt they had gotten together to force him to accept the RN Supervisor's apology. Resident #1 shared that he felt he could no longer trust the lead Caucasian staff and Social Services at the nursing facility. Resident #1 noted that none of the nursing facility staff tried to tell him how the incident was going to be handled, or to talk with him to check and see how was managing since it made him very upset. Resident #1 also noted he did not to talk about it anymore with the lead staff in the nursing facility. Resident #1 revealed he was having a harder time sleeping and was stressed with all the thoughts of his past being on his mind, most of his day, and there were no activities offered to help keep his mind occupied. Resident #1 also shared that several employees saw him while he was upset and no one attempted to comfort him, nor appeared to care about him being upset, and he no longer felt he was being protected. An interview on 3/28/23 at 07:45 PM, with SS revealed she spoke with Resident #1 on 2/10/23 regarding the incident where the RN Supervisor called him a boy and his wanting to be moved to another nursing facility. SS revealed Resident #1 was still upset about the incident on 2/12/23, as he continually expressed his feelings about it, and how it bothered him. SS revealed she did not conduct follow up visits with Resident #1 to see how he was managing after the incident and was not aware he was having issues sleeping or was continually reliving traumatic moments from his past. She revealed she would ask him how he was doing when she saw him moving about the facility, and because he had a BIMS of 15, he could express to her if he had issues related to the incident. She noted she did not link him to any mental health services to assist him to work through the trauma. She revealed she had done a Trauma Informed Care Assessment for Resident #1 but did not review the questions with Resident #1 for the answers entered on the assessment. An interview on 3/28/23 at 07:52 PM with RN Supervisor confirmed he did call Resident #1 a boy on 2/10/23. He revealed he was on the 2nd floor and saw Resident #1 coming off the elevator and Resident #1 is not normally on the 2nd floor. He noted he was being playful with Resident #1, patted Resident #1 on the shoulder, and stated You are on the wrong floor boy. He confirmed that Resident #1 became furious with him, could not remember everything Resident #1 said, but did remember him expressing that he was a grown man with children older than the RN Supervisor and the RN Supervisor will not call him a boy. He also revealed when Resident #1 became as mad as he did, he realized what he had done by calling Resident #1 a boy, and knew it was wrong, but had said it without thinking about what it could mean to Resident #1. He noted could tell that Resident #1 was still not ready to talk with him by the way Resident #1 responded to each of the attempts by the RN Supervisor to talk to Resident #1. He revealed he was not aware that Resident #1 still had possible anxiety and loss of sleep due to the incident and had not talked to any other nursing staff to see if they had followed up on Resident #1. An interview on 3/29/23 at 02:20 PM, with the Activities Director revealed she had not assessed Resident #1 for additional activities to assist to occupy his mind and help him work through his trauma. The Activities Director revealed that she was not aware of the incident with Resident #1 being called a boy by the RN Supervisor on 2/10/23. An interview on 3/29/23 at 02:30 PM with the Assistant Activities Director, revealed she did not assess Resident #1 for additional options for activities to assist to occupy him related to trauma he experienced due to the incident from 2/10/23 of him being called a boy by the RN Supervisor. An interview on 3/29/23 at 05:40 PM, with the DON revealed Resident #1 did not have an order to be assessed by psychiatry to be evaluated for possible psychiatric interventions to assist him to work through the trauma. She noted she was not aware that Resident #1 was still upset regarding the incident. She revealed there was skilled monitoring and documentation being done by the nurses after the incident with Resident #1 that happened on 2/10/23 but confirmed there was no specification that the documentation was skilled monitoring related to the incident. An interview on 3/29/23 at 06:35 PM, with the Former AIT/Administrator revealed she did not agree that the incident should be related to Trauma Informed Care due to Resident #1 not initially expressing that his anger was related to a past trauma, and him only revealing he felt he should be respected by the RN Supervisor related to his age. She noted it was later that Resident #1 started to state that the incident caused him trauma and flashbacks of previous life events. An interview on 3/30/23 at 10:35 PM, with the Administrator and the DON revealed both noting Resident #1 did not tell them or any staff members that he was still having derogatory feelings related to the incident of being called a boy on 2/10/23. They both confirmed that they did not address Resident #1 specifically about the incident after 2/10/23. A telephone interview on 3/30/23 at 11:05 AM, with Licensed Practical Nurse (LPN) #1, revealed Resident #1 came to her several times on 2/12/23 to talk about being upset regarding being called a boy by the RN Supervisor on a previous day. A telephone interview on 3/30/23 at 11:41 AM, with Former Interim Administrator, revealed she had a meeting on 2/13/23 with Resident #1 and noted that he expressed why being called a boy by the RN Supervisor bothered him so badly. She revealed she did not follow up to ask Resident #1 how he was doing related to the incident. The Former Interim Administrator confirmed that Resident #1 should have received trauma informed care to avoid the possibility of psychosocial harm, and that the facility staff did not provide trauma informed care to Resident #1. An interview on 3/30/23 at 01:20 PM, with the Care Plan Nurse revealed she was aware that Resident #1 had been called a boy by the RN Supervisor, because Resident #1 had come into her office area two (2) times, on 2/10/23, tearful and talking about the incident. Record review of the Departmental Notes revealed there was no documentation that revealed Resident #1 received skilled monitoring from the nursing staff related to the incident of being called a boy on 2/10/23. The record review did reveal a nurse note from LPN #1, dated 2/12/2023, that revealed RESIDENT C/O RN SUPERVISOR CALLING HIM A BOY THE OTHER DAY. RESIDENT STATED, I CALLED MY FAMILY AND SHE TOLD ME NOT TO REQUEST TO MOVE, JUST REPORT IT. Record review of the Incident Log revealed there was no incident report completed for the incident of Resident #1 being called a boy by the RN Supervisor on 2/10/23. Record review of the nursing facility's in-services revealed an in-service for all nursing facility staff dated 10/19/22 titled Phase 3 training Number 1 and 2 Quality of Care (Trauma Informed Care and Cultural Diversity). Record review of the Physician Orders List revealed no physician's orders for a referral to mental health services for Resident #1. Record review of the Care Plan for Resident #1 revealed Problem Onset: 2/10/2023 Resident stated he has a HX of trauma. Res. reported that he has encountered racism as a child and witnessed a Caucasian murder an African American which took an emotional effect on him. Certain words trigger flash backs. Example boy . Social to visit as needed. Engage in activities of choice. Speak with a Mental health Therapist to verbalize my feelings. Consult Psych as needed. Record review of documentation from the DON, with a Date of Occurrence of 2/10/23, for Resident #1, revealed . Details of Incident: On 2/10/23 at approximately 1030 AM (RN Supervisor's Name Removed) RN came to this nurse and (Interim Administrator's Name Removed) Administrator and stated he saw (Resident #1's Name Removed) getting off the elevator and stated you're on the wrong floor boy. He stated he said this jokingly but could immediately see that (Resident #1's Name Removed) got upset. (RN Supervisor's Name Removed) states he apologized and came to the administrators office to report what happened. As soon as Administrator and DON met with (RN Supervisor's Name Removed), (Resident #1's Name Removed) was waiting to meet with this nurse. (Resident #1's Name Removed) was upset stating that nurse called me a boy, that the same thing as calling me the N word. Resident got irate and said he was calling state and wanted to go to another facility. We discussed it was his right to call state but not to make a decision about going to another facility while he was upset. Encouraged resident that it was not meant in a derogatory way and again apologized. Resident calmed down and left the office. Findings: Incident did occur and was investigated and was not found to be racial or derogatory and was just conversation. Record review of the Trauma Informed Care Assessments, dated 2/13/23 and 3/29/23, for Resident #1 revealed . For each event check one or more of the boxes to the right to indicate that: (a) it happened to you personally; (b) you witnessed it happen to someone else; (c) you learned about it happening to a close family member or close friend; (d) you were exposed to is as part of your job (for example, paramedic, police, military, or other first responder); (e) you're not sure if it fits; or (f) it doesn't apply to you. Be sure to consider your entire life (growing up as well as adulthood) as you go through the list of events. 2/13/23 . Event: 2. Fire and explosion . Doesn't Apply; . 3/29/23 . Event: Fire and explosion . Witnessed it; . 2/13/23 . Event: Life-threatening illness or injury . Doesn't apply; . 3/29/23 . Event: Life-threatening illness or injury . Happened to me (COVID); . 2/13/23 . Briefly describe the worst even (for example, what happened, who was involved, etc.) . (document revealed no response); . 3/29/23 . Briefly describe the worst event (for example, what happened, who was involved, etc.): Witnessed a homicide as a child-Res. stated he witnessed a white man murder a black woman; . 2/13/23 . How many times altogether have you experienced a similar event as stressful or nearly as stressful as the worst event?: Just once; . 3/29/23 . How many times altogether have you experienced a similar event as stressful or nearly as stressful as the worst event?: More than once (please specify or estimate the total number of times you have had this experience ___): lived on street, on drugs; . Keeping your worst event in mine, please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month. 2/13/23 . 1. Repeated, disturbing, and unwanted memories of the stressful experience? . 1-A little bit; . 3/29/23 . 1. Repeated, disturbing, and unwanted memories of the stressful experience? . 3-Quite a bit; . 2/13/23 . 3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)? . 0-Not at all; . 3/29/23 . 3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)? . 1-A little bit; . 2/13/23 . 4. Feeling very upset when something reminded you of the stressful experience?: . 0-Not at all; . 3/29/23 . 4. Feeling very upset when something reminded you of the stressful experience? . 1-A little bit; . 2/13/23 . 5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)? . 0-Not at all; . 3/29/23 . 5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)? . 1-A little bit; . 2/13/23 . 6. Avoiding memories, thoughts, or feelings related to the stressful experience? . 0-Not at all; . 3/29/23 . 6. Avoiding memories, thoughts, or feelings related to the stressful experience? . 3-Quite a bit; . 2/13/23 . 7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)? . 0-Not at all; . 3/29/23 . 7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)? . 2-Moderately; . 2/13/23 . 11. Having strong negative feelings such as dear, horror, anger, guilt, or shame? . 0-Not at all; . 3/29/23 . 11. Having strong negative feelings such as dear, horror, anger, guilt, or shame? . 1-A little bit; . 2/13/23 . 12. Loss of interest in activities that you used to enjoy? . 0-Not at all; . 3/29/23 . 12. Loss of interest in activities that you used to enjoy. 1-A little bit; . 2/13/23 . 13. Feeling distant or cut off form other people? . 0-Not at all; . 3/29/23 . 13. Feeling distant or cut off from other people? . 1-A little bit; . 2/13/23 . 15. Irritable behavior, angry outbursts, or acting aggressively? . 0-Not at all; . 3/29/23 . 15. Irritable behavior, angry outbursts, or acting aggressively? . 3-Quite a bit; . 2/13/23 . 17. Being super alert or watchful or on guard? . Not at all; . 3/29/23 . 17. Being super alert or watchful or on guard? . 4-Extremely; . 2/13/23 . 18. Feeling jumpy or easily startled? . 0-Not at all; . 3/29/23 . 18. Feeling jumpy or easily startled? . 1-A little bit; . 2/13/23 . 19. Having difficulty concentrating? . 0-Not at all; . 3/29/23 . 19. Having difficulty concentrating? . 1-A little bit; . 20. Trouble falling or staying asleep? . 0-Not at all; . 3/29/23 . 20. Trouble falling or staying asleep? . 3-Quite a bit. Record review of the Life Experience Assessment, dated 12/1/21, for Resident #1, revealed If you have had a troubling event in your lifetime or if you witnessed something that is troubling to you, please complete the areas below. Disturbing memories, dreams, thoughts, or images of a stressful experience? 1-Not at all; . Do you struggle to find meaning, anger to God, giving up on your faith, or questioning lifetime beliefs? . 1-Not at all; . Suddenly acting or feeling as if the stressful situation were happening again? . 1-Not at all; . Feeling very upset when something reminds you of the stressful experience: . 1-Not at all; . do you fee fearfulness, anxiety, loneliness, helplessness but can't explain why? . 1-Not at all; . Do you feel apathy, isolation, have difficulty trusting, have thoughts of self-injury aggression because of a stressful situation? . 1-Not at all. Record review of documentation from the meeting for Resident #1, with no date and no staff signature, revealed On February 13, 2023 (Interim Administrator's Name Removed), Administrator, and (Former AIT/Administrator's Name removed), RN met with (Resident #1's Name Removed) on incident that occurred on February 10/ 2023. (Resident #1's Name Removed) expressed how he felt about the nurse calling him a boy. (Resident #1's Name Removed) stated this incident brought up old memories from his past where he witnessed a black lady being shot and how his whole hometown was prejudiced. The nurse was called down to meet with us with the permission from the resident. The resident stated his concerns with the statement of being called boy to the nurse. Record review of the Face Sheet for Resident #1 revealed an admitted [DATE] and diagnoses that included Acquired Absence of Limb, Unspecified, and Unspecified Sequelae of Cerebral Infarction. Record review of Section C of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/2023, for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 is cognitively intact.

Based on observation, staff interview, facility policy review the facility failed to label and date left over food in the refrigerator for one (1) of two (2) tours. Findings Include: Review of the facility policy titled, Food Storage Labeling, revised 10/17, revealed that the facility will ensure the safety and quality of food by following good storage and labeling procedures. The procedure revealed suggested labeling include the common name and the date of preparation or the use by date. An observation of the standalone refrigerator on 3/2/21, at 11:30 AM, revealed metal containers of fortified sweet potatoes, vegetable soup, and chicken soup not labeled or dated. An interview, on 3/2/21 at 11:45 AM with the Dietary Manager (DM), confirmed the containers should be labeled and dated in order to know how long they had been in the refrigerator, so they could be discarded. The DM revealed she did not know what staff member placed the containers in the refrigerator unlabeled. The DM stated that bad food could cause sickness. An interview, on 03/04/21 at 12:45 PM, with the DM revealed that she and her staff were aware to date and label items in the refrigerator. She confirmed that they failed to date and label the fortified sweet potatoes, the vegetable soup, and the chicken soup. The DM stated that her staff had been in serviced on labeling and dating refrigerated items. Record review revealed an in-service dated 1/12/21, provided by the DM, addressed labeling, and dating of foods. Record review revealed four (4) staff members attended.

Based on observation, staff interview, facility policy review and record review, the facility failed to ensure staff wore masks appropriately covering the nose and mouth to prevent the possible spread of the COVID-19 virus for three (3) of five (5) survey days. Findings Include: The facility policy titled, Personal Protective Equipment, dated 4/1/20, revealed this facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. An observation of the dietary department on 3/2/21, at 11:00 AM, revealed the Dietary Manager (DM) wearing her mask below her nose. Dietary staff #1 and #3 had their masks below their nose while preparing food and setting up trays for the lunch meal. An observation, on 3/3/21, at 1:45 PM, revealed Dietary Staff #2 in the dietary department with his face mask below his nose. An interview, on 3/3/21, at 2:30 PM, with the Dietary Manager (DM), revealed that she and all workers should have their masks over their mouth and nose. On 3/4/21, at 2:14 PM, an interview with Dietary staff #2 revealed he stated that he did not realize his mask was not over his nose. He stated that his mask should be covering his nose because of [MEDICAL CONDITION]. Dietary staff #2 confirmed he has had in service education on proper wearing of Personal Protective Equipment (PPE). An interview, on 3/4/21, at 11:30 AM, with Dietary staff #1 revealed that when she talks her mask comes down. She stated that this was not good because when talking saliva could come in contact with others and the food and possibly spread [MEDICAL CONDITION]. Dietary staff #1 stated that she should get another mask that fits and does not slide down. Dietary staff #1 confirmed she has had in-service education regarding proper wearing of masks. On 3/3/21, at 2:32 PM, an observation revealed Licensed Practical Nurse (LPN) #2 sitting at the nurse's desk with her mask not covering her nose. She then walked down the hall and provided resident care with her mask not covering her nose. On 3/3/21, at 3:40 PM, an interview with LPN #2 revealed that she should wear her mask covering her mouth and nose. She stated that she guessed she was just not paying attention. LPN #2 stated that not properly wearing her mask could cause her or the resident to breathe in germs and COVID-19 is in the air. She stated that she has had several in-services on COVID-19, and they have been told to keep their masks on at all times. On 3/3/21, at 2:48 PM, an interview with the Director of Nursing (DON) revealed that all the staff know they are supposed to wear masks, goggles, or face shields properly when on the floor because they are trying to protect residents from getting COVID-19. On 3/2/21, at 4:00 PM, the Laundry Supervisor did not have a mask on during an interview with this surveyor. She did put a mask on during the interview. The Laundry Supervisor stated that she should wear a mask at all times in the laundry and a mask and goggles when she goes on the floor. She stated that she takes her mask off when she is in the laundry by herself. The Laundry Supervisor stated that according to facility policy and education, she should have a mask on all the time. Record review of a staff posting revealed all staff must wear facemasks at all times while at work. KN95 or N95 masks are to be worn on second and third floors at all times. Record review revealed that LPN #2, the Dietary Manager and Dietary Staff #1 and #3, and the Laundry Supervisor had attended in-service education classes related to face masks in November 2020. Dietary Staff #2's signature did not appear on any in-service sheets reviewed for proper PPE use.

Based on observation, staff interview, facility policy review, the facility failed to prevent the potential of injury to a resident, as evidenced by the absence of a wheelchair arm rest exposing a protruding screw for one (1) of 18 residents reviewed. Resident #1 Findings Include: Record review of the facility policy titled Equipment undated, revealed wheelchairs, walkers, crutches, and canes will be provided to the residents and are maintained as the property of the facility. An observation on 03/01/21, at 02:53 PM, revealed the left arm rest missing on Resident #1's wheelchair. Further observation revealed a screw that was sticking upward approximately 1/2 inch out of the metal piece where armrest should be. An interview on 03/01/21, at 02:54 PM, with Resident #1, confirmed that he does get up in the wheelchair at times. An observation on 03/03/21, at 11:14 AM, revealed Resident #1 up in his wheelchair with no arm rest on the left side. The screw was sticking upwards from metal bar. Resident #1 had on a long sleeve shirt. An observation and interview on 03/03/21, at 11:25 AM, with Licensed Practical Nurse (LPN) #1 confirmed the wheelchair did not have an arm rest on the left side. She confirmed the screw was sticking up and could cause a skin tear and possible infection. LPN #1 pulled Resident #1's sleeve up. There was no injury to his arm. An interview on 03/04/21, at 11:30 AM, with the Director of Nursing (DON) revealed that whoever notices equipment needs repair should report it. The DON stated the wheelchair arm should have been fixed, because getting the resident up in the wheelchair without the arm rest on and the screw sticking up could have caused an injury to the resident.

Based on observation, resident interview, staff interview, and facility policy review, the facility failed to honor Resident #254's dignity and/or preferences to wear underwear instead of adult incontinent briefs. This concern was identified for one (1) of 29 residents observed. Findings include: Review of the facility's Resident Rights Policy, dated (MONTH) (YEAR), revealed it is the policy of this facility to provide services based on the following requirements: The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. The facility will protect and promote the rights of the resident. Observations and interviews, on 09/24/19 at 3:41 PM, and 09/23/19 at 11:08 AM, revealed Resident #254 was wearing adult incontinent briefs. Resident #254 stated he knew when he needed to use the bathroom. An interview, with Resident #254, on 09/24/19 at 2:05 PM, revealed staff started putting a brief on him for bowel movements, then they said they were going to leave the brief on, and he could just use the brief if they couldn't get to him in time. Resident #254 stated he does call, but they don't come, so he has to use the brief. Resident #254 stated the staff has told him to use the diaper and they will come change him. Resident #254 stated he has a urinal, but he can't hold it and put it in place; but if they would place it, he can position it to use it. Review of Resident #254's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/19, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Further review of the MDS revealed Resident #254 was coded to be frequently incontinent of urine, and always incontinent of bowels. An interview, on 09/24/19 at 2:15 PM, revealed Licensed Practical Nurse (LPN) #1 stated Resident #254 had a urinal. LPN #1 also stated they don't have a bowel and bladder training program. On 9/24/19 at 2:24 PM, an interview with the Director of Nursing (DON) revealed she had talked with Resident #254 when he was admitted and was aware that he knew when he needed to go to the bathroom. The DON stated the resident wore a brief when he was admitted from the other facility. The DON agreed this was not right. The DON stated she told the staff when he was admitted that he did not need to be in a brief. The DON stated she was not happy about this. She stated it was their job to promote independence. On 09/24/19 at 3:40 PM, an interview with Resident #254, in the presence of the DON, confirmed the resident's wishes not to wear the incontinent brief. On 09/26/19 at 10:00 AM, an interview with CNA # 1 revealed Resident #254 had a brief on when she made her rounds this morning. She stated he wanted his underwear on, so she changed him.

Based on record review, staff interview, and facility policy review, the facility failed to transmit a Minimum Data Set (MDS) within 14 days of Resident #1's discharge from the facility, due to death. This affected one (1) of 29 residents reviewed, Resident #1. Findings include: Review of the facility's Resident Assessment policy, not dated, revealed the Discharge Assessment is completed using the discharge date as the Assessment Reference Date (ARD). The Assessment must be completed within 14 days of the discharge date /ARD. Review of Resident #1's Discharge Assessment with Assessment Reference Date of [DATE], was still open in the system. The MDS had not been signed off as completed or transmitted. The transmission report dated [DATE], was reviewed without a record of the assessment found. Review of Resident #1's Departmental Notes, revealed Nursing Notes: Dated [DATE] at 4:04 AM, Resident #1 was found without vital signs (deceased ). [DATE] at 4:05 AM, the Coroner and Hospice staff were in route. [DATE] at 7:00 AM, awaiting the funeral home to receive the body. Interview with the MDS Coordinator, on [DATE] at 2:45 PM, revealed the Discharge Assessment was still open and had not been transmitted for Resident #1. She stated the MDS Coordinator at the time was no longer employed by the facility. She stated the MDS Coordinator usually checks to make sure all assessments are completed, signed and transmitted. She stated the MDS is important in this instance, for tracking information to be sent to Centers Of Medicare and Medicaid. Review of the Face Sheet revealed Resident #1 was admitted by the facility, on [DATE], with the included Diagnoses: [REDACTED].

