Every finding on record at Ruleville Community Care Center

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident received treatment and services to manage pain as evidenced by the facility failing to administer fentanyl patches as ordered for one (1) of five (5) medication reviews (Resident #106). This failure resulted in missed doses of prescribed pain medication and escalating pain levels causing actual harm through unnecessary suffering. Resident #106Findings Include: Review of the facility policy titled Pain Evaluation/Management reviewed 8/25 revealed under, Policy: All residents will be evaluated for pain at the time of administration, readmission, quarterly and as needed.An interview on 8/25/2025 at 10:55 AM with Resident #106 revealed he hurt in 26 different areas of his body and had chronic pain every day. He explained he had been using fentanyl patches for about 19 months and took gabapentin and oxycodone twice daily to help manage his pain. The resident further reported he also used lidocaine patches, bio freeze, and Tylenol as needed. He explained that a nurse on the 3-11 shift repeatedly failed to apply his fentanyl patch as ordered, and he had not received it correctly on four separate occasions during his stay. The resident stated, The last time she neglected to apply my patch was on August 5th; I didn't get it until August 6th, after I reported it, which was 14 hours later.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/25/25 revealed under section J, Resident #106 experienced occasional pain during the 5-day look back period and rated his worst pain as an 8 on a scale of 0 (no pain) to 10 (worst pain).Record review of the July 2025 Medication Administration Record (MAR) for Resident #106 revealed an order dated 7/24/25: Fentanyl transdermal patch 72-hour 75 mcg (microgram)/hr. (hour), apply 1 patch transdermal every 72 hours for pain unspecified and remove per schedule. The patch was due to be changed on 7/30/25 at 8:00 PM and was documented as administered. Record review of Resident #106's Fentanyl Controlled Drug Record revealed a dose was not signed out on 7/30/25, indicating he did not receive the fentanyl patch as ordered and missed this dose. The next dose was administered on 8/2/25.Record review of the August 2025 Medication Administration Record (MAR) for Resident #106 revealed and order dated 7/24/25: Fentanyl transdermal patch 72-hour 75 mcg (microgram)/hr. (hour), apply 1 patch transdermal every 72 hours for pain unspecified and remove per schedule. The patch was due to be changed on 8/5/25 at 8:00 PM and was documented as administered. Record review of Resident #106's Fentanyl Controlled Drug Record revealed a dose was not signed out on 8/5/25, indicating he did not receive the patch as ordered.Record review of the August 2025 MAR revealed the fentanyl order was revised on 8/6/25 to be applied every 72 hours at 9:00 AM, and a patch was applied that morning.An interview with Registered Nurse (RN) #2 on 8/27/25 at 7:55 AM confirmed Resident #106 missed fentanyl doses on 7/30/25 and 8/5/25, which the resident himself reported. She acknowledged physician orders were not followed and stated she notified the physician, who changed the order to day shift administration effective 8/6/25. RN #2 further admitted the missed doses could have caused the resident increased pain and confirmed she reported the incident to the Director of Nursing (DON).Record review of Resident #106's July 2025 Medication Administration Record (MAR) revealed a documented pain level on 7/30/25 of 4 out of 10.Record review of the August 2025 MAR revealed the following documented pain levels; On 8/1 pain 5 out of 10, on 8/2 pain 5 out of 10, and on 8/5 pain 10 out of 10, aligning with the missed or delayed administration of fentanyl.An interview with the Director of Nursing (DON) on 8/27/25 at 8:06 AM revealed she was unaware Resident #106 had missed fentanyl doses. She stated her understanding was the administration time was changed because the patch had to be ordered from the pharmacy, which was what RN #2 told her. She acknowledged after reviewing Resident #106's narcotic record, the fentanyl patches were available, and the nurse failed to administer it. The DON confirmed the physician orders were not followed and acknowledged this could have caused Resident #106 increased pain.An interview with the Administrator on 8/27/25 at 12:02 PM revealed she was not aware Resident #106 had missed fentanyl doses or voiced concerns. She stated her expectation was that nurses administer medications exactly as ordered and sign off immediately after giving them. She acknowledged the resident could have experienced increased pain due to the missed fentanyl doses.Record review of the admission Record revealed the facility admitted Resident #106 on 7/18/25 with medical diagnoses that included Unspecified Injury at Unspecified Level of Cervical Spinal Cord, Hereditary and Idiopathic Neuropathy, Chronic Pain, and Polyosteoarthritis.Record review of the Minimum Data Set (MDS) with an ARD of 7/25/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #106 was cognitively intact.