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement the care plan for assessment and ordered treatment of [REDACTED].#1. Resident #1 had a Stage III PU that was not assessed weekly, the facility did not send Resident #1 to Wound Care, ordered treatment was not provided, and the PU deteriorated. Findings include: Review of the facility's Comprehensive Resident Centered Care Plans, Develop/Implement Comprehensive Care Plan policy , not dated, 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. Review of the Care Plan with a Problem Onset date of 6/24/2013, revealed (Resident #1) has a Stage III to the sacral area which is being treated by (Wound Clinic) and treated by staff as ordered. The care plan documented Resident #1 was at risk for further pressure ulcers due to a history of ulcers. Interventions included weekly skin assessments, pictures of any open areas weekly, and treatment of [REDACTED]. Assessments were not completed weekly and the care plan was not updated to include the correct treatment orders. Review of the physician's current (MONTH) 2019 orders revealed an order dated 6/24/13, for weekly skin assessments. There were no current physician's orders [REDACTED]. Review of the medical record revealed Resident #1 had an acquired Pressure Ulcer (PU) on the sacrum, identified on 5/14/17. There were no weekly assessments or photos for Resident #1's Stage III pressure ulcer on the sacral area from 4/25/19 through 6/11/19; the next assessment was documented 7/10/19, which described the Stage III to the sacrum as deteriorated. The measurements of the Stage III PU on 4/25/19, were 0.5 centimeters (cm) x 0.4 cm x 1.2 cm, with tunneling at 12:00 with a maximum distance of 2.1 cm, per Wound care note. The measurements on 7/10/19 included 1.0 cm x 1.0 cm x 1.0 cm, with tunneling at 12:00 of 1.0, with serosanguineous drainage, per facility documentation, with deteriorated documented. Review of the Treatment Administration Record (TAR) for (MONTH) 2019, revealed Calcium Alginate Rope (Not Calcium Alginate with Silver as ordered) was documented as treatment for [REDACTED]. Upon observation of PU care, on 7/16/19, Resident #1 had five (5) additional breaks in the skin around the sacral area wound that were measured by Registered Nurse (RN) #1. Review of a Wound Assessment Report dated 7/16/19, revealed new wounds as documented, with treatments of Duoderm every three (3) days until healed: 1) A new wound on the right outer buttock, which measured 0.50 cm x 1.0 cm, with no depth. 2) A new wound to the right buttock, which measured 2.10 cm x 1.30 cm, with no depth. 3) A new wound to the left buttock, which measured 0.40 cm x 0.30 cm, with no depth. 4) A new wound to the upper coccyx, which measured 0.30 cm x 0.20 cm, with no depth. 5) A new wound to the right lower buttock, which measured 1.0 cm x 0.60 cm, with no depth. An interview on 7/17/19, at 10:45 AM, with Registered Nurse #1, revealed that Resident #1 was going to the Wound Clinic every two (2) weeks, but confirmed the resident had not gone back to the wound clinic since 4/25/19. RN #1 stated that Resident #1 had an appointment on 5/9/19, that was canceled and no further appointments were scheduled. RN #1 confirmed the care plan was not followed for assessment of the wounds and for the resident not going to Wound Care. RN #1 stated that the PU should have been measured weekly to keep track of progress or lack of progress. She confirmed the PU had not been assessed from 4/25/19 until 7/10/19. Review of the Face Sheet revealed that Resident #1 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED].

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide written orders and interventions to promote healing of an existing pressure ulcer and failed to prevent further skin breakdown as evidenced by failure to keep appointments at the Wound Clinic, and failure to monitor, assess, and document the status of an existing pressure ulcer, for one (1) of three (3) residents observed for Pressure Ulcer (PU), Resident #1. Resident #1 had a Stage III PU, which was identified on 5/14/17. No assessment of the Stage III PU was documented from 4/25/19 through 6/11/19. The Stage III PU was assessed, by the facility, as deteriorated on 7/10/19. Observation during wound care revealed new areas of skin breakdown on Resident #1's buttocks on 7/16/19. Resident #1's last wound clinic appointment was on 4/25/19. Findings include: Review of the facility's Skin Care Policy & Procedure policy, not dated, revealed, Skin problems will be minimized to the greatest extent possible through an aggressive approach consisting of four (4) components. Those are: I. Prevention, Evaluation and Screening II. Ongoing Surveillance III. Treatment Orders IV. Treatment Regimen Ongoing Surveillance .C. A weekly, documented assessment will be completed for all pressure and non-pressure areas using designated forms addressing at least the following: 1. Site 2. Stage (I,II, III or IV) 3. Size (length, width, depth) 4. Presence or absence of drainage 5. Presence or absence of odor 6. Color 7. Response to treatment 8. Presence of tunneling. Review of a written complaint intake form, dated 7/11/19, revealed a complaint that Resident #1 was found in urine, with the bed pad brown- stained with urine. The complaint also revealed Resident #1 was noted with another decubitus (Stage II) on her sacral area on 7/4/11. The complainant was concerned the resident wasn't being changed and turned and that's why the wounds were worsening and more developing. Review of Resident #1's medical record revealed a facility acquired Stage III PU on Resident #1's sacrum on 5/14/17, which measured 1.0 centimeters (cm) x 0.50 cm x 1.10 cm. The orders were for weekly skin assessments, photos or the wounds weekly, and to clean the wound with Normal Saline and Calcium Alginate Rope packed loosely in the wound, with a Bordered Super Absorptive Dressing daily and as needed. Review of the current (MONTH) 2019 and (MONTH) 2019 cumulative orders revealed no order for wound treatment of [REDACTED].#1 to go to the Local Wound Clinic on a routine basis. A hand-written order, from the (MONTH) 2019 physician's orders [REDACTED]. There was no documented evidence that Resident #1 was transported to the Wound Clinic on 5/9/19, as scheduled. There were no photos of Resident #1's PU to the sacrum reviewed. Review of the Treatment Administration Record (TAR) dated 6/17/19, 7/1/19, and 7/15/19, revealed the same treatment of [REDACTED]. From 3/31/19 - 6/17/19, the TAR documented to loosely pack Calcium Alginate with Silver, then back to plain Calcium Alginate on 6/17/19. The facility failed to make changes in the treatments to the sacral wound, documented on the TAR. Review of written correspondence with the Director of Nursing (DON), dated 8/15/19 at 10:39 AM, post-exit, revealed there were no written orders for (MONTH) 2019 and (MONTH) 2019 for the sacral wound care for Resident #1; there was an order for [REDACTED]. Record review of the Wound Assessment Report for the Facility Acquired Stage 3 Pressure Ulcer Sacrum, for Resident #1, dated 7/10/19, revealed, .Wound Status: Deteriorated, .Measurements: Length - 1.00 centimeters (cm), Width - 1.00 cm, Depth - 1.00 cm .Tunneling 1.00 cm at (location) 12 o'clock. Review of the facility's Wound Healing Progress Report revealed the last documented measurements, prior to 7/10/19, were on 6/11/19; the Pressure Ulcer Sacrum measured 0.80 cm length by 0.50 cm width and 0.60 cm depth. There were no further wound assessments from 6/11/19 until 7/10/19, which was over four (4) weeks. Prior to 6/11/19, the last assessment of Resident #1's sacral wound was on 4/25/19, and measured 1.0 cm x .30 cm x 1.10 cm (which were not consistent with the Wound Clinic measurements). There were no assessments of Resident #1's PU from 4/25/19 until 6/11/19, which was over six (6) weeks. Review of the (Local Wound Clinic) Progress Note Details dated 4/25/19, revealed Resident #1 had an open Stage III PU to the sacral area. The wound measures 0.5 centimeter (cm) length x 0.4 cm width x 1.2 cm depth; .There is no undermining noted, however, there is tunneling at 12:00 with a maximum distance of 1.2 cm. The wound has no necrotic tissue and had a small amount of serosanguineous drainage. There was no further documentation of Resident #1's sacral ulcer from the local wound clinic. During an observation of wound care on 7/16/19 at 2:47 PM, of the Stage III Pressure Ulcer on the Sacrum, performed by Licensed Practical Nurse (LPN) #1, and assisted by Registered Nurse #1, the dressing was not intact to Resident #1's sacral area. The brief appeared to be clean and dry with scant smeared areas of red drainage on it. The dressing came off as LPN #1 removed the resident's brief. The Stage III Pressure Ulcer to the Sacrum was observed along with five (5) other areas of skin breakdown. The five (5) other areas appeared as superficial red, open areas with a scant amount of sanguineous drainage. These were measured by RN #1. LPN #1 stated that it was pink yesterday. She may have scratched herself. Registered Nurse #1 stated that the areas were excoriation and that Resident #1 had red matter beneath four (4) fingernails of her right hand. It was confirmed that Resident #1 had red matter beneath the fingernails, but no scratch marks were noticed on the skin of the buttock area. Registered Nurse #2, also present, stated that she also felt it was excoriation due to moisture/shearing and that it looked like an area that may have re-opened and being wet would have sped it up. She stated that the RN Supervisor and the nurses on the floor are responsible for making sure residents are turned and incontinent care provided. An interview with Registered Nurse (RN) #1, on 7/17/19, at 10:45 AM, revealed that Resident #1 had not gone back to the wound clinic since 4/25/19. RN #1 stated that Resident #1 had an appointment on 5/9/19, that was canceled and no further appointments were scheduled. She stated that Resident #1 had been going every one (1) to two (2) weeks to the Wound Clinic. She stated that she did not know if the Stage III Pressure Ulcer had been assessed from 4/25/19 through 6/11/19, by the facility and confirmed no documentation of the assessment for this time period. She confirmed that the next and last time the sacral PU was documented/assessed was on 7/10/19, when the wound status was documented as Deteriorated. She stated that the facility policy for wound care was not followed. She stated that you can't keep track of the progress of the wound without frequent assessments and that deterioration of the wound could occur. She confirmed the wound had deteriorated. Interview with RN #1 on 7/16/19, revealed Resident #1 had an appointment to go back to the Wound Clinic on 7/18/19 at 2:00 PM. Review of a facility Wound Assessment Report, dated 7/16/19, revealed Resident #1 had new wounds documented, with treatments of Duoderm every three (3) days until healed: 1) A new wound on the right outer buttock, which measured 0.50 cm x 1.0 cm, with no depth. 2) A new wound to the right buttock, which measured 2.10 cm x 1.30 cm, with no depth. 3) A new wound to the left buttock, which measured 0.40 cm x 0.30 cm, with no depth. 4) A new wound to the upper coccyx, which measured 0.30 cm x 0.20 cm, with no depth. 5) A new wound to the right lower buttock, which measured 1.0 cm x 0.60 cm, with no depth. During an interview with the Resident Party (RP), on 7/15/19, at 12:45 PM, the RP revealed that his wife, whom he stated was a nurse, found a new pressure sore on Resident #1's bottom last week. The RP stated the resident already had a sore on her bottom that was trying to heal. The RP stated, We asked that she be up for lunch and dinner and then back to bed between meals. He stated that the family had found her to be in bed after 4:00 PM on 7/4/19, and she should have been up for dinner. He voiced concerns that Resident #1 had developed two (2) new sores in the last two (2) weeks. He stated that his wife had called the Director of Nursing (DON) about the sore on her bottom. He stated, The reason the sore is not healing is because proper care is not given. In a further interview, on 7/17/19, at 10:30 AM, the RP revealed that he was not aware that the resident had not been going to the wound healing clinic and that he thought she was supposed to go every other Thursday. He confirmed that the facility had notified him yesterday of a new wound and an appointment with the wound clinic tomorrow. He stated that he was told that she had scratched her bottom. He stated that he was under the impression that there was only one (1) new area on her bottom, not five (5). On 7/16/19 at 9:30 AM, in an interview, the DON confirmed that the RP's wife had called her and stated that Resident #1 had another pressure ulcer on her bottom. She stated that she assessed Resident #1 the same day she received the phone call and no other wound was found. She stated that the resident had scars from previously healed wounds and that may have been what the family member saw. She stated the family member did mention that the resident was soiled when she looked at the resident's bottom, and the resident may have had some redness from that. She stated that Resident #1 was treated at a Wound Center for her Pressure Ulcer and was not under the care of the wound specialist who treats residents in this facility. The DON stated that the RP's wife had called her back, after she had assessed Resident #1, and she informed the family member that she had not found any additional wounds. The DON stated that she had no written documentation of the aforementioned conversation with the family member. In an interview on 7/17/19 at 9:47 AM, the DON stated Resident #1 was scheduled to go back to the Wound Clinic tomorrow (7/18/19). She stated she could not find documentation of the PU measurements from 4/25/19 through 7/11/19; I'm hoping it was measured. She stated to her understanding, the treatment nurse was here and responsible for measurements. The DON stated the resident was going to the Wound Clinic per family request. She stated the consequences of not going depended upon whether the wound had really deteriorated, and she wasn't sure that it actually had deteriorated. She confirmed it was facility policy to assess wounds weekly. Review of the Face Sheet revealed that Resident #1 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. .

Based on resident interview, staff interview, record review, and policy review, the facility failed to ensure a resident was free from verbal abuse for one (1) of 22 residents reviewed for abuse. Resident #245. Resident #245, a resident with no cognitive impairment, alleged Certified Nursing Assistant (CNA) #1 verbally abused her and used profanity in her presence on 8/18/18, and reported the incident to the Nurse on 8/19/18. This verbal abuse was witnessed by the resident's Roommate, who had no documented cognitive impairment. Resident #245 was emotionally upset, expressed by crying to staff, about the altercation with the CNA. CNA #1 was allowed to work with other residents until 8/21/18. The failure of the facility to ensure that Resident #245 was not abused by CNA #1, and to protect other residents from abuse by the CNA, placed Resident #245 and other residents at risk, and in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 8/18/18, when the allegation of abuse occurred. The facility's Administrator was notified of the IJ and SQC on 8/22/18. An acceptable credible Allegation of Compliance (A[NAME]) was provided on 8/24/18, in which the facility alleged all corrective actions were completed 8/24/18, and the IJ was removed on 8/25/18. The State Agency validated the A[NAME] and determined that the IJ was removed on 8/25/18, prior to exit. Therefore, the scope and severity for 42 CFR(s) 483.12 (a)(1)-F600 was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility's ABUSE & NEGLECT POLICY, undated, revealed: All residents of this facility have the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, involuntary seclusion, mistreatment, or neglect. Residents must not be subjected to abuse by anyone (including but not limited to: facility staff, .1) Facility must ensure that staff will not use verbal, mental, sexual, or physical abuse, including corporal punishment, or involuntary seclusion 5) The facility will ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries or unknown origin are reported immediately to the Charge Nurse, Director of Nursing Services, or the Administrator of the facility, or other officials, such as the State Board of Health and the Office of the Attorney General. 6) The facility must thoroughly investigate all alleged violations and document this investigation. 7) The facility must ensure and prevent further potential abuse while the investigation is in process. 8) The facility must ensure that results of all investigations are reported the Administrator or designated representative or to other officials in accordance with state law. Abuse Prevention and Prohibition: This facility will develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property Abuse 'Verbal Abuse' is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . 'Mental Abuse' includes, but is not limited to humiliation .This facility will develop and implement written policies that prohibit mistreatment and abuse of residents .18) Should an employee be reported for possible abuse, the employee will be placed on leave, with pay pending the results of the in-house investigation. If validated, the employee is to be discharged , and not eligible for rehire. Record review of the physician's orders [REDACTED].#245 was admitted to the facility on [DATE], under the care of a Local Hospice with the following Diagnoses: [REDACTED]. The resident was her own Responsible Party on admission to the facility. Review of the Nurse's Notes dated 8/17/18, at 3:20 PM, revealed Resident #245 was alert to time, place, person, and situation and was able to make needs known. This entry was signed by Registered Nurse (RN) #3. During an interview on 8/21/18, at 3:00 PM, Resident #245 was alert and oriented to person, place, and time with no cognitive impairment. She was sitting up in her wheelchair in her room. She stated that Certified Nursing Assistant #1 (CNA), assisted by CNA #2, came into her room to provide incontinent care around 7:00 PM, on 8/18/18. The resident stated that she had a bowel movement (BM) in her brief. Resident #245 stated that when CNA #1 pulled the bedcovers back, she made a face as if she smelled something and then she pointed down there and said, What the [***] is that? When asked how it made her feel, Resident #245 stated, It makes you feel kind of sad, embarrassed, I don't know what was wrong with her. She came into the room with a frowned up face. She looked kind of mad. When asked if she felt as if CNA #1 was abusive to her, she said, It did make me feel like abuse. It made me feel humiliated. She added, She shouldn't have said what she said, that's what nursing home is for. She stated the other CNA didn't' say anything offensive. She also stated that CNA #1 took her dinner tray Saturday. She stated, I told her I wanted to keep my sandwich for the night and she said 'Oh yeah', and took the tray, walked off like nobody was talking to her, you are not supposed to do that. The Resident stated that she reported the incident the next day to LPN #1. A phone interview conducted on 8/21/18 at 4:44 PM, with Licensed Practical Nurse (LPN) #1, revealed that she was called to Resident #245's room by CNA #4 on 8/19/18. CNA #4 reported that Resident #245 was crying. LPN #1 said she attempted to determine what caused the crying and the resident told her that she had a bowel movement (8/18/18 around 7:00 PM) and a CNA came in and pulled her covers back and said, What the [***] is this! LPN #1 stated that the resident reported it was the CNA who was taking care of her after 3:00 PM on 8/18/18. LPN #1 stated she checked the schedule and found that CNA #1 had been assigned to Resident #245 the previous evening. LPN #1 stated that CNA #1 was also scheduled to work on 8/19/18, at 3:00 PM, so she met her when she got to work, and asked CNA #1 about the incident. The CNA replied, How do you know it was me? LPN #1 stated she took CNA #1 to Resident #245's room, where Resident #245 identified the CNA as the one who had cursed at her. LPN #1 stated that the resident had her eyes closed when they entered the room and she opened them and immediately stated, That is her. LPN #1 stated that CNA #1 denied the accusation and began to verbally argue with Resident #245 saying, What makes this resident so special? LPN #1 stated she told CNA #1 that was enough and she needed to leave the room. LPN #1 stated that CNA #1 mumbled under her breath, Good, because I'm already late. At this point LPN #1 stated that she called the Director of Nursing (DON) and gave a phone report of the incident. She stated that the DON told her to write the CNA up and put the write up under her door. She stated that the DON told her to make sure that CNA #1 was not assigned to Resident #245. She stated that CNA #1 was assigned to the third floor on 8/19/18, and the CNA did go to the third floor to work her shift. LPN #1 stated that she did consider the incident with Resident #245 as abuse. In an interview on 8/21/18 at 5:15 PM, CNA #1 confirmed that she had been assigned to Resident #245 on 8/18/18. She stated, I never used profane language or anything. She stated when she came to work on Sunday, 8/19/18, the morning nurse, LPN #1, said she cursed Resident #245, and had used curse words in her room like, What this [***] is up or [***] you, something with [***] in it; maybe she misunderstood something I said. CNA #1 continued to deny the accusation. She also denied that she took the resident's tray. She did confirm that the resident's Roommate, Resident # 12, was in the room during the the time that she was performing incontinent care for Resident #245. CNA #1 stated that she was assisted by CNA#2. At the conclusion of the interview, CNA #1 stated, Great. I guess I just spent my 30 minute break in here, didn't I? During an interview on 8/21/18 at 5:30 PM, the DON confirmed that LPN #1 had called her on the afternoon of 8/19/18, to report an allegation of verbal abuse against Resident #245, by CNA #1. She stated she was told that CNA #1, had gone into Resident #245's room, pulled the covers back and said 'What the [***] is that? The DON stated that she was not aware of anyone in the room at the time of the allegation. Stated CNA #2 was pregnant and was hospitalized at present. She stated that she instructed LPN #1 to write up CNA #1, put it under her office door, and make sure that CNA #1 was not assigned to Resident #245. She stated that she allowed CNA #1 to continue to work on 8/19/18, after the allegation of abuse was reported to her. She confirmed that she did not follow the policy of the facility to suspend an employee who is accused of abuse until an investigation was completed. She revealed that it is the policy of the facility that if a resident accused a staff member of abuse, it should be reported to herself or the Administrator. The DON stated that an investigation should be started, and the employee should be removed from the building. She stated that Resident #245 was a newly admitted resident and that she was unsure of her mental status. She stated that she talked to CNA #1 by phone after the reported allegation, and the CNA wasn't in a foul frame of mind. She stated, In hindsight, was it the best decision to let her go on and work with other residents, maybe not. If she had been angry, upset, or out of sorts, I would have sent her home. She revealed that this was CNA #1's second time employed and she felt the CNA was soft spoken and not aggressive. The DON confirmed that she did not talk to Resident #245 on that Sunday, 8/19/18. Review of a signed typed statement, by the DON on 8/21/18, revealed she interviewed Resident #245 and Resident #12 shortly after 4:00 PM on 8/21/18. The DON documented that Resident #245 said CNA #1 had brought her meal tray (8/18/18) and returned later and removed the tray with the resident telling her not to, because she had not eaten. The resident also stated the CNA returned and pulled the covers back and said, What the [***] is this. The DON documented that once CNA #1 returned from her break, then she sent her home. Another typed statement, signed by the DON, dated 8/21/18 at 4:40 PM, revealed she interviewed the Roommate of Resident #245, (Resident #12), who reported she witnessed the incident between CNA #1 and Resident #245 on 8/18/18. Resident #12 confirmed, She said the [***] word. The resident reported no other issues. An interview with Resident #245 and her husband, on 8/22/18, at 4:15 PM, revealed the Husband had been informed of the incident. When asked about the actual care she received from CNA #1 on 8/18/18, the resident stated, She didn't clean me up too good, cause I could still smell it. She also stated, Where is she? What if she disguised herself and came up in here mad and started shooting up the place. You know that happens. The Resident's husband attempted to calm the resident by reassuring her that would not happen. When asked if scared or hesitant to used the call light, the resident stated, No, I'm not scared. I don't supposed to be scared of nobody in here. She's lucky it wasn't another family that would have got her out there on the street. I'm not like that. She needs her job. I wasn't afraid of her. After she said that, I made it known I don't want her to come back in this room. Ain't nothing wrong with my brain. I know when somebody says something to me and it wasn't right. She thought I was one of those patients that wasn't going to say nothing, but she met her match. I don't know what was wrong with her, if she was mad with her boyfriend, she should have kept it at home. Work is not the place for it. An interview with Resident #245's Roommate, Resident #12, on 8/22/18 at 11:02 AM, revealed she had witnessed the encounter between Resident #245 and CNA #1, and confirmed the statements Resident #245 had made about the incident. She stated, It shocked me the way she talked to her. She should have known better than to say that. She was crying that night. I asked her what was wrong and she said that Aide made her upset, don't worry about it. (LPN #1) will get it straight in the morning. Further interview with Resident #245's roommate, Resident #12, on 8/22/18, at 4:10 PM, revealed, Yes, I did think what (CNA #1) said to (Resident #245) was abusive. Yes, I did. She did say [***] to her. I'm not going to lie to you. Review of the Quarterly Minimum Data Set (MDS) for Resident #12, with an Assessment Reference Date (ARD) of 5/22/18, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognitive function. Interview with CNA #4, on 8/4/18 at 9:45 AM, revealed that she was the first to enter Resident #245's room on the morning of 8/19/18. She stated the resident was very upset. She said the resident reported that she had not slept well last night because two (2) girls came into her room and one (1) cursed her and took her tray. She stated that Resident #245 told her that she thought they were going to jump on her and that she thought that she was coming here to be cared for, not to be mistreated. CNA #4 stated, She is in her right mind. During an interview on 8/24/18, at 10:00 AM, CNA #5 stated she was assigned to Resident #245 on 8/19/18. She stated the resident was crying during morning care. CNA #5 stated, She had tears coming out of her. She said she had a bad night, that two (2) CNAs in purple came in her room, said one (1) cursed her out, snatched her tray, and walked out of the room. She said as soon as her husband came, she was going to tell him to get her out of here. Review of a Resident Incident Report, , not dated, revealed Resident #245 reported that CNA was verbally abusive to her. The Resident stated that the CNA used vulgar language upon patient care and refused to set up her meal tray. Review of the Accident/Incident Investigation report, signed by the DON on 8/21/18, revealed that on 8/19/18, Resident #245 told LPN #1 of an allegation that CNA #1 had cursed her when she pulled back the covers (Resident had BM). The resident alleged the CNA stated, What the [***] is this. The resident stated the incident occurred on 8/18/18 at approximately 7:00 PM. The DON was notified by phone, by LPN #1, of the allegation, and the DON instructed LPN #1 to move CNA #1 to another floor away from Resident #245. The report documented CNA #1 was sent home after speaking to the resident and Roommate on 8/21/18. This was two (2) days after the incident had been reported to facility staff, with the CNA continuing to provide care to other residents. The DON failed to follow the facility policy for Abuse by not suspending CNA #1 pending investigation, and failure to report and investigate the allegation of abuse. Review of a Psychosocial Assessment for Resident #245, dated 8/23/18, signed by the Licensed Social Worker (LSW), revealed under the Abuse Assessment: Patient was recently verbally abused by CNA servicing her at (facility). Patient stated she was cursed at and food taken away, not being allowed to eat supper one evening. Also aide did not clean her bottom well when she had a bowel movement. The documented note revealed the Patient is not allowing things to bother her anymore and writes it off as the other person has a problem. An attached Departmental Note, dated 8/23/18 at 4:43 PM, by the LSW, revealed Resident #245 was initially bothered by the incident, that someone would treat her that way, she agreed she did not feel any emotional or physical stress from the incident at that time. Review of the Time/Attendance Detail, dated 8/22/18, revealed that CNA #1 began her shift on 8/18/18 at 3:26 PM, and worked until 11:03 PM, on the day of the alleged abuse. The Time/Attendance Detail record indicated that she worked on 8/19/18, the day that LPN #1 reported the allegation of abuse to the DON, on the 3:00 PM to 11:00 PM shift from 3:26 PM until 11:03 PM. The Time/Attendance Detail report also revealed that CNA #1 was allowed, by the DON, to return to work on 8/20/18, from 3:55 PM until 11:06 PM, and again on 8/21/18, from 4:03 PM until 6:25 PM. Review of the Second Floor Resident Assignment sheet, dated Saturday, (MONTH) 18, (YEAR), revealed that CNA #1 was assigned to the group which included room [ROOM NUMBER]A, Resident #245. Review of the Third Floor Resident Assignment sheet dated Sunday, (MONTH) 19, (YEAR), revealed that CNA #1 was assigned to a group that didn't include Resident #245. Review of the Personnel Action dated 8/21/18, revealed that CNA #1 was sent home on 8/21/18, until the investigation was completed. It also revealed that on 8/22/18, CNA #1 was contacted by the DON per telephone, and was informed of termination status, due to abuse and neglect. Review of an Attendance Record for an In-Service Meeting, held on (MONTH) 22, (YEAR), which included Abuse/Neglect .Incident/Accident, Stress/Burnout, instructed by the DON, revealed that CNA #1 signed the the record as attending the in-service. CNA #1 also signed an Abuse Policy Statement and an Employed Statement of the Vulnerable Adults Act, indicating that she read and understood completely its contents on 4/19/18. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 8/24/18, for the IJ: Statement: The Director of Nursing (DON) was notified on 8/19/18 at 3:46 PM by LPN #1 stating Resident #245 reported CNA #1 for using verbal abuse, using profanity toward her on 8/18/18 at approximately 7:00 PM. DON instructed LPN #1 to write a disciplinary action and move CNA #1 to another group and write a statement. LPN #1 informed DON that CNA #1 was on 3rd floor working away from Resident #245. The Abuse Policy states, Alleged abuse must be reported, investigated and prevent further potential abuse while the investigation is in progress. The DON failed to protect the Resident #245 by not following policy and allowing CNA #1 to work from 8/18/18 through 8/21/18. DON did not report to the Administrator, remove CNA #1 immediately, nor did she investigate allegation of abuse as required. 1. FACILITY ACTIONS: *The Medical Director was contacted on 8/22/18, at approximately 3:20 p.m. by the Administrator and notified of Immediate Jeopardy for alleged abuse of Resident #245. *Attorney General's Office was notified on 8/24/18 at 10:03 a.m by Administrative Assistant (AA #1) of alleged abuse of Resident #245. *The Mississippi State Department of Health was notified on 8/24/2018 at 9:38 a.m. by the Administrative Assistant. *The local police department was notified on 8/23/18 at approximately 3:30 p.m., by the DON of the abuse of resident #245. Report obtained on 8/24/2018. *The Administrator was made aware of alleged incident of Resident #245 when she questioned why the CNA was going to talk to the surveyors 8/21/2018. *The Administrator spoke with the Mississippi Board of Nursing on 8/23/18 at 1:30 p.m. regarding DON's failure to follow abuse and neglect policy and failure to report abuse. *Administrator met with Resident Council on 8/23/2018 at 10:00 am. She allowed and encouraged residents to voice their concerns. No concerns of verbal abuse voiced. 2. INVESTIGATION: *Investigation was begun by the DON on 8/21/18. DON interviewed Resident #245 at 3:30 p.m. asking if she felt secure and comfortable and able to report issues. Resident #245 alleged the CNA pulled back the covers and cursed me. *Social Services spoke with 31 of 31 interviewable residents on 8/22/2018. Statements of verbal abuse were not noted. *Nursing Services interviewed residents on 8/23/2018 with no negative concerns. *Resident #245 was interviewed on 8/22/18, by RN #3 at 8:30 p.m. and stated everything is fine. *The DON interviewed Resident #245's Roommate, Resident #12, on 8/22/18, and stated She said the F word and walked out. Questioned Roommate to see if CNA #1 was inappropriate with her in any way. She stated No. Brief Interview of Mental Status (BIMS) based on 8/16/2018 assessment: Score -15, cognitively intact. *CNA#1 was interviewed regarding Resident #245 by DON on 8/21/2018 at 3:15 p.m. and stated, I did not do it. *CNA#1 was terminated by telephone on 8/22/2018 at approximately 5:00 p.m. by the DON for abuse and neglect of Resident#245. *DON was relieved of her duties on 8/23/2018 at 11:45 a.m. for failure to follow the policies and procedures of abuse and neglect. RN #6 was placed as interim DON until new DON is hired. *Resident #245 was assessed by RN #3 and RN #1 after complaint on 8/19/2018 at 3:46 p.m. No mental or physical problems noted. Brief Interview of Mental Status (BIMS) based on 8/23/2018 assessment: Score -15, cognitively intact. 3. ASSESSMENT: *Psychosocial Assessment was completed on 8/23/2018 at 4:00p.m. by Licensed Social worker. Results is no negative findings. Care plan was updated including verbal abuse on 8/23/2018 by RN #3. *Physician#1 completed a Psychological (Psyche) consultation on Resident #245 at 8/24/2018 at 10:00 a.m. with no negative findings, Resident is doing well, found no remaining issues since altercation with staff. 4. IN-SERVICES: *In-service on Care Plans was initiated on 8/23/18, by the Care Plan Coordinator with 105 employees from all disciplines in attendance. Topics include verbal abuse and abuse policy. *All staff will be in-serviced upon hire, annually and as needed on Abuse and Neglect by AA #1. *No staff will be allowed to work until in-serviced. *Social Worker from another facility, not associated with this facility, initiated an in-service on 8/22/18 at 2:30 p.m. on Abuse and Neglect for all staff members. In-service was completed on 8/23/2018. Topics included: -Abuse and Neglect -Forms of Abuse -Reporting -Investigation -Removal of Employee 5. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT COMMITTEE (QAPI): *The Quality Assurance Performance Improvement Committee (QAPI) conducted our first meeting on 8/22/18 at 5:45 p.m., with the Medical Director, after confirming alleged abuse of Resident#245, to review policies and procedures for abuse and neglect and proper reporting procedures. In-services on abuse and neglect were recommended. Attending were Administrator, DON, Medical Director, Infection Control Nurse, and RN Supervisors. No policy or procedure changes, no further recommendations at this time. *QAPI Committee met on 8/23/18 at 10:00 a.m. to discuss residents well being and consultation of Psychiatrist to evaluate and assist in resident care. The facility alleges that all corrective actions were completed on 8/24/18, and the Immediate Jeopardy was removed on 8/25/18. The State Agency (SA) validated the facility's A[NAME] and determined the facility took the following actions to correct the IJ: 1. FACILITY ACTIONS: The SA vailidated through interview with the Medical Director that he was contacted on 8/22/18 by the Administrator and notified of Immediate Jeopardy for alleged abuse of Resident #245. The SA validated through interview with the Administrator and document review, that the Attorney General's Office was notified on 8/24/18, by Administrative Assistant (AA #1) of alleged abuse of Resident #245 The SA validated through interview with the Administrator and document review that the Mississippi State Department of Health was notified of the alleged abuse of Resident #245, on 8/24/2018, by the Administrative Assistant. The SA validated through interview with the Administrator and record review that the local police department was notified on 8/23/18 at approximately 3:30 p.m., by the DON of the abuse of resident #245 and that a report was obtained on 8/24/2018. The SA validated through interview with the Administrator that she was made aware of alleged incident of Resident #245 when she questioned why the CNA was going to talk to the surveyors 8/21/2018; it had not been reported to her prior. The SA validated through record review and interview with the Administrator that she spoke with the Mississippi Board of Nursing on 8/23/18, regarding the DON's failure to follow abuse and neglect policy and failure to report the abuse to the appropriate agencies. The SA validated through interview with the Administrator, review of the Resident Council Meeting Minutes, and attendance log, that the Administrator met with Resident Council on 8/23/2018 at 10:00 a.m. where she allowed and encouraged residents to voice their concerns. No concerns of verbal abuse was documented. 2. INVESTIGATION: The SA validated through interview with the DON and Resident #245 that the investigation was begun by the DON on 8/21/18, and Resident interview was completed. The SA validated that Resident #245 reported to the DON that the CNA pulled back the covers and cursed her. The SA validated through record review, and interview with random Residents, the Administrato,r and Social Services, that Social Services spoke with 31 of 31 interviewable residents on 8/22/2018. Per interview, statements of verbal abuse were not noted. The SA validated through record review and interview with the Administrator and DON that Nursing Services interviewed residents on 8/23/2018 with no negative concerns of abuse. The SA validated through record review that Resident #245 was interviewed on 8/22/18, by RN #3 at and the resident stated everything was fine at that time. The SA validated through record review and interview with the DON and Resident #245, that the DON interviewed Resident #245's roommate, Resident #12, on 8/22/18, who confirmed the CNA used profanity, the F word, and walked out. It was confirmed by interview that that DON questioned the Roommate to see if CNA #1 was inappropriate with her in any way and the Roomate denied being treated inappropriately. Record review confirmed Resident #12's Brief Interview of Mental Status (BIMS), based on 8/16/2018 assessment, was a Score of 15, which indicated the resident had no cognitive impairment. The SA validated through interview with the DON and record review that CNA #1 was interviewed regarding Resident #245 by the DON on 8/21/2018 at 3:15 p.m. and the CNA denied abusing the resident. The SA validated through interview with the DON and the Administrator, and document review, that CNA #1 was terminated by telephone on 8/22/2018, by the DON for abuse and neglect of Resident#245. The SA validated through interview with the Administrator and record review, that the DON was relieved of her duties on 8/23/2018 at 11:45 a.m. for failure to follow the policies and procedures of abuse and neglect; RN#6 was placed as interim DON. The SA validated through interview with the DON and the Administrator and record review that Resident #245 was assessed by RN #3 and RN #1 after the complaint of abuse on 8/19/2018 at 3:46 p.m. No mental or physical problems noted and/or documented. Review of the Mimimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 8/23/2018, revealed Resident #245 was cognitively intact with a BIMS of 15. 3. ASSESSMENT: The SA validated through interview with the Administrator and record review that a Psychosocial Assessment was completed on 8/23/2018, by the Licensed Social Worker, with no concerns noted. The SA validated through interview with the Interim Director of Nursing and record review, that the care plan was updated for Resident #245, including verbal abuse on 8/23/2018, by RN #3. The SA validated through interview with the Administrator and record review that Physician #1 completed a Psych consultation on Resident#245 at 8/24/2018 at 10:00 a.m., and documented, Resident is doing well, found no remaining issues since altercation with staff. 4. IN-SERVICES: The SA validated through interview with the Administrator and staff from Nursing, Dietary, Activities, Social Services, and Housekeeping/Maintenance, and record review of sign-in sheets, that an In-service on Care Plans was initiated on 8/23/18 by the Care Plan Coordinator with 105 employees from all disciplines in attendance. Topics include verbal abuse and abuse policy. The SA validated through interview with the Administrator and record review, that all staff will be in-serviced upon hire, annually and as needed on Abuse and Neglect by AA #1. Review of the new hire list revealed no staff had been hired since 8/18/18. The SA validated through interview with the Administrator and record review that no staff will be allowed to work until in-serviced. The SA validated through interview with the Administrator, staff from Nursing, Dietary, Activities, Social Services, and record review of sign-in sheets, that a Social Worker from another facility initiated an in-service on 8/22/18 related to Abuse and Neglect for all staff members. In-service was completed on 8/23/2018. Topics include: Abuse and Neglect, Forms of Abuse, Reporting, Investigation, and Removal of Employee. 5. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT COMMITTEE (QAPI): The SA valildated through interview with the Medical Director, Administrator and three (3) staff members who attended the meeting, and record review of sign-in sheets, that the the Quality Assurance Performance Improvement Committee (QAPI) conducted the first meeting on 8/22/18 at 5:45 p.m. with the Medical Director, after confirming alleged abuse of Resident#245 to review policies and procedures for abuse and neglect and proper reporting procedures. In-services on abuse and neglect were recommended at that time. The sign-in sheets validated the attendance of the Administrator, DON, Medical Director, Infection Control Nurse, and RN Supervisors. No policy or procedure changes or further recommendations were made at this time, per interview with staff in attendance. The SA valildated through interview with the Medical Director, Administrator and three (3) staff members who attended the meeting, and record review of the sign-in sheet, that the QAPI Committee met on 8/23/2018 at 10:00 a.m. to discuss the resident's well being and consultation of a Psychiatrist to evaluate and assist in resident care. The SA validated that all corrective actions were completed as of 8/24/18, and the IJ was removed as of 8/25/18.