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement a care plan for resident's dependent on staff for nail care (Resident #6, #16, #102), showers (Resident #88, #94) and pain management (Resident #106) for six (6) of 31 sampled residents. Resident #6, #16, #88, #94, #102, #106 Findings Include: Review of the facility policy titled Comprehensive Person-Centered Care Plans unrevised, revealed, Policy: Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Resident #6 Record review of the Care plans for Resident #6 revealed under, Goals: I will maintain my current level of ADL (activities of daily living) status. Also revealed under, Interventions: extensive assist of one for personal hygiene. On 8/25/2025 at 11:12 AM, during an observation and interview with Resident #6, he held out his right hand and stated, I have claws, and voiced that he needed his nails trimmed. The resident's nails were long, approximately 3/8 (three-eighths) of an inch in length from the fingertip. On 8/25/25 at 11:31 AM, an observation and interview with Registered Nurse (RN) #2 confirmed Resident #6 had long nails that needed to be cut. Record review of the admission Record revealed the facility admitted Resident #6 on 4/23/19 with a medical diagnosis that included Type 2 Diabetes Mellitus without Complications. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/5/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #6 was cognitively intact. RESIDENT #16 Record review of Resident #16's Care Plan Report date initiated 10/15/24 revealed that she required staff assistance with ADLs and interventions included total dependence x (times) 1 (one) with dressing, bathing, and personal hygiene. An observation on 08/25/25 at 2:00 PM revealed Resident #16 sitting up in her wheelchair in the dining room. Her fingernails on both hands were approximately one-half inch long and had a brown substance underneath. During an observation and interview on 08/26/25 at 4:55 PM with Certified Nursing Assistant (CNA) #4, she confirmed that Resident #16 had long fingernails with a brown substance underneath. Record review of Resident #16's admission Record revealed an admission date of 01/18/19 and that she had diagnoses that included Bipolar Disorder and Hemiplegia and Hemiparesis following Cerebral Infarction. Record review of Resident #16's MDS with ARD of 08/13/25 under Section C revealed a BIMS Score of 15 which indicated that she was cognitively intact. Section GG revealed Resident #16 was dependent with personal hygiene. Resident #88 Record review of Resident #88's Care Plan Report date initiated 3/13/25 revealed that she was at risk for decline in ADLs (Activities of Daily Living) and had interventions that included Shower every other day with supervision. An observation and interview on 08/26/2025 at 9:18 AM with Resident #88 revealed that she had greasy hair. She revealed that she washed her hair every time she showered and said that she had not had a shower or bath since last Tuesday, 08/19/25. Resident #88 revealed that her hair was oily, and she felt dirty if she didn't get her shower and stated, I feel dirty now. She also revealed that she did not refuse her showers and that no one offered her shower this past Saturday. She stated, They must have been too busy. During an observation and interview on 08/26/25 at 12:10 PM with Licensed Practical Nurse (LPN) #4, she confirmed that Resident #88 had greasy hair and needed a shower. Resident #88 told LPN #4 that she had not had a shower in over a week, and LPN #4 told her that she would make sure she got a shower after lunch. Record review of Resident #88's admission Record revealed an admission date of 11/19/24 and that she had diagnoses that included Type II Diabetes Mellitus and Bipolar Disorder. Record review of Resident #88's MDS with ARD of 05/14/25 under Section C revealed a BIMS Score of 15 which indicated that she had no cognitive deficits. RESIDENT #94 Record review of Resident #94's Care Plan Report date initiated 04/8/25 revealed under focus that she had limited physical mobility and required extensive assistance x (times) 2 (two) with bed mobility, dressing, bathing, and toileting. An observation and interview on 08/25/2025 at 11:53 AM with Resident #94 revealed her lying in bed and she had greasy hair and a mild body odor. Resident #94 revealed that she hadn't had a shower or bath in a week, and she needed one. She revealed that the staff were not giving showers and baths like they were supposed to. During an observation and interview on 08/26/25 at 12:20 PM with Licensed Practical Nurse (LPN) #4, she confirmed that Resident #94 had greasy hair and a mild body odor. LPN #4 revealed that Resident #94's bath/shower days were Mondays, Wednesdays and Fridays and that she should have gotten a shower yesterday. Record review of Resident #94's admission Record revealed an admission date of 03/21/25 and that she had diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction. Record review of Resident #94's MDS with ARD of 06/25/25 under Section C revealed a BIMS Score of 15 which indicated that she had no cognitive deficits. Resident #102 Record review of the Care plans date initiated 08/29/25 for Resident #102 revealed under, Goals: I will maintain my current level of ADL (activities of daily living) status. Also revealed under, Interventions: extensive