Based on staff interview, record review and facility policy review, the facility failed to implement their facility policy for Abuse and Neglect as evidenced by failure to remove an employee from the facility following an allegation of abuse, investigate the allegation, and report the allegation to the Administrator and State Agencies, for one (1) of 22 residents reviewed for an incident of abuse, Resident #245. On 8/19/19, Resident #245 reported to Licensed Practical Nurse (LPN) #1 of an allegation of verbal abuse by Certified Nursing Assistant (CNA) #1, which occurred on 8/18/18, at approximately 7:00 PM. CNA #1 was not suspend pending investigation and was allowed to work until 8/21/18. The facility did not start an investigation until 8/21/18, after the State Agency questioned the allegation, and the incident was not reported to the Administrator or State Agencies, as required, until 8/21/18. The failure of the facility to suspend CNA #1, report the allegation of abuse to the State Agencies and Administrator, and investigate the allegation timely, placed Resident #245 and other residents at risk, and in a situation that was likely to cause, serious injury, harm, impairment , or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 8/18/18, when the allegation of abuse occurred. The facility's Administrator was notified of the IJ and SQC on 8/22/18. An acceptable credible Allegation of Compliance (A[NAME]) was accepted on 8/24/18, in which the facility alleged all corrective actions were completed 8/24/18, and the IJ was removed on 8/25/18. The State Agency validated the A[NAME] and determined that the IJ was removed on 8/25/18, prior to exit. Therefore, the scope and severity for IJ and SQC at 42 CFR 483.12(b)(1) was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy entitled, ABUSE & NEGLECT POLICY,undated, revealed: Policy Statement: All residents of this facility have the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, involuntary seclusion, mistreatment, or neglect. Residents must not be subjected to abuse by anyone (including but not limited to: facility staff, ) .1) Facility must ensure that staff will not use verbal, mental, sexual, or physical abuse, including corporal punishment, or involuntary seclusion 5) The facility will ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries or unknown origin are reported immediately to the Charge Nurse, Director of Nursing services, or the Administrator of the facility, or other officials, such as the State Board of Health and the Office of the Attorney General. 6) The facility must thoroughly investigate all alleged violations and document this investigation. 7) The facility must ensure and prevent further potential abuse while the investigation is in process. 8) The facility must ensure that results of all investigations are reported the Administrator or designated representative or to other officials in accordance with state law. Abuse Prevention and Prohibition: This facility will develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property Abuse 'Verbal Abuse' is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . 'Mental Abuse' includes, but is not limited to humiliation .18) Should an employee be reported for possible abuse, the employee will be placed on leave, with pay pending the results of the in-house investigation. If validated, the employee is to be discharged , and not eligible for rehire 24) The staff will report all incidents. Incident reports will be completed, and thoroughly investigated. Incident reports shall be reviewed by the Director of Nursing Services, Medical Director, and Administrator. All incidents are to be reported to the family/Responsible Party. Record review of the physician's orders [REDACTED].#245 on 8/17/18, under the care of a local Hospice with the following Diagnoses: [REDACTED]. The resident was her own Responsible Party (RP) on admission to the facility. Review of the Nurse's Notes, dated 8/17/18, at 3:20 PM, revealed: Resident is alert to time, place, person, and situation. Is able to make needs known. This entry was signed by Registered Nurse (RN) #3. Review of a Resident Incident Report, not dated, revealed Resident #245 reported that a CNA was verbally abusive to her. Resident #245 stated that CNA used vulgar language upon patient care and refused to set up her meal tray. Review of the Accident/Incident Investigation report, dated 8/21/18, revealed that on 8/19/18, at 3:46 PM, the DON was notified via phone, by LPN #1, of an allegation of verbal abuse (between CNA #1 and Resident #245) which occurred on 8/18/18, at approximately 7:00 PM. The DON instructed LPN #1 to write a disciplinary action against CNA #1, move CNA #1 to another group, and write a statement. The DON failed to follow the facility policy for Abuse by not reporting the allegation to the Mississippi Department of Health within two (2) hours of knowledge of the incident, failed to suspend CNA #1 pending investigation to protect other residents, and failed to investigate the allegation of abuse in a timely manner. CNA #1 was not suspended until 8/21/18. The investigation by the facility began on 8/21/18, after the State Agency inquired about the abuse allegation. Interview on 8/21/18, at 3:00 PM, revealed Resident #245 was alert and oriented to person, place, and time with no cognitive impairment. Resident #245 stated that CNA #1, assisted by CNA #2, came into her room to provide incontinent care around 7:00 PM, on 8/18/18. The resident stated that she had a bowel movement (BM) in her brief. Resident #245 stated when CNA #1 pulled the bedcovers back, she made a face as if she smelled something, and then she pointed down there, indicating her brief area, and said, What the [***] is that? When asked how it made her feel, Resident #245 stated, It makes you feel kind of sad, embarrassed. When asked if she felt as if CNA #1 was abusive to her, she said, It did make me feel like abuse. It made me feel humiliated. She also stated that CNA #1 took her dinner tray when she had asked her not to. Resident #245 stated that she reported the allegation to LPN #1 on 8/19/18. A phone interview conducted on 8/21/18 at 4:44 PM, with Licensed Practical Nurse (LPN) #1, revealed that she was called to Resident #245's room by CNA #4 on 8/19/18. CNA #4 reported that Resident #245 was crying. LPN #1 said that she attempted to determine what caused the resident to cry, and the resident told her that she had a bowel movement and a CNA came in and pulled her covers back and said, What the [***] is this!. She stated that the resident told her it was the CNA who took care of her after 3:00 PM on 8/18/18. LPN #1 said she checked the schedule and found that CNA #1 had been assigned to Resident #245 the previous evening. CNA #1 was also scheduled to work on 8/19/18, at 3:00 PM, so she met her when she got to work and asked her to come to the second floor. She stated she asked CNA #1 about the incident and the CNA stated, How do you know it was me? LPN #1 stated she took CNA #1 to Resident #245's room, where Resident #245 identified the CNA as the one who had cursed at her. LPN #1 stated that the resident had her eyes closed when they entered the room and she opened them and immediately stated, That is her. LPN #1 stated CNA #1 denied the accusation and began to verbally argue with Resident #245 saying, What makes this resident so special? LPN #1 stated she told CNA #1 that this was enough and she needed to leave the room. LPN #1 stated that CNA #1 mumbled under her breath, Good, because I'm already late. LPN #1 stated she called the Director of Nursing (DON) and gave a phone report of the incident, who told her to write up the CNA, make sure she didn't work with Resident #245, and put the write up under her door. LPN #1 stated that CNA #1 was assigned to the third floor on 8/19/18, and confirmed the CNA worked her shift on 8/19/18. LPN #1 stated that she did consider the incident as abuse. In an interview on 8/21/18 at 5:15 PM, CNA #1 confirmed that she had been assigned to Resident #245 on 8/18/18. She stated, I never used profane language or anything. She stated that when she came to work on Sunday, 8/19/18, the morning nurse, LPN #1, said she cursed Resident #245 out, and had used curse words in her room like, What this [***] is up or [***] you, something with [***] in it; maybe she misunderstood something I said. CNA #1 continued to deny the accusation. She also denied that she took the resident's tray. She did confirm that the resident's Roommate, Resident # 12, was in the room during the the time that she was performing incontinent care for Resident #245. CNA #1 stated that she was assisted by CNA#2. At the conclusion of the interview, CNA #1 stated, Great. I guess I just spent my 30 minute break in here, didn't I? During an interview on 8/21/18 at 5:30 PM, the DON confirmed that LPN #1 had called her on the afternoon of 8/19/18, to report an allegation of verbal abuse against Resident #245, by CNA #1. She stated she was told that CNA #1, had gone into Resident #245's room, pulled the covers back and said 'What the [***] is that? The DON stated that she was not aware of anyone in the room at the time of the allegation. She stated that CNA #2 was hospitalized and unavailable for interview during the survey. She stated she instructed LPN #1 to write up CNA #1, put the documentation under her office door, and make sure that CNA #1 was not assigned to Resident #245. She stated that she allowed CNA #1 to continue to work on 8/19/18, after the allegation of abuse was reported to her. She confirmed that she did not implement the policy of the facility to suspend an employee who is accused of abuse until an investigation was completed. She revealed that it is the policy of the facility that if a resident accused a staff member of abuse, it should be reported to herself or the Administrator and other agencies; an investigation should be started, and the employee should be removed from the building. She stated that she talked to CNA #1 by phone after the reported allegation, and the CNA wasn't in a foul frame of mind. She stated it might not have been the best decision to let her continue to work, in hindsight. The DON stated that she didn't talk with Resident #245 or the Roomate on that Sunday, 8/19/18. The DON confirmed the allegation of abuse had not been reported to the State Agency as required. Review of a signed typed statement, by the DON on 8/21/18, revealed she interviewed Resident #245 and Resident #12 shortly after 4:00 PM, on 8/21/18. Documentation revealed Resident #245 said CNA #1 had brought her meal tray (8/18/18) and returned later and removed the tray with the resident telling her not to, because she had not eaten. The resident also stated the CNA returned and pulled the covers back and said, What the [***] is this. The DON documented that once CNA #1 returned from her break, she then sent her home. Another typed statement, signed by the DON, dated 8/21/18 at 4:40 PM, revealed she interviewed the Roommate of Resident #245, (Resident #12), who reported she witnessed the incident between CNA #1 and Resident #245 on 8/18/18. Resident #12 confirmed, She said the [***] word. The resident reported no other issues. An interview, conducted with Resident #245 and her husband, on 8/22/18, at 4:15 PM, revealed the Husband had been informed of the incident. When asked about the actual care she received from CNA #1 on 8/18/18, the resident stated, She didn't clean me up too good, cause I could still smell it. She also stated, Where is she? What if she disguised herself and came up in here mad and started shooting up the place. You know that happens. The Resident's husband attempted to calm and reassure her that would not happen. When asked if scared or hesitant to use the call light, the resident stated, No, I'm not scared. She stated, After she said that, I made it known I don't want her to come back in this room. Ain't nothing wrong with my brain. I know when somebody says something to me and it wasn't right. She thought I was one of those patients that wasn't going to say nothing, but she met her match. I don't know what was wrong with her, if she was mad with her boyfriend, she should have kept it at home. Work is not the place for it. An interview with Resident #245's Roommate, Resident #12, on 8/22/18 at 11:02 AM, revealed she had witnessed the encounter between Resident #245 and CNA #1 and confirmed the statements Resident #245 had made about the incident. She stated, It shocked me the way she talked to her. She should have known better than to say that. She was crying that night. I asked her what was wrong and she said that Aide made her upset, don't worry about it. (LPN #1) will get it straight in the morning. Further interview with Resident #245's roommate, Resident #12, on 8/22/18, at 4:10 PM, revealed, Yes, I did think what (CNA #1) said to (Resident #245) was abusive. Yes, I did. She did say [***] to her. I'm not going to lie to you. Review of the Quarterly Minimum Data Set (MDS) for Resident #12, with an Assessment Reference Date (ARD) of 5/22/18, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognitive function. In an interview on 8/4/18 at 9:45 AM, CNA #4 revealed that she was the first to enter Resident #245's room on the morning of 8/19/18. She stated the resident was very upset. She said the resident stated that she had not slept well the night prior, because two (2) girls came into her room and one (1) cursed her and took her tray. She stated Resident #245 told her that she thought they were going to jump on her and that she thought that she was coming here to be cared for, not to be mistreated. CNA #4 stated, She is in her right mind. During an interview on 8/24/18, at 10:00 AM, CNA #5 stated that she was assigned to Resident #245 on 8/19/18. She stated that the resident was crying during morning care. CNA #5 stated, She had tears coming out of her. She said she had a bad night, that two (2) CNAs in purple came in her room, said one (1) cursed her out, snatched her tray, and walked out of the room. She said as soon as her husband came, she was going to tell him to get her out of here. Review of the Time/Attendance Detail, dated 8/22/18, revealed that CNA #1 began work on 8/18/18 at 3:26 PM until 11:03 PM, on the day of the alleged abuse. Review of the second (2nd) Floor Resident Assignment sheet, dated Saturday, (MONTH) 18, (YEAR), revealed that CNA #1 was assigned to Group V (GP V), which included room [ROOM NUMBER]A, Resident #245. The Time/Attendance Detail record indicated that she worked on the 8/19/18, the day that LPN #1 reported allegation of abuse to the DON, on the 3:00 PM to 11:00 PM shift from 3:26 PM until 11:03 PM. Review of the third (3rd) Floor Resident Assignment sheet dated Sunday, (MONTH) 19, (YEAR), revealed that CNA #1 was assigned to Group I (GP I). The Time/Attendance Detail report also revealed that CNA #1 was allowed, by the DON, to return to work on 8/20/18, from 3:55 PM until 11:06 PM, and again on 8/21/18, from 4:03 PM until 6:25 PM. Review of the Personnel Action dated 8/21/18, revealed that CNA #1 was sent home on 8/21/18, until the investigation was completed. It also revealed that on 8/22/18, CNA #1 was contacted by the DON per telephone and was informed of termination status, due to abuse and neglect. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 8/24/18, for the IJ: Statement: The Director of Nursing (DON) was notified on 8/19/18 at 3:46 PM by LPN #1 stating Resident #245 reported CNA #1 for using verbal abuse, using profanity toward her on 8/18/18 at approximately 7:00 PM. DON instructed LPN #1 to write a disciplinary action and move CNA #1 to another group and write a statement. LPN #1 informed DON that CNA #1 was on 3rd floor working away from Resident #245. The Abuse Policy states, Alleged abuse must be reported, investigated and prevent further potential abuse while the investigation is in progress. The DON failed to protect the Resident #245 by not following policy and allowing CNA #1 to work from 8/18/18 through 8/21/18. DON did not report to the Administrator, remove CNA #1 immediately, nor did she investigate allegation of abuse as required. 1. FACILITY ACTIONS: *The Medical Director was contacted on 8/22/18, at approximately 3:20 p.m. by the Administrator and notified of Immediate Jeopardy for alleged abuse of Resident #245. *Attorney General's Office was notified on 8/24/18 at 10:03 a.m by Administrative Assistant (AA #1) of alleged abuse of Resident #245. *The Mississippi State Department of Health was notified on 8/24/2018 at 9:38 a.m. by the Administrative Assistant. *The local police department was notified on 8/23/18 at approximately 3:30 p.m., by the DON of the abuse of resident #245. Report obtained on 8/24/2018. *The Administrator was made aware of alleged incident of Resident #245 when she questioned why the CNA was going to talk to the surveyors 8/21/2018. *The Administrator spoke with the Mississippi Board of Nursing on 8/23/18 at 1:30 p.m. regarding DON's failure to follow abuse and neglect policy and failure to report abuse. *Administrator met with Resident Council on 8/23/2018 at 10:00 am. She allowed and encouraged residents to voice their concerns. No concerns of verbal abuse voiced. 2. INVESTIGATION: *Investigation was begun by the DON on 8/21/18. DON interviewed Resident #245 at 3:30 p.m. asking if she felt secure and comfortable and able to report issues. Resident #245 alleged the CNA pulled back the covers and cursed me. *Social Services spoke with 31 of 31 interviewable residents on 8/22/2018. Statements of verbal abuse were not noted. *Nursing Services interviewed residents on 8/23/2018 with no negative concerns. *Resident #245 was interviewed on 8/22/18, by RN #3 at 8:30 p.m. and stated everything is fine. *The DON interviewed Resident #245's Roommate, Resident #12, on 8/22/18, and stated She said the F word and walked out. Questioned Roommate to see if CNA #1 was inappropriate with her in any way. She stated No. Brief Interview of Mental Status (BIMS) based on 8/16/2018 assessment: Score -15, cognitively intact. *CNA#1 was interviewed regarding Resident #245 by DON on 8/21/2018 at 3:15 p.m. and stated, I did not do it. *CNA#1 was terminated by telephone on 8/22/2018 at approximately 5:00 p.m. by the DON for abuse and neglect of Resident#245. *DON was relieved of her duties on 8/23/2018 at 11:45 a.m. for failure to follow the policies and procedures of abuse and neglect. RN #6 was placed as interim DON until new DON is hired. *Resident #245 was assessed by RN #3 and RN #1 after complaint on 8/19/2018 at 3:46 p.m. No mental or physical problems noted. Brief Interview of Mental Status (BIMS) based on 8/23/2018 assessment: Score -15, cognitively intact. 3. ASSESSMENT: *Psychosocial Assessment was completed on 8/23/2018 at 4:00p.m. by Licensed Social worker. Results is no negative findings. Care plan was updated including verbal abuse on 8/23/2018 by RN #3. *Physician#1 completed a Psychological (Psyche) consultation on Resident #245 at 8/24/2018 at 10:00 a.m. with no negative findings, Resident is doing well, found no remaining issues since altercation with staff. 4. IN-SERVICES: *In-service on Care Plans was initiated on 8/23/18, by the Care Plan Coordinator with 105 employees from all disciplines in attendance. Topics include verbal abuse and abuse policy. *All staff will be in-serviced upon hire, annually and as needed on Abuse and Neglect by AA #1. *No staff will be allowed to work until in-serviced. *Social Worker from another facility, not associated with this facility, initiated an in-service on 8/22/18 at 2:30 p.m. on Abuse and Neglect for all staff members. In-service was completed on 8/23/2018. Topics included: -Abuse and Neglect -Forms of Abuse -Reporting -Investigation -Removal of Employee 5. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT COMMITTEE (QAPI): *The Quality Assurance Performance Improvement Committee (QAPI) conducted our first meeting on 8/22/18 at 5:45 p.m., with the Medical Director, after confirming alleged abuse of Resident#245, to review policies and procedures for abuse and neglect and proper reporting procedures. In-services on abuse and neglect were recommended. Attending were Administrator, DON, Medical Director, Infection Control Nurse, and RN Supervisors. No policy or procedure changes, no further recommendations at this time. *QAPI Committee met on 8/23/18 at 10:00 a.m. to discuss residents well being and consultation of Psychiatrist to evaluate and assist in resident care. The facility alleges that all corrective actions were completed on 8/24/18, and the Immediate Jeopardy was removed on 8/25/18. The State Agency (SA) validated the facility's A[NAME] and determined the facility took the following actions to correct the IJ: 1. FACILITY ACTIONS: The SA vailidated through interview with the Medical Director that he was contacted on 8/22/18 by the Administrator and notified of Immediate Jeopardy for alleged abuse of Resident #245. The SA validated through interview with the Administrator and document review, that the Attorney General's Office was notified on 8/24/18, by Administrative Assistant (AA #1) of alleged abuse of Resident #245 The SA validated through interview with the Administrator and document review that the Mississippi State Department of Health was notified of the alleged abuse of Resident #245, on 8/24/2018, by the Administrative Assistant. The SA validated through interview with the Administrator and record review that the local police department was notified on 8/23/18 at approximately 3:30 p.m., by the DON of the abuse of resident #245 and that a report was obtained on 8/24/2018. The SA validated through interview with the Administrator that she was made aware of alleged incident of Resident #245 when she questioned why the CNA was going to talk to the surveyors 8/21/2018; it had not been reported to her prior. The SA validated through record review and interview with the Administrator that she spoke with the Mississippi Board of Nursing on 8/23/18, regarding the DON's failure to follow abuse and neglect policy and failure to report the abuse to the appropriate agencies. The SA validated through interview with the Administrator, review of the Resident Council Meeting Minutes, and attendance log, that the Administrator met with Resident Council on 8/23/2018 at 10:00 a.m. where she allowed and encouraged residents to voice their concerns. No concerns of verbal abuse was documented. 2. INVESTIGATION: The SA validated through interview with the DON and Resident #245 that the investigation was begun by the DON on 8/21/18, and Resident interview was completed. The SA validated that Resident #245 reported to the DON that the CNA pulled back the covers and cursed her. The SA validated through record review, and interview with random Residents, the Administrato,r and Social Services, that Social Services spoke with 31 of 31 interviewable residents on 8/22/2018. Per interview, statements of verbal abuse were not noted. The SA validated through record review and interview with the Administrator and DON that Nursing Services interviewed residents on 8/23/2018 with no negative concerns of abuse. The SA validated through record review that Resident #245 was interviewed on 8/22/18, by RN #3 at and the resident stated everything was fine at that time. The SA validated through record review and interview with the DON and Resident #245, that the DON interviewed Resident #245's roommate, Resident #12, on 8/22/18, who confirmed the CNA used profanity, the F word, and walked out. It was confirmed by interview that that DON questioned the Roommate to see if CNA #1 was inappropriate with her in any way and the Roomate denied being treated inappropriately. Record review confirmed Resident #12's Brief Interview of Mental Status (BIMS), based on 8/16/2018 assessment, was a Score of 15, which indicated the resident had no cognitive impairment. The SA validated through interview with the DON and record review that CNA #1 was interviewed regarding Resident #245 by the DON on 8/21/2018 at 3:15 p.m. and the CNA denied abusing the resident. The SA validated through interview with the DON and the Administrator, and document review, that CNA #1 was terminated by telephone on 8/22/2018, by the DON for abuse and neglect of Resident#245. The SA validated through interview with the Administrator and record review, that the DON was relieved of her duties on 8/23/2018 at 11:45 a.m. for failure to follow the policies and procedures of abuse and neglect; RN#6 was placed as interim DON. The SA validated through interview with the DON and the Administrator and record review that Resident #245 was assessed by RN #3 and RN #1 after the complaint of abuse on 8/19/2018 at 3:46 p.m. No mental or physical problems noted and/or documented. Review of the Mimimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 8/23/2018, revealed Resident #245 was cognitively intact with a BIMS of 15. 3. ASSESSMENT: The SA validated through interview with the Administrator and record review that a Psychosocial Assessment was completed on 8/23/2018, by the Licensed Social Worker, with no concerns noted. The SA validated through interview with the Interim Director of Nursing and record review, that the care plan was updated for Resident #245, including verbal abuse on 8/23/2018, by RN #3. The SA validated through interview with the Administrator and record review that Physician #1 completed a Psych consultation on Resident#245 at 8/24/2018 at 10:00 a.m., and documented, Resident is doing well, found no remaining issues since altercation with staff. 4. IN-SERVICES: The SA validated through interview with the Administrator and staff from Nursing, Dietary, Activities, Social Services, and Housekeeping/Maintenance, and record review of sign-in sheets, that an In-service on Care Plans was initiated on 8/23/18 by the Care Plan Coordinator with 105 employees from all disciplines in attendance. Topics include verbal abuse and abuse policy. The SA validated through interview with the Administrator and record review, that all staff will be in-serviced upon hire, annually and as needed on Abuse and Neglect by AA #1. Review of the new hire list revealed no staff had been hired since 8/18/18. The SA validated through interview with the Administrator and record review that no staff will be allowed to work until in-serviced. The SA validated through interview with the Administrator, staff from Nursing, Dietary, Activities, Social Services, and record review of sign-in sheets, that a Social Worker from another facility initiated an in-service on 8/22/18 related to Abuse and Neglect for all staff members. In-service was completed on 8/23/2018. Topics include: Abuse and Neglect, Forms of Abuse, Reporting, Investigation, and Removal of Employee. 5. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT COMMITTEE (QAPI): The SA valildated through interview with the Medical Director, Administrator and three (3) staff members who attended the meeting, and record review of sign-in sheets, that the the Quality Assurance Performance Improvement Committee (QAPI) conducted the first meeting on 8/22/18 at 5:45 p.m. with the Medical Director, after confirming alleged abuse of Resident#245 to review policies and procedures for abuse and neglect and proper reporting procedures. In-services on abuse and neglect were recommended at that time. The sign-in sheets validated the attendance of the Administrator, DON, Medical Director, Infection Control Nurse, and RN Supervisors. No policy or procedure changes or further recommendations were made at this time, per interview with staff in attendance. The SA valildated through interview with the Medical Director, Administrator and three (3) staff members who attended the meeting, and record review of the sign-in sheet, that the QAPI Committee met on 8/23/2018 at 10:00 a.m. to discuss the resident's well being and consultation of a Psychiatrist to evaluate and assist in resident care. The SA validated that all corrective actions were completed as of 8/24/18, and the IJ was removed as of 8/25/18.

Based on staff interview, record review and facility policy review, the facility failed to report, in a timely manner, an allegation of staff to resident verbal abuse to the State Designated Agencies for one (1) of 22 residents reviewed for abuse, Resident #245. An allegation of verbal abuse was reported against Certified Nursing Assistant (CNA) #1, by Resident #245, on the morning of 8/19/18 to LPN #1. The alleged abuse occurred on 8/18/18 around 7:00 PM. The Director of Nursing was notified of the allegation on 8/19/18, and did not report the allegation to the Administrator or appropriate State Agencies until 8/21/18, after the State Agency questioned the allegation. This allowed CNA #1 to continue working with vulnerable adults from 8/18/18 until 8/21/18. The failure of the facility to ensure an allegation of verbal abuse was reported to the Administrator of the facility and to the appropriate State Agencies, within two (2) hours of knowledge of the allegation, as required, placed Resident #245 and all other residents at risk, and in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 8/18/18, when the allegation of abuse occurred. The facility's Administrator was notified of the IJ and SQC on 8/22/18. An acceptable credible Allegation of Compliance (A[NAME]) was provided on 8/24/18, in which the facility alleged all corrective actions were completed 8/24/18, and the IJ was removed on 8/25/18. The State Agency validated the A[NAME] and determined that the IJ was removed on 8/25/18, prior to exit. Therefore, the scope and severity for 42 CFR(s) 483.12 (c)(1)(4)- F609 was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy entitled, ABUSE & NEGLECT POLICY, undated, revealed: 5) The facility will ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries or unknown origin are reported immediately to the Charge Nurse, Director of Nursing Services, or the Administrator of the facility, or other officials, such as the State Board of Health and the Office of the Attorney General. Under the section: Abuse Prevention and Prohibition: This facility will develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property Abuse 'Verbal Abuse' is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . 'Mental Abuse' includes, but is not limited to humiliation. Reporting Resident Abuse: All employees of this facility must immediately report any incident of resident neglect, abuse,or misappropriation of resident property. Such incidents will be investigated, and any findings of alleged abuse will be reported to the state agencies of Mississippi State Department of Health and Medicaid Fraud Control Unit Office of the Attorney General. Review of the Accident/Incident Investigation report dated 8/21/18, revealed that on 8/19/18, at 3:46 PM, the Director of Nursing (DON) was notified by LPN #1 of an allegation of verbal abuse from Resident #245, which occurred on 8/18/18, at approximately 7:00 PM, by CNA #1. The DON instructed LPN #1 to write a disciplinary action against CNA #1, move CNA #1 to another group, and write a statement. The DON failed to follow the facility policy for Abuse by not reporting the allegation to the Administrator and to the Regulatory State Agencies within two (2) hours of the report. The facility failed to suspend CNA #1 pending investigation, and failed to investigate the allegation of abuse in a timely manner. Record review revealed the facility admitted Resident #245 on 8/17/18. Review of the Nurse's Notes, dated 8/17/18, at 3:20 PM, revealed, Resident is alert to time, place, person, and situation. Is able to make needs known. This entry was signed by Registered Nurse (RN) #3. During an interview on 8/21/18, at 3:00 PM, Resident #245 was alert and oriented to person, place, and time with no cognitive impairment. She stated that Certified Nursing Assistant (CNA) #1 came into her room to provide incontinent care around 7:00 PM, on 8/18/18. The resident stated that she had a bowel movement (BM) in her brief, and when CNA #1 pulled the bedcovers back, she made a face as if she smelled something and then said, What the [***] is that? When asked how it made her feel, Resident #245 stated, It makes you feel kind of sad, embarrassed, I don't know what was wrong with her. She came into the room with a frowned up face. She looked kind of mad. When asked if she felt as if CNA #1 was abusive to her, she said, It did make me feel like abuse. It made me feel humiliated. She also stated that CNA #1 took her dinner tray even after she had asked to keep her sandwich for the night. The Resident stated that she reported the incident the next day to LPN #1. A phone interview conducted on 8/21/18 at 4:44 PM, with Licensed Practical Nurse (LPN) #1, confirmed Resident #245 had reported an allegation against CNA #1 for verbal abuse and using profanity on 8/19/18, for an incident that occurred 8/18/18 at 7:00 PM. LPN #1 confirmed calling the DON on 8/19/18, to report the allegation, and the DON instructed her to write the CNA up and move her from Resident #245's area, which she did. LPN #1 confirmed she thought the incident was considered abusive to Resident #245. In an interview,on 8/21/18 at 5:30 PM, the DON stated the report of the incident between Resident #245 and CNA #1, that occurred on 8/18/18, had not been called in to the State. She confirmed that LPN #1 had called her on the afternoon of 8/19/18, to report an allegation of verbal abuse against Resident #245 by CNA #1. She stated she was told that CNA#1 had gone into Resident #245's room, pulled the covers back and said, 'What the [***] is that? She stated that she allowed CNA #1 to continue to work on 8/19/18 after the allegation of abuse was reported to her. She confirmed that she did not follow the policy of the facility. Interview with ,and a document dated and signed by the Administrator on 8/21/18 at 4:30/5:00 PM, revealed she was not aware of the allegation of abuse, made by Resident #245 against CNA #1, until 8/21/18, when the surveyors asked to speak to CNA #1. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 8/24/18, for the IJ: Statement: The Director of Nursing (DON) was notified on 8/19/18 at 3:46 PM by LPN #1 stating Resident #245 reported CNA #1 for using verbal abuse, using profanity toward her on 8/18/18 at approximately 7:00 PM. DON instructed LPN #1 to write a disciplinary action and move CNA #1 to another group and write a statement. LPN #1 informed DON that CNA #1 was on 3rd floor working away from Resident #245. The Abuse Policy states, Alleged abuse must be reported, investigated and prevent further potential abuse while the investigation is in progress. The DON failed to protect the Resident #245 by not following policy and allowing CNA #1 to work from 8/18/18 through 8/21/18. DON did not report to the Administrator, remove CNA #1 immediately, nor did she investigate allegation of abuse as required. 1. FACILITY ACTIONS: *The Medical Director was contacted on 8/22/18, at approximately 3:20 p.m. by the Administrator and notified of Immediate Jeopardy for alleged abuse of Resident #245. *Attorney General's Office was notified on 8/24/18 at 10:03 a.m by Administrative Assistant (AA #1) of alleged abuse of Resident #245. *The Mississippi State Department of Health was notified on 8/24/2018 at 9:38 a.m. by the Administrative Assistant. *The local police department was notified on 8/23/18 at approximately 3:30 p.m., by the DON of the abuse of resident #245. Report obtained on 8/24/2018. *The Administrator was made aware of alleged incident of Resident #245 when she questioned why the CNA was going to talk to the surveyors 8/21/2018. *The Administrator spoke with the Mississippi Board of Nursing on 8/23/18 at 1:30 p.m. regarding DON's failure to follow abuse and neglect policy and failure to report abuse. *Administrator met with Resident Council on 8/23/2018 at 10:00 am. She allowed and encouraged residents to voice their concerns. No concerns of verbal abuse voiced. 2. INVESTIGATION: *Investigation was begun by the DON on 8/21/18. DON interviewed Resident #245 at 3:30 p.m. asking if she felt secure and comfortable and able to report issues. Resident #245 alleged the CNA pulled back the covers and cursed me. *Social Services spoke with 31 of 31 interviewable residents on 8/22/2018. Statements of verbal abuse were not noted. *Nursing Services interviewed residents on 8/23/2018 with no negative concerns. *Resident #245 was interviewed on 8/22/18, by RN #3 at 8:30 p.m. and stated everything is fine. *The DON interviewed Resident #245's Roommate, Resident #12, on 8/22/18, and stated She said the F word and walked out. Questioned Roommate to see if CNA #1 was inappropriate with her in any way. She stated No. Brief Interview of Mental Status (BIMS) based on 8/16/2018 assessment: Score -15, cognitively intact. *CNA#1 was interviewed regarding Resident #245 by DON on 8/21/2018 at 3:15 p.m. and stated, I did not do it. *CNA#1 was terminated by telephone on 8/22/2018 at approximately 5:00 p.m. by the DON for abuse and neglect of Resident#245. *DON was relieved of her duties on 8/23/2018 at 11:45 a.m. for failure to follow the policies and procedures of abuse and neglect. RN #6 was placed as interim DON until new DON is hired. *Resident #245 was assessed by RN #3 and RN #1 after complaint on 8/19/2018 at 3:46 p.m. No mental or physical problems noted. Brief Interview of Mental Status (BIMS) based on 8/23/2018 assessment: Score -15, cognitively intact. 3. ASSESSMENT: *Psychosocial Assessment was completed on 8/23/2018 at 4:00p.m. by Licensed Social worker. Results is no negative findings. Care plan was updated including verbal abuse on 8/23/2018 by RN #3. *Physician#1 completed a Psychological (Psyche) consultation on Resident #245 at 8/24/2018 at 10:00 a.m. with no negative findings, Resident is doing well, found no remaining issues since altercation with staff. 4. IN-SERVICES: *In-service on Care Plans was initiated on 8/23/18, by the Care Plan Coordinator with 105 employees from all disciplines in attendance. Topics include verbal abuse and abuse policy. *All staff will be in-serviced upon hire, annually and as needed on Abuse and Neglect by AA #1. *No staff will be allowed to work until in-serviced. *Social Worker from another facility, not associated with this facility, initiated an in-service on 8/22/18 at 2:30 p.m. on Abuse and Neglect for all staff members. In-service was completed on 8/23/2018. Topics included: -Abuse and Neglect -Forms of Abuse -Reporting -Investigation -Removal of Employee 5. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT COMMITTEE (QAPI): *The Quality Assurance Performance Improvement Committee (QAPI) conducted our first meeting on 8/22/18 at 5:45 p.m., with the Medical Director, after confirming alleged abuse of Resident#245, to review policies and procedures for abuse and neglect and proper reporting procedures. In-services on abuse and neglect were recommended. Attending were Administrator, DON, Medical Director, Infection Control Nurse, and RN Supervisors. No policy or procedure changes, no further recommendations at this time. *QAPI Committee met on 8/23/18 at 10:00 a.m. to discuss residents well being and consultation of Psychiatrist to evaluate and assist in resident care. The facility alleges that all corrective actions were completed on 8/24/18, and the Immediate Jeopardy was removed on 8/25/18. The State Agency (SA) validated the facility's A[NAME] and determined the facility took the following actions to correct the IJ: 1. FACILITY ACTIONS: The SA vailidated through interview with the Medical Director that he was contacted on 8/22/18 by the Administrator and notified of Immediate Jeopardy for alleged abuse of Resident #245. The SA validated through interview with the Administrator and document review, that the Attorney General's Office was notified on 8/24/18, by Administrative Assistant (AA #1) of alleged abuse of Resident #245 The SA validated through interview with the Administrator and document review that the Mississippi State Department of Health was notified of the alleged abuse of Resident #245, on 8/24/2018, by the Administrative Assistant. The SA validated through interview with the Administrator and record review that the local police department was notified on 8/23/18 at approximately 3:30 p.m., by the DON of the abuse of resident #245 and that a report was obtained on 8/24/2018. The SA validated through interview with the Administrator that she was made aware of alleged incident of Resident #245 when she questioned why the CNA was going to talk to the surveyors 8/21/2018; it had not been reported to her prior. The SA validated through record review and interview with the Administrator that she spoke with the Mississippi Board of Nursing on 8/23/18, regarding the DON's failure to follow abuse and neglect policy and failure to report the abuse to the appropriate agencies. The SA validated through interview with the Administrator, review of the Resident Council Meeting Minutes, and attendance log, that the Administrator met with Resident Council on 8/23/2018 at 10:00 a.m. where she allowed and encouraged residents to voice their concerns. No concerns of verbal abuse was documented. 2. INVESTIGATION: The SA validated through interview with the DON and Resident #245 that the investigation was begun by the DON on 8/21/18, and Resident interview was completed. The SA validated that Resident #245 reported to the DON that the CNA pulled back the covers and cursed her. The SA validated through record review, and interview with random Residents, the Administrato,r and Social Services, that Social Services spoke with 31 of 31 interviewable residents on 8/22/2018. Per interview, statements of verbal abuse were not noted. The SA validated through record review and interview with the Administrator and DON that Nursing Services interviewed residents on 8/23/2018 with no negative concerns of abuse. The SA validated through record review that Resident #245 was interviewed on 8/22/18, by RN #3 at and the resident stated everything was fine at that time. The SA validated through record review and interview with the DON and Resident #245, that the DON interviewed Resident #245's roommate, Resident #12, on 8/22/18, who confirmed the CNA used profanity, the F word, and walked out. It was confirmed by interview that that DON questioned the Roommate to see if CNA #1 was inappropriate with her in any way and the Roomate denied being treated inappropriately. Record review confirmed Resident #12's Brief Interview of Mental Status (BIMS), based on 8/16/2018 assessment, was a Score of 15, which indicated the resident had no cognitive impairment. The SA validated through interview with the DON and record review that CNA #1 was interviewed regarding Resident #245 by the DON on 8/21/2018 at 3:15 p.m. and the CNA denied abusing the resident. The SA validated through interview with the DON and the Administrator, and document review, that CNA #1 was terminated by telephone on 8/22/2018, by the DON for abuse and neglect of Resident#245. The SA validated through interview with the Administrator and record review, that the DON was relieved of her duties on 8/23/2018 at 11:45 a.m. for failure to follow the policies and procedures of abuse and neglect; RN#6 was placed as interim DON. The SA validated through interview with the DON and the Administrator and record review that Resident #245 was assessed by RN #3 and RN #1 after the complaint of abuse on 8/19/2018 at 3:46 p.m. No mental or physical problems noted and/or documented. Review of the Mimimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 8/23/2018, revealed Resident #245 was cognitively intact with a BIMS of 15. 3. ASSESSMENT: The SA validated through interview with the Administrator and record review that a Psychosocial Assessment was completed on 8/23/2018, by the Licensed Social Worker, with no concerns noted. The SA validated through interview with the Interim Director of Nursing and record review, that the care plan was updated for Resident #245, including verbal abuse on 8/23/2018, by RN #3. The SA validated through interview with the Administrator and record review that Physician #1 completed a Psych consultation on Resident#245 at 8/24/2018 at 10:00 a.m., and documented, Resident is doing well, found no remaining issues since altercation with staff. 4. IN-SERVICES: The SA validated through interview with the Administrator and staff from Nursing, Dietary, Activities, Social Services, and Housekeeping/Maintenance, and record review of sign-in sheets, that an In-service on Care Plans was initiated on 8/23/18 by the Care Plan Coordinator with 105 employees from all disciplines in attendance. Topics include verbal abuse and abuse policy. The SA validated through interview with the Administrator and record review, that all staff will be in-serviced upon hire, annually and as needed on Abuse and Neglect by AA #1. Review of the new hire list revealed no staff had been hired since 8/18/18. The SA validated through interview with the Administrator and record review that no staff will be allowed to work until in-serviced. The SA validated through interview with the Administrator, staff from Nursing, Dietary, Activities, Social Services, and record review of sign-in sheets, that a Social Worker from another facility initiated an in-service on 8/22/18 related to Abuse and Neglect for all staff members. In-service was completed on 8/23/2018. Topics include: Abuse and Neglect, Forms of Abuse, Reporting, Investigation, and Removal of Employee. 5. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT COMMITTEE (QAPI): The SA valildated through interview with the Medical Director, Administrator and three (3) staff members who attended the meeting, and record review of sign-in sheets, that the the Quality Assurance Performance Improvement Committee (QAPI) conducted the first meeting on 8/22/18 at 5:45 p.m. with the Medical Director, after confirming alleged abuse of Resident#245 to review policies and procedures for abuse and neglect and proper reporting procedures. In-services on abuse and neglect were recommended at that time. The sign-in sheets validated the attendance of the Administrator, DON, Medical Director, Infection Control Nurse, and RN Supervisors. No policy or procedure changes or further recommendations were made at this time, per interview with staff in attendance. The SA valildated through interview with the Medical Director, Administrator and three (3) staff members who attended the meeting, and record review of the sign-in sheet, that the QAPI Committee met on 8/23/2018 at 10:00 a.m. to discuss the resident's well being and consultation of a Psychiatrist to evaluate and assist in resident care. The SA validated that all corrective actions were completed as of 8/24/18, and the IJ was removed as of 8/25/18.