assist. Observations on 08/25/25 at 11: 00 AM and on 08/26/25 at 11:02 AM, revealed that Resident #102 had long fingernails approximately one-half inch long past the nail bed on both hands with a brown substance underneath. During an observation and interview on 08/27/25 at 8:55 AM with the Administrator (ADM), she confirmed that Resident #102 had long fingernails with a brown substance underneath. She revealed that nail care should be completed by CNAs during their bath/shower times. Record review of the admission Record revealed the facility admitted Resident #102 on 08/04/25 with a medical diagnosis that included Major Depressive Disorder and Acquired Absence of Left Leg Below Knee. Record review of the MDS with an ARD of 08/13/25 revealed under section C, a BIMS summary score of 15, indicating Resident #102 was cognitively intact. An interview with the MDS Nurse #1 on 08/27/25 at 10:30 AM revealed the purpose of the care plan was to let staff know what was going on with the residents and what interventions were needed. She explained the care plan was a way of communicating with the staff. She confirmed Resident #6, 16, 88, 94, and 102's care plans were not followed related to personal hygiene. Resident #106 Review of Resident #106's Care Plans revealed under, Focus: I complain of chronic pain and acute pain to different areas of my body, I have dx (diagnosis) of polyarthritis. Also revealed under, Interventions: Give meds as order for pain: Fentanyl patch. On 8/25/2025 at 10:55 AM, an observation and interview with Resident #106 revealed he was lying in bed and reported experiencing chronic pain every day. The resident stated, I hurt in 26 different areas on my body. He explained he had been using fentanyl patches for about 19 months and took gabapentin and oxycodone twice daily to help manage his pain. The resident further reported he also used lidocaine patches, bio freeze, and Tylenol as needed. He explained that a nurse on the 3-11 shift repeatedly failed to apply his fentanyl patch as ordered, and he had not received it correctly on four separate occasions during his stay. The resident stated, The last time she neglected to apply my patch was on August 5th; I didn't get it until August 6th, after I reported it, which was 14 hours later. Record review of the July and August 2025 Medication Administration Record (MAR) for Resident #106 revealed an order dated 7/24/25, Fentanyl transdermal patch 72-hour 75 MCG (microgram)/HR (hour) apply 1 patch trans dermally every 72 hours for pain unspecified and remove per schedule. Record review of Resident #106's Fentanyl Controlled Drug Record confirmed a dose was not signed out on 7/30 and 8/5, indicating he did not receive the patch as ordered. On 8/27/25 at 7:55 AM, an interview with Registered Nurse (RN) #2 on 8/27/25 at 7:55 AM confirmed Resident #106 missed fentanyl doses on 7/30 and 8/5. An interview with MDS Nurse #1 on 8/27/25 at 11:57 AM revealed the care plan was not followed to give the fentanyl patch as ordered for pain management. Record review revealed the facility admitted Resident #106 on 7/18/25 with medical diagnoses that included Unspecified Injury at Unspecified Level of Cervical Spinal Cord, Hereditary and Idiopathic Neuropathy, Chronic Pain, and Polyosteoarthritis. Record review of the MDS with an ARD of 7/25/25 revealed under section C, a BIMS summary score of 15, indicating Resident #106 was cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide basic hygiene care by not ensuring that a dependent resident received showers (Resident #88 and Resident #94) and routine nail care (Resident #6, Resident #16, and Resident #102) for five (5) of eight (8) residents reviewed for activities of daily living (ADLs). Findings Include Review of the facility policy titled Fingernails/Toenails Care unrevised, revealed, Policy: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Record review of undated facility policy, Bath/Shower-Dependent revealed, A bath (shower/tub) for cleanliness and comfort is scheduled at least weekly for each resident. Resident #6 An observation and interview with Resident #6 on 8/25/2025 at 11:12 AM in the resident's room, he held out his right hand and stated, I have claws, and voiced that he needed his nails trimmed. He explained he had been trying to get someone to help him for a couple of days. The resident's nails were long, approximately 3/8 (three-eighths) of an inch in length from the fingertip. His left fingers were contracted and turned inward toward his palm. Record review of the August 2025 Treatment Administration Record revealed no indication of nail care orders for Resident #6. An observation and interview with Registered Nurse (RN) #2 on 8/25/25 at 11:31 AM confirmed Resident #6 had long nails. She stated the resident was diabetic and that his nails had to be trimmed by a nurse. She revealed his nails should be checked weekly to determine if they needed cutting and confirmed that he could develop an infection or skin breakdown on his contracted hand from long nails. Record review of the admission Record revealed the facility admitted Resident #6 on 4/23/19 with a medical diagnosis that included Type 2 Diabetes Mellitus without Complications. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/5/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #6 was cognitively intact. RESIDENT #16 An observation on 08/25/25 at 2:00 PM and again on 08/26/25 at 8:38 AM, revealed that Resident #16 had long fingernails approximately one-half inch long on both hands with a brown substance underneath. During an observation and interview on 08/26/25 at 4:55 PM with Certified Nursing Assistant (CNA) #4, she confirmed that Resident #16 had long fingernails with a brown substance underneath. CNA #4 revealed that long, dirty fingernails could cause infection and stated, She could scratch herself. During an observation and interview on 08/26/25 at 5:00 PM with Licensed Practical Nurse (LPN) #3, she confirmed that Resident #16 had long fingernails with a brown substance underneath. She revealed that nail care should be completed by CNAs during their bath/shower times. LPN #3 also revealed that fingernails should be cleaned every day and as needed. Record review of Resident #16's admission Record revealed an admission date of 01/18/19 and that she had diagnoses that included Bipolar Disorder and Hemiplegia and Hemiparesis following Cerebral Infarction. Record review of Resident #16's MDS with ARD of 08/13/25 under Section C revealed a BIMS score of 15 which indicated that she was cognitively intact and under Section GG that she was dependent with her personal hygiene needs. RESIDENT #88 An observation and interview on 08/26/2025 at 9:18 AM with Resident #88 she stated that her hair was oily, and she felt dirty if she didn't get her shower and stated, I feel dirty right now. This observation confirmed that the resident's hair appeared greasy. She stated that she washed her hair every time she showered and said that she had not had a shower or bath since last Tuesday, 08/19/25. She revealed that she normally got her shower on Tuesdays, Thursdays, and Saturdays. She also revealed that she did not refuse her showers and that no one offered her a shower this past Saturday. She stated, They must have been too busy. An interview on 08/26/25 at 12:00 PM with Resident #88, revealed that the CNA's sometimes told her that they were too busy to help her with a shower. An observation and interview on 08/26/25 at 12:08 PM with CNA #5, confirmed that Resident #88's hair appeared greasy and that she should receive her showers on Tuesdays, Thursdays and Saturdays. During an observation and interview on 08/26/25 at 12:10 PM with LPN #4, she confirmed that Resident #88 had greasy hair and needed a shower. An observation also revealed Resident #88 report to LPN #4 that she had not had a shower in over a week. Record review of Resident #88's admission Record revealed an admission date of 11/19/24 and that she had diagnoses that included Type II Diabetes Mellitus and Bipolar Disorder. Record review of Resident #88's MDS with ARD of 05/14/25 under Section C revealed a BIMS Score of 15 which indicated that she had no cognitive deficits and in Section GG that she required supervision or touching assistance with showering and bathing. RESIDENT #94 An observation and interview on 08/25/25 at 11:53 AM and again on 8/26/25 at 11:13 AM with Resident #94 revealed she had a mild body odor and hair that appeared greasy. Resident #94 revealed that staff were not giving baths like they were supposed to, and it had been about a week since she had one. She stated she was supposed to take a bath or shower yesterday but did not. During an observation and interview on Tuesday, 08/26/25, at 12:20 PM with LPN #4, she confirmed that Resident #94 had greasy hair and a mild body odor and confirmed that she should have received one yesterday. Record review of Resident #94's admission Record revealed an admission date of 03/21/25 and that she had diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction. Record review of Resident #94's MDS with ARD of 06/25/25 under Section C revealed a BIMS score of 15 which indicated that she had no cognitive deficits and Section GG that she was dependent with her bathing/showering and personal hygiene needs. RESIDENT #102 An observation on 08/25/25 at 11:00 AM and again on 08/26/25 at 11:02 AM, revealed that Resident #102 had long fingernails approximately one-half inch long on both hands with a brown substance underneath. During an observation and interview on 08/25/25 at 11:05 AM with CNA #2, she confirmed that Resident #102 had long fingernails with a brown substance underneath. She revealed that his long, dirty fingernails could cause infection and stated, He could scratch himself. During an observation and interview on 08/27/25 at 8:55 AM with the Administrator (ADM), she confirmed that Resident #102 had long fingernails with a brown substance underneath. She revealed that nail care should be completed by CNAs during their bath/shower times. Record review of Resident #102's admission Record revealed an admission date of 8/04/25 and that he had diagnoses that included Major Depressive Disorder and Acquired Absence of Left Leg Below Knee. Record review of Resident #102's MDS with ARD of 8/13/25 under Section C revealed a BIMS Score of 15 which indicated that he was cognitively intact and in Section GG that he was substantial/maximal assistance with his personal hygiene needs.