Based on interview, record review, and facility policy review, the facility failed to have documented evidence of thoroughly investigating an allegation of abuse, failed to suspend the accused employee, and failed to report the allegation of abuse and take appropriate action to ensure further abuse didn't occur, for one (1) incident of abuse, of 22 residents reviewed, Resident #245. Resident #245 alleged Certified Nursing Assistant (CNA) #1 verbally abused her on 8/18/18 around 7:00 PM. She reported the allegation to LPN #1 on 8/191/18, who then reported to the Director of Nursing (DON). The DON failed to suspend CNA #1 and start an investigation until 8/21/18. She did not inform the Administrator or Stage Agencies of the allegation, as required. CNA #1 continued to work with residents from 8/18/18 until 8/21/18. The failure of the facility to suspend the staff member to protect other residents, investigate the allegation to determine the extent of the abuse, and report the allegation of abuse as required, placed Resident #245 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 8/18/18, when the allegation of abuse occurred. The facility's Administrator was notified of the IJ and SQC on 8/22/18. An acceptable credible Allegation of Compliance (A[NAME]) was accepted on 8/24/18, in which the facility alleged all corrective actions were completed 8/24/18, and the IJ was removed on 8/25/18. The State Agency validated the A[NAME] and determined that the IJ was removed on 8/25/18, prior to exit. Therefore, the scope and severity for IJ and SQC 42 CFR 482.12(c)(1)-(4) was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy entitled, ABUSE & NEGLECT POLICY (no date); revealed: Policy and Procedure; Subject: Abuse/Neglect; Policy Statement: All residents of this facility have the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, involuntary seclusion, mistreatment, or neglect. Residents must not be subjected to abuse by anyone (including but not limited to: facility staff, ) .1) Facility must ensure that staff will not use verbal, mental, sexual, or physical abuse, including corporal punishment, or involuntary seclusion 5) The facility will ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries or unknown origin are reported immediately to the Charge Nurse, Director of Nursing Services, or the Administrator of the facility, or other officials, such as the State Board of Health and the Office of the Attorney General. 6) The facility must thoroughly investigate all alleged violations and document this investigation. 7) The facility must ensure and prevent further potential abuse while the investigation is in process. 8) The facility must ensure that results of all investigations are reported the Administrator or designated representative or to other officials in accordance with state law. Abuse Prevention and Prohibition: This facility will develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property Abuse 'Verbal Abuse' is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . 'Mental Abuse' includes, but is not limited to humiliation .This facility will develop and implement written policies that prohibit mistreatment and abuse of residents .18) Should an employee be reported for possible abuse, the employee will be placed on leave, with pay pending the results of the in-house investigation. If validated, the employee is to be discharged , and not eligible for rehire 24) The staff will report all incidents. Incident reports will be completed, and thoroughly investigated. Incident reports shall be reviewed by the Director of Nursing Services, Medical Director, and Administrator. All incidents are to be reported to the family/responsible party. Review of the Accident/Incident Investigation report, dated 8/21/18, revealed that on 8/19/18, at 3:46 PM, the Director of Nursing (DON) was notified by Licensed Practical Nurse (LPN) #1 of an allegation of verbal abuse which occurred on 8/18/18, at approximately 7:00 PM. The DON instructed LPN #1 to write a disciplinary action against Certified Nursing Assistant (CNA) #1, move CNA #1 to another group, and write a statement. The DON failed to follow the facility policy for Abuse by not reporting the allegation to the Mississippi Department of Health within two (2) hours of the report, failed to suspend CNA #1 pending investigation, and failed to investigate and document the investigation, prior to 8/21/18. A record review of the physician's orders [REDACTED].#245 was admitted to the facility on [DATE], under Hospice, with the following Diagnoses: [REDACTED]. The resident was her own Responsible Party on admission to the facility. Nurse's Notes on admission revealed that Resident #245 was alert and oriented to person, place and time. During an interview with Resident #245 on 8/21/18, at 3:00 PM, she was alert and oriented to person, place, and time with no cognitive impairment. Resident #245 stated that she had a bowel movement (BM) when CNA #1 came to her room on 8/18/18 around 7:00 PM. She stated the CNA pulled back the covers and stated, What the [***] is that, while making a face. When asked how it made her feel, Resident #245 stated, It makes you feel kind of sad, embarrassed, I don't know what was wrong with her. She came into the room with a frowned up face. She looked kind of mad. Resident #245 stated that it had made her feel abused and humiliated. She also stated that CNA #1 took her dinner tray when she hadn't finished eating. She stated, I told her I wanted to keep my sandwich for the night and she said 'Oh yeah', and took the tray, walked off like nobody was talking to her, you are not supposed to do that. During a phone interview, conducted on 8/21/18, at 4:44 PM, LPN #1 confirmed she was called to Resident #245's room by CNA #4 on 8/19/18. CNA #4 reported that Resident #245 was crying. LPN #1 said the resident told her that she had a BM and a CNA came in and pulled her covers back and said, What the [***] is this!. She stated that the resident told her it was staff who took care of her after 3:00 PM on 8/18/18. LPN #1 confirmed she checked the schedule and found that CNA #1 had been assigned to Resident #245 the previous evening and was scheduled to work on 8/19/18, at 3:00 PM. LPN #1 stated she met CNA #1 when she got to work and asked her about the allegation and took CNA #1 to Resident #245's room. LPN #1 stated Resident #245 identified the CNA as the one who had cursed her. LPN #1 stated CNA #1 became argumentative and she asked her to leave the room and then she called the Director of Nursing (DON) and gave a phone report of the incident. She stated that the DON told her to write the CNA up and put the documentation under her door. She stated that the DON told her to make ensure CNA #1 was not assigned to Resident #245. She stated that CNA #1 was assigned to the third (3rd) floor on 8/19/18, and worked that whole shift. LPN #1 stated that she considered the alleged incident as abuse. An interview with the DON on 8/21/18, at 5:30 PM, revealed the allegation of abuse for Resident #245 had not been reported to the State yet. She confirmed that LPN #1 had called her on the afternoon of 8/19/18, to report an allegation of verbal abuse against Resident #245 by CNA #1. She stated she was told that CNA #1 had gone into Resident #245's room, pulled the covers back and said, 'What the [***] is that. She confirmed that she allowed CNA #1 to continue to work on 8/19/18, after the allegation of abuse was reported to her. She confirmed that she did not follow the policy of the facility to suspend an employee who is accused of abuse until an investigation was completed. She confirmed that the policy of the facility was for her or the Administrator to report an allegation of abuse, start an investigation, and remove the employee from the building. She stated that Resident #245 was a newly admitted resident and that she was unsure of her mental status. She stated, In hindsight, was it the best decision to let her go on and work with other residents, maybe not. If she had been angry, upset, or out of sorts, I would have sent her home. Review of a typed statement, signed by the DON on 8/21/18, revealed she interviewed Resident #245 and Resident #12 shortly after 4:00 PM, on 8/21/18. The DON documented Resident #245 said CNA #1 had brought her meal tray (8/18/18) and returned later and removed the tray with the resident telling her not to, because she had not eaten. The resident also stated the CNA returned and pulled the covers back and said, What the [***] is this. The DON documented that once CNA #1 returned from her break, then she sent her home. Another typed statement, signed by the DON, dated 8/21/18 at 4:40 PM, revealed she interviewed the Roommate of Resident #245, (Resident #12), who reported she witnessed the incident between CNA #1 and Resident #245 on 8/18/18. Resident #12 confirmed, She said the [***] word. The resident reported no other issues. Interview with the Administrator and a signed statement, on 8/21/18, at 4:30/5:00 PM revealed she had not reported the allegation of abuse to the State Agency because she wasn't aware of the allegation until 8/21/18. Review of the Time/Attendance Detail dated 8/22/18, revealed that CNA #1 began work on 8/18/18 at 3:26 PM until 11:03 PM, on the day of the alleged abuse. She worked on the 8/19/18, the day that LPN #1 reported allegation of abuse to the DON, on the 3/11 shift from 03:26 PM until 11:03 PM. She worked on 8/20/18, from 3:55 PM until 11:06 PM, and again on 8/21/18, from 4:03 PM until 6:25 PM. CNA #1 worked three (3) shifts after she verbally abused Resident #245. Review of the 2nd Floor Resident Assignment sheet dated Saturday, (MONTH) 18, (YEAR), revealed that CNA #1 was assigned to Group V (GP V), which included room [ROOM NUMBER]A, Resident #245. Review of the 3rd Floor Resident Assignment sheet dated Sunday, (MONTH) 19, (YEAR), revealed that CNA #1 was assigned to Group I (GP I), not with Resident #245's group. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 8/24/18, for the IJ: Statement: The Director of Nursing (DON) was notified on 8/19/18 at 3:46 PM by LPN #1 stating Resident #245 reported CNA #1 for using verbal abuse, using profanity toward her on 8/18/18 at approximately 7:00 PM. DON instructed LPN #1 to write a disciplinary action and move CNA #1 to another group and write a statement. LPN #1 informed DON that CNA #1 was on 3rd floor working away from Resident #245. The Abuse Policy states, Alleged abuse must be reported, investigated and prevent further potential abuse while the investigation is in progress. The DON failed to protect the Resident #245 by not following policy and allowing CNA #1 to work from 8/18/18 through 8/21/18. DON did not report to the Administrator, remove CNA #1 immediately, nor did she investigate allegation of abuse as required. 1. FACILITY ACTIONS: *The Medical Director was contacted on 8/22/18, at approximately 3:20 p.m. by the Administrator and notified of Immediate Jeopardy for alleged abuse of Resident #245. *Attorney General's Office was notified on 8/24/18 at 10:03 a.m by Administrative Assistant (AA #1) of alleged abuse of Resident #245. *The Mississippi State Department of Health was notified on 8/24/2018 at 9:38 a.m. by the Administrative Assistant. *The local police department was notified on 8/23/18 at approximately 3:30 p.m., by the DON of the abuse of resident #245. Report obtained on 8/24/2018. *The Administrator was made aware of alleged incident of Resident #245 when she questioned why the CNA was going to talk to the surveyors 8/21/2018. *The Administrator spoke with the Mississippi Board of Nursing on 8/23/18 at 1:30 p.m. regarding DON's failure to follow abuse and neglect policy and failure to report abuse. *Administrator met with Resident Council on 8/23/2018 at 10:00 am. She allowed and encouraged residents to voice their concerns. No concerns of verbal abuse voiced. 2. INVESTIGATION: *Investigation was begun by the DON on 8/21/18. DON interviewed Resident #245 at 3:30 p.m. asking if she felt secure and comfortable and able to report issues. Resident #245 alleged the CNA pulled back the covers and cursed me. *Social Services spoke with 31 of 31 interviewable residents on 8/22/2018. Statements of verbal abuse were not noted. *Nursing Services interviewed residents on 8/23/2018 with no negative concerns. *Resident #245 was interviewed on 8/22/18, by RN #3 at 8:30 p.m. and stated everything is fine. *The DON interviewed Resident #245's Roommate, Resident #12, on 8/22/18, and stated She said the F word and walked out. Questioned Roommate to see if CNA #1 was inappropriate with her in any way. She stated No. Brief Interview of Mental Status (BIMS) based on 8/16/2018 assessment: Score -15, cognitively intact. *CNA#1 was interviewed regarding Resident #245 by DON on 8/21/2018 at 3:15 p.m. and stated, I did not do it. *CNA#1 was terminated by telephone on 8/22/2018 at approximately 5:00 p.m. by the DON for abuse and neglect of Resident#245. *DON was relieved of her duties on 8/23/2018 at 11:45 a.m. for failure to follow the policies and procedures of abuse and neglect. RN #6 was placed as interim DON until new DON is hired. *Resident #245 was assessed by RN #3 and RN #1 after complaint on 8/19/2018 at 3:46 p.m. No mental or physical problems noted. Brief Interview of Mental Status (BIMS) based on 8/23/2018 assessment: Score -15, cognitively intact. 3. ASSESSMENT: *Psychosocial Assessment was completed on 8/23/2018 at 4:00p.m. by Licensed Social worker. Results is no negative findings. Care plan was updated including verbal abuse on 8/23/2018 by RN #3. *Physician#1 completed a Psychological (Psyche) consultation on Resident #245 at 8/24/2018 at 10:00 a.m. with no negative findings, Resident is doing well, found no remaining issues since altercation with staff. 4. IN-SERVICES: *In-service on Care Plans was initiated on 8/23/18, by the Care Plan Coordinator with 105 employees from all disciplines in attendance. Topics include verbal abuse and abuse policy. *All staff will be in-serviced upon hire, annually and as needed on Abuse and Neglect by AA #1. *No staff will be allowed to work until in-serviced. *Social Worker from another facility, not associated with this facility, initiated an in-service on 8/22/18 at 2:30 p.m. on Abuse and Neglect for all staff members. In-service was completed on 8/23/2018. Topics included: -Abuse and Neglect -Forms of Abuse -Reporting -Investigation -Removal of Employee 5. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT COMMITTEE (QAPI): *The Quality Assurance Performance Improvement Committee (QAPI) conducted our first meeting on 8/22/18 at 5:45 p.m., with the Medical Director, after confirming alleged abuse of Resident#245, to review policies and procedures for abuse and neglect and proper reporting procedures. In-services on abuse and neglect were recommended. Attending were Administrator, DON, Medical Director, Infection Control Nurse, and RN Supervisors. No policy or procedure changes, no further recommendations at this time. *QAPI Committee met on 8/23/18 at 10:00 a.m. to discuss residents well being and consultation of Psychiatrist to evaluate and assist in resident care. The facility alleges that all corrective actions were completed on 8/24/18, and the Immediate Jeopardy was removed on 8/25/18. The State Agency (SA) validated the facility's A[NAME] and determined the facility took the following actions to correct the IJ: 1. FACILITY ACTIONS: The SA vailidated through interview with the Medical Director that he was contacted on 8/22/18 by the Administrator and notified of Immediate Jeopardy for alleged abuse of Resident #245. The SA validated through interview with the Administrator and document review, that the Attorney General's Office was notified on 8/24/18, by Administrative Assistant (AA #1) of alleged abuse of Resident #245 The SA validated through interview with the Administrator and document review that the Mississippi State Department of Health was notified of the alleged abuse of Resident #245, on 8/24/2018, by the Administrative Assistant. The SA validated through interview with the Administrator and record review that the local police department was notified on 8/23/18 at approximately 3:30 p.m., by the DON of the abuse of resident #245 and that a report was obtained on 8/24/2018. The SA validated through interview with the Administrator that she was made aware of alleged incident of Resident #245 when she questioned why the CNA was going to talk to the surveyors 8/21/2018; it had not been reported to her prior. The SA validated through record review and interview with the Administrator that she spoke with the Mississippi Board of Nursing on 8/23/18, regarding the DON's failure to follow abuse and neglect policy and failure to report the abuse to the appropriate agencies. The SA validated through interview with the Administrator, review of the Resident Council Meeting Minutes, and attendance log, that the Administrator met with Resident Council on 8/23/2018 at 10:00 a.m. where she allowed and encouraged residents to voice their concerns. No concerns of verbal abuse was documented. 2. INVESTIGATION: The SA validated through interview with the DON and Resident #245 that the investigation was begun by the DON on 8/21/18, and Resident interview was completed. The SA validated that Resident #245 reported to the DON that the CNA pulled back the covers and cursed her. The SA validated through record review, and interview with random Residents, the Administrato,r and Social Services, that Social Services spoke with 31 of 31 interviewable residents on 8/22/2018. Per interview, statements of verbal abuse were not noted. The SA validated through record review and interview with the Administrator and DON that Nursing Services interviewed residents on 8/23/2018 with no negative concerns of abuse. The SA validated through record review that Resident #245 was interviewed on 8/22/18, by RN #3 at and the resident stated everything was fine at that time. The SA validated through record review and interview with the DON and Resident #245, that the DON interviewed Resident #245's roommate, Resident #12, on 8/22/18, who confirmed the CNA used profanity, the F word, and walked out. It was confirmed by interview that that DON questioned the Roommate to see if CNA #1 was inappropriate with her in any way and the Roomate denied being treated inappropriately. Record review confirmed Resident #12's Brief Interview of Mental Status (BIMS), based on 8/16/2018 assessment, was a Score of 15, which indicated the resident had no cognitive impairment. The SA validated through interview with the DON and record review that CNA #1 was interviewed regarding Resident #245 by the DON on 8/21/2018 at 3:15 p.m. and the CNA denied abusing the resident. The SA validated through interview with the DON and the Administrator, and document review, that CNA #1 was terminated by telephone on 8/22/2018, by the DON for abuse and neglect of Resident#245. The SA validated through interview with the Administrator and record review, that the DON was relieved of her duties on 8/23/2018 at 11:45 a.m. for failure to follow the policies and procedures of abuse and neglect; RN#6 was placed as interim DON. The SA validated through interview with the DON and the Administrator and record review that Resident #245 was assessed by RN #3 and RN #1 after the complaint of abuse on 8/19/2018 at 3:46 p.m. No mental or physical problems noted and/or documented. Review of the Mimimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 8/23/2018, revealed Resident #245 was cognitively intact with a BIMS of 15. 3. ASSESSMENT: The SA validated through interview with the Administrator and record review that a Psychosocial Assessment was completed on 8/23/2018, by the Licensed Social Worker, with no concerns noted. The SA validated through interview with the Interim Director of Nursing and record review, that the care plan was updated for Resident #245, including verbal abuse on 8/23/2018, by RN #3. The SA validated through interview with the Administrator and record review that Physician #1 completed a Psych consultation on Resident#245 at 8/24/2018 at 10:00 a.m., and documented, Resident is doing well, found no remaining issues since altercation with staff. 4. IN-SERVICES: The SA validated through interview with the Administrator and staff from Nursing, Dietary, Activities, Social Services, and Housekeeping/Maintenance, and record review of sign-in sheets, that an In-service on Care Plans was initiated on 8/23/18 by the Care Plan Coordinator with 105 employees from all disciplines in attendance. Topics include verbal abuse and abuse policy. The SA validated through interview with the Administrator and record review, that all staff will be in-serviced upon hire, annually and as needed on Abuse and Neglect by AA #1. Review of the new hire list revealed no staff had been hired since 8/18/18. The SA validated through interview with the Administrator and record review that no staff will be allowed to work until in-serviced. The SA validated through interview with the Administrator, staff from Nursing, Dietary, Activities, Social Services, and record review of sign-in sheets, that a Social Worker from another facility initiated an in-service on 8/22/18 related to Abuse and Neglect for all staff members. In-service was completed on 8/23/2018. Topics include: Abuse and Neglect, Forms of Abuse, Reporting, Investigation, and Removal of Employee. 5. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT COMMITTEE (QAPI): The SA valildated through interview with the Medical Director, Administrator and three (3) staff members who attended the meeting, and record review of sign-in sheets, that the the Quality Assurance Performance Improvement Committee (QAPI) conducted the first meeting on 8/22/18 at 5:45 p.m. with the Medical Director, after confirming alleged abuse of Resident#245 to review policies and procedures for abuse and neglect and proper reporting procedures. In-services on abuse and neglect were recommended at that time. The sign-in sheets validated the attendance of the Administrator, DON, Medical Director, Infection Control Nurse, and RN Supervisors. No policy or procedure changes or further recommendations were made at this time, per interview with staff in attendance. The SA valildated through interview with the Medical Director, Administrator and three (3) staff members who attended the meeting, and record review of the sign-in sheet, that the QAPI Committee met on 8/23/2018 at 10:00 a.m. to discuss the resident's well being and consultation of a Psychiatrist to evaluate and assist in resident care. The SA validated that all corrective actions were completed as of 8/24/18, and the IJ was removed as of 8/25/18.

Based on interview and record review, the facility failed to revise a baseline care plan to include an allegation of verbal abuse for one (1) of 22 residents care plans reviewed, Resident #245. Resident #245 alleged verbal abuse by Certified Nursing Assistant (CNA #1) on 8/18/18. The care plan was not updated to include the allegation or actual verbal abuse, nor interventions put in place for corrective actions and prevention. The failure of the facility to update the care plan to include verbal abuse, for staff to be aware and put interventions in place to prevent further abuse, placed Resident #245 and other residents at risk in a situation of the likelihood for serious injury, harm, impairment , or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC)which began on 8/18/18, when the allegation of abuse allegedly occurred. The facility's Administrator was notified of the IJ and SQC on 8/22/18. An acceptable credible Allegation of Compliance (A[NAME]) was accepted on 8/24/18, in which the facility alleged all corrective actions were completed 8/24/18, and the IJ was removed on 8/25/18. The State Agency validated the A[NAME] on 8/27/18, and determined that the IJ was removed on 8/25/18, prior to exit. Therefore, the scope and severity for IJ and SQC 42 CFR 483.21(b)(2)(i)-(iii) was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy, COMPREHENSIVE RESIDENT CENTERED CARE PLANS, undated, revealed the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Record review of the Baseline Care Plan for Resident #245, dated 8/17/18, revealed the care plan was not revised after an allegation of abuse on 8/18/18, which was reported by the resident, to the facility staff, on 8/19/18. Interview with Resident #245 on 8/21/18, at 3:00 PM, revealed the resident was alert and oriented to person, place, and time with no cognitive impairment, sitting up in her wheelchair in her room. Resident #245 stated that Certified Nursing Assistant (CNA ) #1 came into her room to provide incontinent care around 7:00 PM on 8/18/18. The resident stated that she had a bowel movement (BM) in her brief and the CNA pulled back the covers and said, What the [***] is that? When asked how it made her feel, Resident #245 stated it made her feel kind of sad, embarrassed, and humiliated. She stated it felt like abuse. She added, She shouldn't have said what she said, that's what a nursing home is for. She also stated that CNA #1 took her dinner tray that same evening. She stated, I told her I wanted to keep my sandwich for the night and she said 'Oh yeah', and took the tray, walked off like nobody was talking to her, you are not supposed to do that. The Resident stated that she reported the incident the next day to LPN #1. She stated she asked for that CNA not to come to her room anymore. A phone interview conducted on 8/21/18 at 4:44 PM, with Licensed Practical Nurse (LPN) #1, revealed that she was called to Resident #245's room by CNA #4 on 8/19/18, because the resident was crying. LPN #1 confirmed Resident #245 alleged that a CNA, confirmed to be CNA #1, had used profanity and made the statement What the [***] is this, when she pulled the covers back and saw the BM. She stated that the resident told her it was the one who was taking care of her after 3:00 PM on 8/18/18. LPN #1 stated that CNA #1 denied the accusation and began to verbally argue with Resident #245 when the resident identified her as the CNA in violation. LPN #1 stated she told CNA #1 that this was enough and that she needed to leave the room. LPN #1 stated that CNA #1 left the room, went to another floor and worked the shift after she had called the Director of Nursing (DON) to report the allegation. She stated that the DON directed her to ensure the CNA wasn't assigned to Resident #245. LPN #1 stated she considered CNA's actions as abuse. Review of the Personnel Action dated 8/21/18, revealed that CNA #1 was sent home on 8/21/18, until the investigation was completed. It also revealed that on 8/22/18, CNA #1 was contacted by the DON per telephone, and was informed of termination status due to abuse and neglect. An interview with the Interim Director of Nursing (IDON), on 8/23/18, at 2:35 PM, revealed she was asked to review the Baseline Care Plan in Resident #245's chart to address the allegation of abuse reported on 8/19/18. She stated, I don't see one here. A care plan should be updated when something significant develops. The purpose of a care plan is to outline what it will take to care for that resident. To show what the facility is going to do to provide their care. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 8/24/18, for the IJ: Statement: The Director of Nursing (DON) was notified on 8/19/18 at 3:46 PM by LPN #1 stating Resident #245 reported CNA #1 for using verbal abuse, using profanity toward her on 8/18/18 at approximately 7:00 PM. DON instructed LPN #1 to write a disciplinary action and move CNA #1 to another group and write a statement. LPN #1 informed DON that CNA #1 was on 3rd floor working away from Resident #245. The Abuse Policy states, Alleged abuse must be reported, investigated and prevent further potential abuse while the investigation is in progress. The DON failed to protect the Resident #245 by not following policy and allowing CNA #1 to work from 8/18/18 through 8/21/18. DON did not report to the Administrator, remove CNA #1 immediately, nor did she investigate allegation of abuse as required. 1. FACILITY ACTIONS: *The Medical Director was contacted on 8/22/18, at approximately 3:20 p.m. by the Administrator and notified of Immediate Jeopardy for alleged abuse of Resident #245. *Attorney General's Office was notified on 8/24/18 at 10:03 a.m by Administrative Assistant (AA #1) of alleged abuse of Resident #245. *The Mississippi State Department of Health was notified on 8/24/2018 at 9:38 a.m. by the Administrative Assistant. *The local police department was notified on 8/23/18 at approximately 3:30 p.m., by the DON of the abuse of resident #245. Report obtained on 8/24/2018. *The Administrator was made aware of alleged incident of Resident #245 when she questioned why the CNA was going to talk to the surveyors 8/21/2018. *The Administrator spoke with the Mississippi Board of Nursing on 8/23/18 at 1:30 p.m. regarding DON's failure to follow abuse and neglect policy and failure to report abuse. *Administrator met with Resident Council on 8/23/2018 at 10:00 am. She allowed and encouraged residents to voice their concerns. No concerns of verbal abuse voiced. 2. INVESTIGATION: *Investigation was begun by the DON on 8/21/18. DON interviewed Resident #245 at 3:30 p.m. asking if she felt secure and comfortable and able to report issues. Resident #245 alleged the CNA pulled back the covers and cursed me. *Social Services spoke with 31 of 31 interviewable residents on 8/22/2018. Statements of verbal abuse were not noted. *Nursing Services interviewed residents on 8/23/2018 with no negative concerns. *Resident #245 was interviewed on 8/22/18, by RN #3 at 8:30 p.m. and stated everything is fine. *The DON interviewed Resident #245's Roommate, Resident #12, on 8/22/18, and stated She said the F word and walked out. Questioned Roommate to see if CNA #1 was inappropriate with her in any way. She stated No. Brief Interview of Mental Status (BIMS) based on 8/16/2018 assessment: Score -15, cognitively intact. *CNA#1 was interviewed regarding Resident #245 by DON on 8/21/2018 at 3:15 p.m. and stated, I did not do it. *CNA#1 was terminated by telephone on 8/22/2018 at approximately 5:00 p.m. by the DON for abuse and neglect of Resident#245. *DON was relieved of her duties on 8/23/2018 at 11:45 a.m. for failure to follow the policies and procedures of abuse and neglect. RN #6 was placed as interim DON until new DON is hired. *Resident #245 was assessed by RN #3 and RN #1 after complaint on 8/19/2018 at 3:46 p.m. No mental or physical problems noted. Brief Interview of Mental Status (BIMS) based on 8/23/2018 assessment: Score -15, cognitively intact. 3. ASSESSMENT: *Psychosocial Assessment was completed on 8/23/2018 at 4:00p.m. by Licensed Social worker. Results is no negative findings. Care plan was updated including verbal abuse on 8/23/2018 by RN #3. *Physician#1 completed a Psychological (Psyche) consultation on Resident #245 at 8/24/2018 at 10:00 a.m. with no negative findings, Resident is doing well, found no remaining issues since altercation with staff. 4. IN-SERVICES: *In-service on Care Plans was initiated on 8/23/18, by the Care Plan Coordinator with 105 employees from all disciplines in attendance. Topics include verbal abuse and abuse policy. *All staff will be in-serviced upon hire, annually and as needed on Abuse and Neglect by AA #1. *No staff will be allowed to work until in-serviced. *Social Worker from another facility, not associated with this facility, initiated an in-service on 8/22/18 at 2:30 p.m. on Abuse and Neglect for all staff members. In-service was completed on 8/23/2018. Topics included: -Abuse and Neglect -Forms of Abuse -Reporting -Investigation -Removal of Employee 5. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT COMMITTEE (QAPI): *The Quality Assurance Performance Improvement Committee (QAPI) conducted our first meeting on 8/22/18 at 5:45 p.m., with the Medical Director, after confirming alleged abuse of Resident#245, to review policies and procedures for abuse and neglect and proper reporting procedures. In-services on abuse and neglect were recommended. Attending were Administrator, DON, Medical Director, Infection Control Nurse, and RN Supervisors. No policy or procedure changes, no further recommendations at this time. *QAPI Committee met on 8/23/18 at 10:00 a.m. to discuss residents well being and consultation of Psychiatrist to evaluate and assist in resident care. The facility alleges that all corrective actions were completed on 8/24/18, and the Immediate Jeopardy was removed on 8/25/18. The State Agency (SA) validated the facility's A[NAME] and determined the facility took the following actions to correct the IJ: 1. FACILITY ACTIONS: The SA vailidated through interview with the Medical Director that he was contacted on 8/22/18 by the Administrator and notified of Immediate Jeopardy for alleged abuse of Resident #245. The SA validated through interview with the Administrator and document review, that the Attorney General's Office was notified on 8/24/18, by Administrative Assistant (AA #1) of alleged abuse of Resident #245 The SA validated through interview with the Administrator and document review that the Mississippi State Department of Health was notified of the alleged abuse of Resident #245, on 8/24/2018, by the Administrative Assistant. The SA validated through interview with the Administrator and record review that the local police department was notified on 8/23/18 at approximately 3:30 p.m., by the DON of the abuse of resident #245 and that a report was obtained on 8/24/2018. The SA validated through interview with the Administrator that she was made aware of alleged incident of Resident #245 when she questioned why the CNA was going to talk to the surveyors 8/21/2018; it had not been reported to her prior. The SA validated through record review and interview with the Administrator that she spoke with the Mississippi Board of Nursing on 8/23/18, regarding the DON's failure to follow abuse and neglect policy and failure to report the abuse to the appropriate agencies. The SA validated through interview with the Administrator, review of the Resident Council Meeting Minutes, and attendance log, that the Administrator met with Resident Council on 8/23/2018 at 10:00 a.m. where she allowed and encouraged residents to voice their concerns. No concerns of verbal abuse was documented. 2. INVESTIGATION: The SA validated through interview with the DON and Resident #245 that the investigation was begun by the DON on 8/21/18, and Resident interview was completed. The SA validated that Resident #245 reported to the DON that the CNA pulled back the covers and cursed her. The SA validated through record review, and interview with random Residents, the Administrato,r and Social Services, that Social Services spoke with 31 of 31 interviewable residents on 8/22/2018. Per interview, statements of verbal abuse were not noted. The SA validated through record review and interview with the Administrator and DON that Nursing Services interviewed residents on 8/23/2018 with no negative concerns of abuse. The SA validated through record review that Resident #245 was interviewed on 8/22/18, by RN #3 at and the resident stated everything was fine at that time. The SA validated through record review and interview with the DON and Resident #245, that the DON interviewed Resident #245's roommate, Resident #12, on 8/22/18, who confirmed the CNA used profanity, the F word, and walked out. It was confirmed by interview that that DON questioned the Roommate to see if CNA #1 was inappropriate with her in any way and the Roomate denied being treated inappropriately. Record review confirmed Resident #12's Brief Interview of Mental Status (BIMS), based on 8/16/2018 assessment, was a Score of 15, which indicated the resident had no cognitive impairment. The SA validated through interview with the DON and record review that CNA #1 was interviewed regarding Resident #245 by the DON on 8/21/2018 at 3:15 p.m. and the CNA denied abusing the resident. The SA validated through interview with the DON and the Administrator, and document review, that CNA #1 was terminated by telephone on 8/22/2018, by the DON for abuse and neglect of Resident#245. The SA validated through interview with the Administrator and record review, that the DON was relieved of her duties on 8/23/2018 at 11:45 a.m. for failure to follow the policies and procedures of abuse and neglect; RN#6 was placed as interim DON. The SA validated through interview with the DON and the Administrator and record review that Resident #245 was assessed by RN #3 and RN #1 after the complaint of abuse on 8/19/2018 at 3:46 p.m. No mental or physical problems noted and/or documented. Review of the Mimimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 8/23/2018, revealed Resident #245 was cognitively intact with a BIMS of 15. 3. ASSESSMENT: The SA validated through interview with the Administrator and record review that a Psychosocial Assessment was completed on 8/23/2018, by the Licensed Social Worker, with no concerns noted. The SA validated through interview with the Interim Director of Nursing and record review, that the care plan was updated for Resident #245, including verbal abuse on 8/23/2018, by RN #3. The SA validated through interview with the Administrator and record review that Physician #1 completed a Psych consultation on Resident#245 at 8/24/2018 at 10:00 a.m., and documented, Resident is doing well, found no remaining issues since altercation with staff. 4. IN-SERVICES: The SA validated through interview with the Administrator and staff from Nursing, Dietary, Activities, Social Services, and Housekeeping/Maintenance, and record review of sign-in sheets, that an In-service on Care Plans was initiated on 8/23/18 by the Care Plan Coordinator with 105 employees from all disciplines in attendance. Topics include verbal abuse and abuse policy. The SA validated through interview with the Administrator and record review, that all staff will be in-serviced upon hire, annually and as needed on Abuse and Neglect by AA #1. Review of the new hire list revealed no staff had been hired since 8/18/18. The SA validated through interview with the Administrator and record review that no staff will be allowed to work until in-serviced. The SA validated through interview with the Administrator, staff from Nursing, Dietary, Activities, Social Services, and record review of sign-in sheets, that a Social Worker from another facility initiated an in-service on 8/22/18 related to Abuse and Neglect for all staff members. In-service was completed on 8/23/2018. Topics include: Abuse and Neglect, Forms of Abuse, Reporting, Investigation, and Removal of Employee. 5. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT COMMITTEE (QAPI): The SA valildated through interview with the Medical Director, Administrator and three (3) staff members who attended the meeting, and record review of sign-in sheets, that the the Quality Assurance Performance Improvement Committee (QAPI) conducted the first meeting on 8/22/18 at 5:45 p.m. with the Medical Director, after confirming alleged abuse of Resident#245 to review policies and procedures for abuse and neglect and proper reporting procedures. In-services on abuse and neglect were recommended at that time. The sign-in sheets validated the attendance of the Administrator, DON, Medical Director, Infection Control Nurse, and RN Supervisors. No policy or procedure changes or further recommendations were made at this time, per interview with staff in attendance. The SA valildated through interview with the Medical Director, Administrator and three (3) staff members who attended the meeting, and record review of the sign-in sheet, that the QAPI Committee met on 8/23/2018 at 10:00 a.m. to discuss the resident's well being and consultation of a Psychiatrist to evaluate and assist in resident care. The SA validated that all corrective actions were completed as of 8/24/18, and the IJ was removed as of 8/25/18.

Based on interview, record review, MS Board of Nursing web site review, and policy and procedure review, the facility failed to ensure qualified staff were available and designated on the care plan to perform deep suctioning for a [MEDICAL CONDITION] resident, if needed, on a 24 hour basis for one (1) of one (1) resident with a [MEDICAL CONDITION] (Trach), Resident #15. Resident #15 was observed with a [MEDICAL CONDITION] in place. Review of the nursing schedule revealed the facility failed to ensure 24 hour, seven (7) days a week coverage by qualified professionals; a Registered Nurse (RN) and/or a Respiratory Therapist (RT) to provide deep suctioning or emergency care to a resident with a [MEDICAL CONDITION] for approximately 159 days from (MONTH) (YEAR) until (MONTH) (YEAR). The failure to have a qualified personnel designated on the care plan and available to perform deep suctioning for residents with a Trach, if needed, placed Resident #15 and other residents admitted to the facility with a Trach, in a situation that was likely to cause serious injury, harm, impairment, or death. Resident #15 was the only Resident in the facility with [MEDICAL CONDITION] the survey. The situation was determined to be an Immediate Jeopardy (IJ) on 8/22/18, when the facility failed to ensure residents with [MEDICAL CONDITION] care planned for the appropriate discipline and have readily available and qualified staff to deep suction, if needed, 24 hours a day. The facility's Administrator (ADM) was notified of the IJ on 8/22/18. An acceptable Allegation of Compliance (AoC) was received on 8/24/18, in which the facility alleged all corrective actions were completed on 8/23/18, and the IJ removed 8/24/18. The State Agency (SA) validated the AoC and determined the IJ to be removed on 8/24/18, prior to exit. Therefore, the scope and severity for the IJ at CFRs 483.21(b)(3)(ii) Comprehensive Care Plan Services Provided by Qualified Persons was lowered to a D level, while the facility develops and implements a Plan of Correction (P[NAME]) and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory requirements. Findings include: Review of the facility policy titled, Comprehensive resident Centered Care Plans, undated revealed it is the policy of this facility to provide services based on the following requirements. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will be provided by qualified qualified persons in accordance with each resident's written plan of care and be culturally-competent and trauma informed. Review of the facility's Nursing Services policy, dated (MONTH) (YEAR), revealed the facility will have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety, and attain or maintain the highest practible physical, mental, and psychosocial well-being of each resident, as determined by their resident assessments and individual plan of care and considering the number, acuity and [DIAGNOSES REDACTED]. Review of the MS State Board of Nursing (BON) web site, revealed frequently asked questions (FAQ's). The BON's statement regarding the LPN's scope of practice with [MEDICAL CONDITION] care revealed : It is not within the scope of practice for the LPN to perform deep Right Main Stem suctioning. If deep suctioning is required for a patient, a Registered Nurse (RN) must perform the procedure. The facility admitted Resident #15 on 6/17/18, with [DIAGNOSES REDACTED]. Review of Resident #15's Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 5/22/18, revealed staff assessed Resident #15 to have moderately impaired cognition. Review of Resident #15's Plan of Care, with a target date of 10/12/18, revealed Resident #15 to be at risk for respiratory complications related to intact Tracheotomy. Thick secretions noted coming from [MEDICAL CONDITION]. Resident is suctioned as needed (prn). Resident has disturbance of Salivary secretions at various times. The goal and target date revealed: Airway will remain patent as evidenced by (AEB): no shortness of breath (SOB), clear lung sounds, and normal skin color through the next review date, 10/12/18. The approaches revealed, deep suctioning through the Trach, provide suctioning prn and [MEDICAL CONDITION] four (4) hours and as needed using sterile technique. This care plan did not specify which suction the Registered Nurse or License Practical Nurse was to perform. The approach, to [MEDICAL CONDITION] four (4) hours and as needed, does not specify if the suction task was deep suction or surface suction. Review of the medical record revealed on 3/27/17, Resident #15 was sent to the Emergency Department (ED) for [MEDICAL CONDITION]. He was again transferred to the ED on 3/29/18 and 4/4/18, for a cracked [MEDICAL CONDITION], with replacement of [MEDICAL CONDITION] 4/4/18 due to the Resident had pulled [MEDICAL CONDITION]. Resident #15 went to the ED for a [MEDICATION NAME] on 4/11/18, where [MEDICAL CONDITION] determined to be positioned correctly and slight mucus plugs washed and suctioned. Resident was in no distress. Interview and observation on 8/24/18 at 11:40 AM, revealed Resident #15, had a [MEDICAL CONDITION] in place and indicated through gestures and a communication board that he had not had any breathing problems and had not been to the hospital for any problems with breathing recently. Resident #15 was unable to respond verbally but did understand questions and answered yes and no questions with a thumbs up or a thumbs down sign. Review of the working schedule for nurses, from (MONTH) 28, (YEAR) to (MONTH) 21, (YEAR) revealed a total of 193 shifts ( 7 PM-7 AM, 3 PM-11 PM and/or 11 PM-7 AM) in which there was no documented RN coverage for the facility. The facility did not have RT available during these shifts. The (MONTH) (YEAR) schedule, revealed on 8/9/18, 8/10/18, 8/14/18, and 8/15/18, there were no Registered Nurses on staff inside the facility from the hours of 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM, to deep suction the resident if needed. Interview on 8/23/18 at 3:20 PM with the Director of Nursing (DON), confirmed the care plan revealed to deep suction through [MEDICAL CONDITION] to suction every four (4) hours and as needed, but did not provide instructions to the Licensed Practical Nurses on depth for them to suction. The DON stated the care plan was developed to determine special needs for a resident and showed what the facility was going to do to provide care to the Resident. She confirmed the care plan did not indicate who was responsible for deep suction of Resident #15. Interview on 8-22-18 at 2:55 PM with the DON, confirmed the facility did not always have 24 hour a day coverage by an RN, and the facility had no RT employed/available to deep suction a [MEDICAL CONDITION] resident, if needed. The DON stated all kinds of things could happen if the Resident did not receive deep suctioning if needed, like [MEDICAL CONDITION] or Anoxia. The DON stated if the Resident was in distress, the nursing staff would suction what they could and call the On-call Nurse or the Ambulance. The DON stated she lived seven (7) miles away and could be at the facility in about five (5) minutes by taking the back roads. She stated that one (1) of her RN's lived closer and staff could call her. She stated if the Resident was in severe distress the staff would call the Ambulance. Interview on 08/22/18 at 1:50 PM, with Licensed Practical Nurse (LPN) #3 revealed she was responsible for suctioning Resident #15 every four (4) hours as ordered. LPN #3 stated she did not deep suction him, she only went down about three (3) or four (4) inches. Interview on 08/23/18 at 3:15 PM with the DON, revealed the depth the Licensed Practical Nurse should suction would depend on the size of the Trach. She stated the nurse should measure the length of the cannula and and deduct from there. The DON confirmed she was not sure what the depth of suctioning would be for Resident #15. Interview on 8/27/18 time with Registered Nurse (RN) #7 stated she developed Resident #15's Comprehensive Care Plan but did not update it with order changes. She stated the nurses are responsible for the update and she adds the changes to the care plan at the next scheduled assessment. RN #7 confirmed the care plan for Resident #15 did not designate which nurse would do the function of suctioning. The facility submitted an acceptable Allegation of Compliance (AoC) on 8/24/18, for the IJ. Review of the facility's AoC revealed the facility took the following corrective actions to remove the IJ prior to exit: An Immediate Jeopardy was determined on (MONTH) 22, (YEAR) regarding the facility not having a Registered Nurse or Respiratory Therapist on duty 24 hours a day, 7 days a week for possible deep suctioning of a [MEDICAL CONDITION], if needed, for Resident #15 who has a [MEDICAL CONDITION] and active physician orders to suction every four (4) hours and as needed. The (MONTH) (YEAR) schedule reflected dates of 8/9/18, 8/10/18, 8/14/18, and 8/15/18, with no Registered Nurse or Respiratory Therapist on staff inside the facility from the hours of 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM to deep suction the resident if needed. Audit of all Registered Nurses on schedules conducted by Director of Nurses (DON) on 8/22/18 at approximately 9:00 PM. Audit reveals no Registered Nurse coverage on 159 days of a mixture of 3:00 PM-11:00 PM and 11:00 PM-7:00 AM shifts during the time frame (MONTH) 24, (YEAR) through (MONTH) 23, (YEAR). 1. FACILITY ACTIONS *Physician was notified on 8/22/2018 at 3:26 PM, by Director of Nursing (DON) and new orders were received to shallow suction by LPN and to deep suction by RN, as needed for Resident#15, the only Resident with a [MEDICAL CONDITION]. *The Medical Director was contacted by the Administrator and notified at approximately 4:30 PM on 8/22/18, of Immediate Jeopardy for no RN coverage for 159 days for a mixture of 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts to provide Resident [MEDICAL CONDITION] deep suctioning. *Resident #15's care plan reviewed and updated 8/23/18, approximately 4:30 PM by RN #6, for new suctioning orders specifying the difference between what LPN's and RN's are allowed to suction. Only RN's deep suction a [MEDICAL CONDITION]. *The DON was relieved of her duties and the facility placed an Interim DON on 8/23/18 at approximately 11:45 AM, to oversee the nursing staff in the continuum of resident care. The schedule has been audited by the Director of Nursing through the end of (MONTH) to ensure coverage of RN staff by in-house RN's until additional RN staff can be hired. Interim Director of Nurses is now checking schedule daily to ensure appropriate staffing regarding care of [MEDICAL CONDITION]. 2. INVESTIGATIONS *On (MONTH) 27, (YEAR), Resident #15 was sent out to the Emergency Department (ED) for [MEDICAL CONDITION]. He was again transferred to the ED on (MONTH) 4, (YEAR), for a cracked [MEDICAL CONDITION]. After returning from the ED, Resident #15 was sent back out to the ED later that same day for bleeding at the [MEDICAL CONDITION] site. None of the above ED visits were related to a lack of deep suctioning of the [MEDICAL CONDITION]. 3. ASSESSMENT *Physical assessment of Resident #15 was completed on 8/22/18 by RN #3 at approximately 3:38 PM. Assessment revealed the [MEDICAL CONDITION] clean, patent, with scant, clear, thin secretions that are easily suctioned, respirations are even and unlabored and no abnormal breath sounds are noted through-out. 4. IN-SERVICE *In-service was done on 8/23/2018 at 4:00 PM by the Care Plan Coordinator, with 105 employees from all disciplines in attendance. Topics included staff [MEDICATION NAME] within their scope of practice (including only RNs doing deep suctioning), and updating the care plan anytime there is a change in physician orders. *An in-service was initiated on 8/22/18 at approximately 5:00 PM, and conducted by a Respiratory Therapist from the local hospital. In-service included policy and procedure and standard of care and scope of practice for LPN's and RN's. In-service was completed for 34 nurses on 8/23/2018. Nurses will not be allowed to work until in-serviced. 5. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT (QAPI) *Policy and procedure for [MEDICAL CONDITION] was reviewed by Quality Assurance Performance Improvement Committee on 8/23/18 at 5:45 PM, attended by the Medical Director, DON, Administrator, RN #3, RN #2, RN #4, RN #5, and Medical Records Director. Policy was revised to include the difference of RN (deep suctioning) and LPN (shallow suctioning) guidelines. Discussion included addition of RN staffing during the evening and night shifts to provide deep suctioning of the [MEDICAL CONDITION] 24 hours/7 days per week. The Facility alleges the correction of the Immediate Jeopardy was resolved as of 8/23/18, and Immediate Jeopardy removed as of 8/24/18. The Survey team validated the facility's AoC: #1. The SA validated through interview with the DON and record review, that new orders were obtained from the physician to clarify the orders for suctioning the resident. #2. The SA validated by phone interview with the Medical Director that he had been notified by the Administrator of the IJ concerning Resident #15. #3. The SA validated through interview with the DON and record review, that the resident's care plan had been updated to specify which nurses are responsible for deep suctioning and the type of suctioning LPN's are allowed to perform. #4. The SA validated through interview with the Administrator and record review that the nurse's schedule had been updated to to ensure RN coverage 24 hours a day for deep suction of a resident with a Trach. #5. The SA validated through record review that Resident #15's ED visits in (MONTH) (YEAR) and (MONTH) (YEAR), were not related to a lack of deep suctioning, the Resident had [MEDICAL CONDITION] on (MONTH) 4, (YEAR). Review of documentation revealed the resident was able to cough up secretions. #6. The SA Validated through interview with the DON and record review that Resident #15 was assessed 8/22/18 by an RN . Documentation included the [MEDICAL CONDITION] was clean and patent with scant, clear, thin secretions, with no respiratory distress. #7. The SA validated through interview and record review that a care plan in-service was conducted by the Care Plan Coordinator for all employees that instructed them on scope of practice of nurses and updating care plans. #8. The SA validated through record review and interview with the DON and Administrator that an in-service was done by a Respiratory Therapist from the hospital on [DATE], and was attended by all nurses. Scope of Practice and Policy and Procedures concerning [MEDICAL CONDITION] suctioning were addressed, which included only RNs were allowed to deep suction a Trach. #9. The SA validated through interview with the Administrator and the DON, and review of the schedule, that no nursing staff was allowed to work until in-serviced on [MEDICAL CONDITION] suctioning. #10. The SA validated through interview with the Medical Director and the Administrator and record review of the sign-in sheet, that a QA meeting was held on 8/23/18, with recommendations and implementation of the recommendations. The SA validated that all corrective actions taken by the facility were completed as of 8/23/18, and the IJ was removed on 8/24/18, prior to exit.

Based on observation, interview, record review, facility policy review, State Board of Nursing documentation review, and the Nurse Practice Act, the facility failed to provide consistent respiratory care services to a resident with a [MEDICAL CONDITION] (Trach) by qualified personnel, a Registered Nurse (RN) and/or Respiratory Therapist (RT), 24 hours each day to deep suction the Trach, if needed and/or provide other emergency care related to the Trach, for one (1) of one (1) residents reviewed with a [MEDICAL CONDITION], Resident #15. Resident #15 was admitted with a [MEDICAL CONDITION] with orders to suction every four (4) hours. The order did not indicate shallow or deep suction. There were approximately 159 days, or 193 shifts that a RN/RT was not available from (MONTH) (YEAR) through (MONTH) (YEAR). Resident #15 had one (1) Emergency Department (ED) visit in (MONTH) (YEAR) for [MEDICAL CONDITION], with a potential for increased secretions, another ED visit in (MONTH) (YEAR), for a crack in [MEDICAL CONDITION], and two (2) visits on (MONTH) 4, (YEAR) for the cracked [MEDICAL CONDITION] with bleeding at the site, and withTrach replacement; and for a [MEDICATION NAME] to determine [MEDICAL CONDITION]. The facility's failure to provide a RN/RT to provide deep suctioning of a resident with a [MEDICAL CONDITION] on a 24 hour a day basis, placed Resident #15 and other residents admitted with a Trach, in a situation that was likely to cause serious harm, injury or death to Resident #15 or any residents admitted with [MEDICAL CONDITION]. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), identified on 8/22/18, when the facility failed to ensure qualified, RN and /or RT staffing to provide 24 hour a day coverage to deep suction residents with a [MEDICAL CONDITION], if needed. The facility's Administrator (ADM) was notified of the IJ on 8/22/18. An acceptable Allegation of Compliance (AoC) was received on 8/24/18, in which the facility alleged all corrective actions were completed on 8/23/18, and the IJ removed on 8/24/18. The State Agency (SA) validated the AoC on 8/23/18 and determined the IJ to be removed on 8/24/18 prior to exit. The scope and severity for the IJ and SQC at CFR 483.21(b)(3)(ii) was lowered to a D level, while the facility develops and implements a Plan of Correction (P[NAME]) and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory requirements. Findings include: Review of the facility policy titled, [MEDICAL CONDITION] Suctioning, undated, revealed the purpose of [MEDICAL CONDITION] suctioning is to improve gas exchange, decrease airway resistance, and reduce infection risks by removing secretions from the Trachea and Main Stem Bronchi. Suctioning may also be performed to obtain samples of Tracheal secretions for laboratory analysis. The procedure revealed suctioning of airways should be performed ONLY for a clinical indication, and NOT as a routine, fixed schedule. The policy did not indicate who was responsible for deep suction of a resident with a Trach. Review of the Mississippi State Board of Nursing Laws and Rules Administrative Code Part 2830 Practice of Nursing Title 30: Professions and Occupations Chapter 2, Functions of the Licensed Practical Nurse, revealed : Rule 2.1- LPN Supervision; The LPN gives nursing care which does not require the specialized skill, judgement, and knowledge required of an RN, Advanced Practice Registered Nurse (APRN), Licensed Physician, or Licensed Dentist. Review of the Ms State Board of Nursing (BON) web site, revealed frequently asked questions (FAQ's). The BON's statement regarding the LPN's scope of practice with [MEDICAL CONDITION] care revealed : It is within the scope of practice of the LPN to [MEDICAL CONDITION] and suction secretions from [MEDICAL CONDITION]. However, it is not within the scope of practice for the LPN to perform deep Right Main Stem suctioning. If deep suctioning is required for a patient, a Registered Nurse (RN) must perform the procedure. Review of the working schedule from (MONTH) 28, (YEAR) to (MONTH) 21, (YEAR) revealed a total of 193 shifts (7 PM-7 AM, 3 PM-11 PM and 11 PM-7 AM) in which there was no documented RN coverage for the facility. The facility did not employ a Respiratory Therapist. The facility admitted Resident #15 on 6/17/18, with [DIAGNOSES REDACTED]. Review of Resident #15's Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 5/22/18, revealed staff assessed Resident #15 to have moderately impaired cognition. Review of a Physician Order, dated 1/18/16, revealed to suction Resident #15'[MEDICAL CONDITION] four (4) hours and as needed. The order did not address whether to shallow suction or deep suction, nor who was responsible to carry out this order. Review of Resident #15's current care plan revealed, Deep suction through the Trach. Only a Nurse (N) was designated for the duty. Review of the medical record revealed a Departmental Note, dated 3/26/18 at 2:10 PM, which documented Resident #15 was noted coughing through [MEDICAL CONDITION] large amount of thick white secretions with small amount of blood tinge after the Nebulizer treatment. Resident #15 was admitted to the Emergency Department (ED) on 3/27/18, with red streaked thick white discharge from the Trach. Chest X-ray revealed [MEDICAL CONDITION], which seems to be worsened. He was prescribed antibiotics and returnedd to the facility. He presented to the ED on 3/29/18, with a cracked Trach, left side. There was no distress and Resident #15 returned to the facility with recommendation to see Pulmonologist [MEDICAL CONDITION]. Review of a Departmental Note, dated 4/5/18 at 2:50 AM, revealed Resident #15 had pulled out [MEDICAL CONDITION] was transferred to the ED at 3:08 AM, with no respiratory distress. Review of a Patient Visit Information, dated 4/4/18, revealed [MEDICAL CONDITION] replaced and a mild amout of bleeding is expected due to difficult placement (of Trach). Apply suction as needed, and the resident returned to the facility. Review of an Office Visit Report, dated 4/5/18, revealed Resident #15 had [MEDICAL CONDITION] on 4/4/18, with some complications and bleeding, but the chest X-ray couldn't confirm placement and he was referred for a [MEDICATION NAME]. He was in no distress from [MEDICAL CONDITION] that time. Review of the [MEDICATION NAME] Procedure Note, dated 4/11/18, revealed slight mucus plugs were washed and suctioned and [MEDICAL CONDITION] in good position. Interview and observation of Resident #15, on 8/24/18 at 11:40 AM, revealed he had not had any breathing problems and not been to the hospital recently for any problems with breathing. Resident #15 was unable to respond verbally but did understand questions and answered questions with a thumbs up or a thumbs down sign. Resident #15 had a communication board on his over bed table to assist with communication. Interview on 8/22/18 at 2:55 PM, with the DON, confirmed the facility did not always have 24 hour a day coverage by an RN to deep suction a [MEDICAL CONDITION], if needed. The DON stated Anoxia or [MEDICAL CONDITION] could occur if the Resident did not receive deep suctioning as needed. The DON stated if the Resident was in distress, the nursing staff would suction what they could, then call the On-call Nurse or the Ambulance. The DON stated she lived seven (7) miles from the facility, which would take her about five (5) minutes to get to the facility and there was another RN who lived closer to the facility. She stated if the Resident was in severe distress, the staff would call the ambulance. The DON confirmed the facility had not RT. Interview on 08/22/18 at 1:50 PM, with Licensed Practical Nurse (LPN) #3, revealed she was responsible for suctioning Resident #15 every four (4) hours as ordered. LPN #3 stated she did not deep suction him, she only went down about three (3) or four (4) inches. Interview on 8/23/18 at 11:45 AM, with RN #3, revealed Resident #15 had not required deep suctioning by her. RN #3 stated she had not deep suctioned Resident #15 any this year that she could recall; he always has clear secretions. Interview on 8/23/18 at 11:48 AM, with RN #2, and 11:50 AM with LPN #1, revealed they both had suctioned Resident #15, but not deep suctioned. Interview on 8/23/18 at 11:50 AM, with LPN #4, revealed Resident #15's secretions were clear and he usually coughed them up. LPN #4 confirmed Resident #15 had an order to be suctioned every four (4) hours, but there was no designation as to the kind of suction, or who was to perform the suction. Interview on 08/23/18 at 3:15 PM, with the DON, revealed the depth the Licensed Practical Nurse should suction would depend on the size of the Trach; she wasn't sure what the depth of suctioning should be for Resident #15. She stated the nurse should measure the length of the cannula and and deduct from there. Interview on 8/23/18 at 3:20 PM, with the DON, confirmed the physician orders revealed to suction every four (4) hours and as needed, however, the orders did not provide instructions as to what type of suctioning or which nurse should perform the task. The facility submitted an acceptable Allegation of Compliance (AoC) on 8/24/18, for the IJ. Review of the facility's AoC revealed the facility took the following corrective actions to remove the IJ prior to exit: An Immediate Jeopardy was determined on (MONTH) 22, (YEAR) regarding the facility not having a Registered Nurse or Respiratory Therapist on duty 24 hours a day, 7 days a week for possible deep suctioning of a [MEDICAL CONDITION], if needed, for Resident #15 who has a [MEDICAL CONDITION] and active physician orders to suction every four (4) hours and as needed. The (MONTH) (YEAR) schedule reflected dates of 8/9/18, 8/10/18, 8/14/18, and 8/15/18, with no Registered Nurse or Respiratory Therapist on staff inside the facility from the hours of 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM to deep suction the resident if needed. Audit of all Registered Nurses on schedules conducted by Director of Nurses (DON) on 8/22/18 at approximately 9:00 PM. Audit reveals no Registered Nurse coverage on 159 days of a mixture of 3:00 PM-11:00 PM and 11:00 PM-7:00 AM shifts during the time frame (MONTH) 24, (YEAR) through (MONTH) 23, (YEAR). 1. FACILITY ACTIONS *Physician was notified on 8/22/2018 at 3:26 PM, by Director of Nursing (DON) and new orders were received to shallow suction by LPN and to deep suction by RN, as needed for Resident#15, the only Resident with a [MEDICAL CONDITION]. *The Medical Director was contacted by the Administrator and notified at approximately 4:30 PM on 8/22/18, of Immediate Jeopardy for no RN coverage for 159 days for a mixture of 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts to provide Resident [MEDICAL CONDITION] deep suctioning. *Resident #15's care plan reviewed and updated 8/23/18, approximately 4:30 PM by RN #6, for new suctioning orders specifying the difference between what LPN's and RN's are allowed to suction. Only RN's deep suction a [MEDICAL CONDITION]. *The DON was relieved of her duties and the facility placed an Interim DON on 8/23/18 at approximately 11:45 AM, to oversee the nursing staff in the continuum of resident care. The schedule has been audited by the Director of Nursing through the end of (MONTH) to ensure coverage of RN staff by in-house RN's until additional RN staff can be hired. Interim Director of Nurses is now checking schedule daily to ensure appropriate staffing regarding care of [MEDICAL CONDITION]. 2. INVESTIGATIONS *On (MONTH) 27, (YEAR), Resident #15 was sent out to the Emergency Department (ED) for [MEDICAL CONDITION]. He was again transferred to the ED on (MONTH) 4, (YEAR), for a cracked [MEDICAL CONDITION]. After returning from the ED, Resident #15 was sent back out to the ED later that same day for bleeding at the [MEDICAL CONDITION] site. None of the above ED visits were related to a lack of deep suctioning of the [MEDICAL CONDITION]. 3. ASSESSMENT *Physical assessment of Resident #15 was completed on 8/22/18 by RN #3 at approximately 3:38 PM. Assessment revealed the [MEDICAL CONDITION] clean, patent, with scant, clear, thin secretions that are easily suctioned, respirations are even and unlabored and no abnormal breath sounds are noted through-out. 4. IN-SERVICE *In-service was done on 8/23/2018 at 4:00 PM by the Care Plan Coordinator, with 105 employees from all disciplines in attendance. Topics included staff [MEDICATION NAME] within their scope of practice (including only RNs doing deep suctioning), and updating the care plan anytime there is a change in physician orders. *An in-service was initiated on 8/22/18 at approximately 5:00 PM, and conducted by a Respiratory Therapist from the local hospital. In-service included policy and procedure and standard of care and scope of practice for LPN's and RN's. In-service was completed for 34 nurses on 8/23/2018. Nurses will not be allowed to work until in-serviced. 5. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT (QAPI) *Policy and procedure for [MEDICAL CONDITION] was reviewed by Quality Assurance Performance Improvement Committee on 8/23/18 at 5:45 PM, attended by the Medical Director, DON, Administrator, RN #3, RN #2, RN #4, RN #5, and Medical Records Director. Policy was revised to include the difference of RN (deep suctioning) and LPN (shallow suctioning) guidelines. Discussion included addition of RN staffing during the evening and night shifts to provide deep suctioning of the [MEDICAL CONDITION] 24 hours/7 days per week. The Facility alleges the correction of the Immediate Jeopardy was resolved as of 8/23/18, and Immediate Jeopardy removed as of 8/24/18. The Survey team validated the facility's AoC: #1. The SA validated through interview with the DON and record review, that new orders were obtained from the physician to clarify the orders for suctioning the resident. #2. The SA validated by phone interview with the Medical Director that he had been notified by the Administrator of the IJ concerning Resident #15. #3. The SA validated through interview with the DON and record review, that the resident's care plan had been updated to specify which nurses are responsible for deep suctioning and the type of suctioning LPN's are allowed to perform. #4. The SA validated through interview with the Administrator and record review that the nurse's schedule had been updated to to ensure RN coverage 24 hours a day for deep suction of a resident with a Trach. #5. The SA validated through record review that Resident #15's ED visits in (MONTH) (YEAR) and (MONTH) (YEAR), were not related to a lack of deep suctioning, the Resident had [MEDICAL CONDITION] on (MONTH) 4, (YEAR). Review of documentation revealed the resident was able to cough up secretions. #6. The SA Validated through interview with the DON and record review that Resident #15 was assessed 8/22/18 by an RN . Documentation included the [MEDICAL CONDITION] was clean and patent with scant, clear, thin secretions, with no respiratory distress. #7. The SA validated through interview and record review that a care plan in-service was conducted by the Care Plan Coordinator for all employees that instructed them on scope of practice of nurses and updating care plans. #8. The SA validated through record review and interview with the DON and Administrator that an in-service was done by a Respiratory Therapist from the hospital on [DATE], and was attended by all nurses. Scope of Practice and Policy and Procedures concerning [MEDICAL CONDITION] suctioning were addressed, which included only RNs were allowed to deep suction a Trach. #9. The SA validated through interview with the Administrator and the DON, and review of the schedule, that no nursing staff was allowed to work until in-serviced on [MEDICAL CONDITION] suctioning. #10. The SA validated through interview with the Medical Director and the Administrator and record review of the sign-in sheet, that a QA meeting was held on 8/23/18, with recommendations and implementation of the recommendations. The SA validated that all corrective actions taken by the facility were completed as of 8/23/18, and the IJ was removed on 8/24/18, prior to exit.

Based on record review, interview, and facility policy review, the facility failed to provide qualified, sufficient nursing staff, a Registered Nurse (RN) to provide respiratory services/deep suctioning on a 24 hour basis for a resident with a [MEDICAL CONDITION] (Trach) tube for one (1) of one (1) resident reviewed with a [MEDICAL CONDITION], Resident #15. Review of the nursing schedule revealed there were approximately 159 day or 193 shifts with no RN coverage. Resident #15 was the [MEDICAL CONDITION] in the facility. He was sent to the Emergency Department (ED) for [MEDICAL CONDITION] and a [MEDICAL CONDITION] (MONTH) of (YEAR), and sent to the ED twice in (MONTH) (YEAR), for a cracked and/or [MEDICAL CONDITION], with replacement of [MEDICAL CONDITION] and a [MEDICATION NAME]. The facility's failure to provide RN coverage every shift to provide deep suctioning of a resident with a [MEDICAL CONDITION] if needed and/or [MEDICAL CONDITION] on a 24 hour a day basis, placed Resident #15, and other residents who may be admitted , in a situation that was likely to cause serious harm, injury or death to residents with [MEDICAL CONDITION]. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 8/22/18, when the facility failed to ensure RN coverage 24 hours per day to deep suction residents with a [MEDICAL CONDITION], if needed. The facility's Administrator (ADM) was notified of the IJ on 8/22/18. An acceptable Allegation of Compliance (AoC) was received on 8/24/18, in which the facility alleged all corrective actions were completed on 8/23/18, and the IJ removed 8/24/18. The State Agency (SA) validated the AoC and determined the IJ to be removed on 8/24/18, prior to exit. The scope and severity for the IJ and SQC at CFR 483.21(b)(3)(ii) was lowered to a D level, while the facility develops and implements a Plan of Correction (P[NAME]) and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory requirements. Findings include: Review of the facility's Nursing Services policy, dated (MONTH) (YEAR), revealed it is the policy of the facility to provide services based on the following requirements: Under the area titled Nursing Services, Sufficient Nursing Services section, the policy revealed the facility will have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety, and attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident, as determined by their resident assessments and individual plan of care and considering the number, acuity and [DIAGNOSES REDACTED]. Review of the Mississippi State Board of Nursing Laws and Rules Administrative Code Part 2830 Part 2830 Practice of Nursing Title 30: Professions and Occupations Chapter 2, Functions of the Licensed Practical Nurse, revealed : Rule 2.1- LPN Supervision; The LPN gives nursing care which does not require the specialized skill, judgement, and knowledge required of an RN, Advanced Practice Registered Nurse (APRN), Licensed Physician, or Licensed Dentist. Review of the MS State Board of Nursing (BON) web site, revealed frequently asked questions (FAQ's). The BON's statement requiring the LPN's scope of practice with [MEDICAL CONDITION] care revealed: It is within the scope of practice of the LPN to [MEDICAL CONDITION] and suction secretions from [MEDICAL CONDITION]. However, it is not within the scope of practice for the LPN to perform deep right main stem suctioning. If deep suctioning is required for a patient,a Registered Nurse (RN) must perform the procedure. Review of the working schedule for (MONTH) 1, (YEAR) to (MONTH) 31, (YEAR) revealed a total of 43 (7 AM-7 PM) shifts, six (6)-(3 PM-11 PM) shifts, and 53 (11 PM-7 AM) shifts in which there was no documented RN coverage to deep suction the resident with a Trach, if needed. Review of the working schedule for (MONTH) 1, (YEAR) to (MONTH) 24, (YEAR), revealed a total of 55 (7 PM-7 AM) shifts, 17 (3 PM-11 PM) shifts, and 19 (11 PM-7 AM) shifts in which there was no documented RN coverage to deep suction the resident with a Trach, if needed. This was a total of 193 shifts not covered with a Registered Nurse. (The facility does not utilize RT services). The facility admitted Resident #15 on 6/17/18, with [DIAGNOSES REDACTED]. Review of Resident #15's Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 5/22/18, revealed staff assessed Resident #15 to have moderately impaired cognition. Review of the physician's orders [REDACTED].#15'[MEDICAL CONDITION] four (4) hours and as needed. The order did not address whether to shallow suction or deep suction, nor who was responsible to carry out this order. The care plan documented to deep suction through [MEDICAL CONDITION](which only a RN can do). Review of the medical record revealed Resident #15 was admitted to the Emergency Department (ED) on several occasions; on 3/27/18, with red streaked thick white discharge from the Trach, with a [DIAGNOSES REDACTED]. Resident #15'[MEDICAL CONDITION] out on 4/4/18 and presented to the ED for replacement, which was difficult and returned with recommendations to apply suction as needed. Resident #15 had a [MEDICATION NAME] on 4/11/18, which revealed slight mucus plugs were washed and suctioned, and [MEDICAL CONDITION] in good position. Interview on 8-22-18 at 2:55 PM with the DON, confirmed the facility did not have 24 hour a day coverage by an RN or Respiratory Therapist (RT) to deep suction a [MEDICAL CONDITION] resident, if needed. The DON confirmed negative results of [MEDICAL CONDITION] or Anoxia could occur is the resident needed deep suctioning and it was not available. The DON confirmed that she lived seven (7) miles from the facility and another nurse lived closer, however, if the Resident was in severe distress, the staff would call the ambulance. Interview on 08/22/18 at 1:50 PM, with Licensed Practical Nurse (LPN) #3 revealed she was responsible for suctioning Resident #15 every four (4) hours as ordered. LPN #3 stated she did not deep suction him, she only went down about three (3) or four (4) inches. Interview on 8/23/18 at 11:45 AM with RN #3 revealed Resident #15 had not required deep suctioning by her that she could recall. Interview on 8/23/18 at 11:48 AM with RN #2 revealed she had suctioned Resident #15, but had not deep suctioned him. Interview on 8/23/18 at 11:50 AM with LPN #4 revealed Resident #15's secretions were clear and he usually coughed them up. LPN #4 confirmed Resident #15 had order to be suctioned every four (4) hours. Interview on 8/23/18 at 11:52 AM with LPN #1 revealed she had suctioned Resident #15, but did not deep suction him. Interview on 8/24/18 at 5:30 PM, with the DON, revealed Registered Nurse (RN) staffing had been discussed back in (MONTH) when the new regulations came out. The DON stated she guessed follow-up on RN staffing just fell through the cracks. The facility submitted an acceptable Allegation of Compliance (AoC) on 8/24/18, for the IJ. Review of the facility's AoC revealed the facility took the following corrective actions to remove the IJ prior to exit: An Immediate Jeopardy was determined on (MONTH) 22, (YEAR) regarding the facility not having a Registered Nurse or Respiratory Therapist on duty 24 hours a day, 7 days a week for possible deep suctioning of a [MEDICAL CONDITION], if needed, for Resident #15 who has a [MEDICAL CONDITION] and active physician orders [REDACTED]. The (MONTH) (YEAR) schedule reflected dates of 8/9/18, 8/10/18, 8/14/18, and 8/15/18, with no Registered Nurse or Respiratory Therapist on staff inside the facility from the hours of 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM to deep suction the resident if needed. Audit of all Registered Nurses on schedules conducted by Director of Nurses (DON) on 8/22/18 at approximately 9:00 PM. Audit reveals no Registered Nurse coverage on 159 days of a mixture of 3:00 PM-11:00 PM and 11:00 PM-7:00 AM shifts during the time frame (MONTH) 24, (YEAR) through (MONTH) 23, (YEAR). 1. FACILITY ACTIONS *Physician was notified on 8/22/2018 at 3:26 PM, by Director of Nursing (DON) and new orders were received to shallow suction by LPN and to deep suction by RN, as needed for Resident#15, the only Resident with a [MEDICAL CONDITION]. *The Medical Director was contacted by the Administrator and notified at approximately 4:30 PM on 8/22/18, of Immediate Jeopardy for no RN coverage for 159 days for a mixture of 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts to provide Resident [MEDICAL CONDITION] deep suctioning. *Resident #15's care plan reviewed and updated 8/23/18, approximately 4:30 PM by RN #6, for new suctioning orders specifying the difference between what LPN's and RN's are allowed to suction. Only RN's deep suction a [MEDICAL CONDITION]. *The DON was relieved of her duties and the facility placed an Interim DON on 8/23/18 at approximately 11:45 AM, to oversee the nursing staff in the continuum of resident care. The schedule has been audited by the Director of Nursing through the end of (MONTH) to ensure coverage of RN staff by in-house RN's until additional RN staff can be hired. Interim Director of Nurses is now checking schedule daily to ensure appropriate staffing regarding care of [MEDICAL CONDITION]. 2. INVESTIGATIONS *On (MONTH) 27, (YEAR), Resident #15 was sent out to the Emergency Department (ED) for [MEDICAL CONDITION]. He was again transferred to the ED on (MONTH) 4, (YEAR), for a cracked [MEDICAL CONDITION]. After returning from the ED, Resident #15 was sent back out to the ED later that same day for bleeding at the [MEDICAL CONDITION] site. None of the above ED visits were related to a lack of deep suctioning of the [MEDICAL CONDITION]. 3. ASSESSMENT *Physical assessment of Resident #15 was completed on 8/22/18 by RN #3 at approximately 3:38 PM. Assessment revealed the [MEDICAL CONDITION] clean, patent, with scant, clear, thin secretions that are easily suctioned, respirations are even and unlabored and no abnormal breath sounds are noted through-out. 4. IN-SERVICE *In-service was done on 8/23/2018 at 4:00 PM by the Care Plan Coordinator, with 105 employees from all disciplines in attendance. Topics included staff [MEDICATION NAME] within their scope of practice (including only RNs doing deep suctioning), and updating the care plan anytime there is a change in physician orders. *An in-service was initiated on 8/22/18 at approximately 5:00 PM, and conducted by a Respiratory Therapist from the local hospital. In-service included policy and procedure and standard of care and scope of practice for LPN's and RN's. In-service was completed for 34 nurses on 8/23/2018. Nurses will not be allowed to work until in-serviced. 5. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT (QAPI) *Policy and procedure for [MEDICAL CONDITION] was reviewed by Quality Assurance Performance Improvement Committee on 8/23/18 at 5:45 PM, attended by the Medical Director, DON, Administrator, RN #3, RN #2, RN #4, RN #5, and Medical Records Director. Policy was revised to include the difference of RN (deep suctioning) and LPN (shallow suctioning) guidelines. Discussion included addition of RN staffing during the evening and night shifts to provide deep suctioning of the [MEDICAL CONDITION] 24 hours/7 days per week. The Facility alleges the correction of the Immediate Jeopardy was resolved as of 8/23/18, and Immediate Jeopardy removed as of 8/24/18. The Survey team validated the facility's AoC: #1. The SA validated through interview with the DON and record review, that new orders were obtained from the physician to clarify the orders for suctioning the resident. #2. The SA validated by phone interview with the Medical Director that he had been notified by the Administrator of the IJ concerning Resident #15. #3. The SA validated through interview with the DON and record review, that the resident's care plan had been updated to specify which nurses are responsible for deep suctioning and the type of suctioning LPN's are allowed to perform. #4. The SA validated through interview with the Administrator and record review that the nurse's schedule had been updated to to ensure RN coverage 24 hours a day for deep suction of a resident with a Trach. #5. The SA validated through record review that Resident #15's ED visits in (MONTH) (YEAR) and (MONTH) (YEAR), were not related to a lack of deep suctioning, the Resident had [MEDICAL CONDITION] on (MONTH) 4, (YEAR). Review of documentation revealed the resident was able to cough up secretions. #6. The SA Validated through interview with the DON and record review that Resident #15 was assessed 8/22/18 by an RN . Documentation included the [MEDICAL CONDITION] was clean and patent with scant, clear, thin secretions, with no respiratory distress. #7. The SA validated through interview and record review that a care plan in-service was conducted by the Care Plan Coordinator for all employees that instructed them on scope of practice of nurses and updating care plans. #8. The SA validated through record review and interview with the DON and Administrator that an in-service was done by a Respiratory Therapist from the hospital on [DATE], and was attended by all nurses. Scope of Practice and Policy and Procedures concerning [MEDICAL CONDITION] suctioning were addressed, which included only RNs were allowed to deep suction a Trach. #9. The SA validated through interview with the Administrator and the DON, and review of the schedule, that no nursing staff was allowed to work until in-serviced on [MEDICAL CONDITION] suctioning. #10. The SA validated through interview with the Medical Director and the Administrator and record review of the sign-in sheet, that a QA meeting was held on 8/23/18, with recommendations and implementation of the recommendations. The SA validated that all corrective actions taken by the facility were completed as of 8/23/18, and the IJ was removed on 8/24/18, prior to exit.