Based on observation, interview, record review and facility policy review the facility failed to provide restorative nursing services for residents with contractures for two (2) of 31 sampled residents. Resident #16 and Resident #94. Findings Include: Review of the facility policy, Range of Motion revealed that A range of motion program will be developed for a resident as indicated Purposes of ROM (Range of Motion) 1. Maintain or improve joint and soft tissue mobility. 2 Minimize contractures RESIDENT #16 An observation and interview on 08/25/25 at 2:45 PM with Resident #16, revealed her sitting in her wheelchair in the dining room. She had a contracture to her left wrist/hand and there was no orthotic device in use. An observation on 08/26/25 at 8:38 AM revealed Resident #16 lying in bed in her room. She had contracture to her left wrist/hand, and she had no orthotic device in place. She revealed that they sometimes rolled a towel and put it in her hand, but she couldn't remember the last time they applied it. Record review of Resident #16's Occupational Therapy Discharge Summary revealed that she discharged from therapy services on 01/10/25 with an orthotic. RNP (Restorative Nursing Program) staff trained on performance of PROM (Passive Range of Motion) exercises as well as donning/doffing orthotic with nursing staff verbalizing understanding and providing return demonstration with 100% accuracy Record review of Resident #16's admission Record revealed an admission date of 01/18/19 and that she had diagnoses that included Bipolar Disorder and Hemiplegia and Hemiparesis following Cerebral Infarction. Record review of Resident #16's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/13/25 under Section C revealed a BIMS Score of 15 which indicated that she was cognitively intact. RESIDENT #94 An observation and interview on 08/25/2025 at 11:53 AM with Resident #94 revealed her lying in bed feeding herself lunch using her right hand. She had a contracture to her left wrist/hand and there was no orthotic device in place. She revealed that they used to put something in her hand to help keep it open, but it had been over a month since they used it. Record review of Resident #94's Occupational Therapy Discharge Summary revealed that she discharged from therapy services on 05/14/25. RNP (Restorative Nursing Program) has been established for orthotic wear/management which will maintain current ROM (Range of Motion) and reduce risk for further contracture. Record review of Resident #94's admission Record revealed an admission date of 03/21/25 and that she had diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction. Record review of Resident #94's MDS with ARD of 06/25/25 under Section C revealed a BIMS score of 15 which indicated that she had no cognitive deficits. An interview on 08/26/25 at 3:55 PM with the Director of Nurses (DON) revealed that once they received recommendations from the therapy department, it was the restorative department's responsibility to carry them out. She revealed that if recommendations included an orthotic device, an order needed to be put in place to include how to apply the device, when to put it on, how long to leave it and when to take it off. The DON reviewed the recommendations from the therapy department for Resident #16 and Resident #94 and confirmed that there were no orders in the system for orthotics and that the orthotics had not been implemented per recommendations. She revealed that they needed a better system and better communication between the departments to prevent any further recommendations from being missed. The DON agreed that failing to apply the orthotic devices for Residents #16 and #94 could result in a decline in range of motion, mobility, and worsening contractures. An interview on 08/26/25 at 4:16 PM with Occupational Therapy (OT), revealed that once a resident was discharged from therapy services, they referred them to restorative or to the functional maintenance program. She revealed that they instructed the staff on how to apply devices per recommendation and instructed them on the range of motion exercises. OT revealed that they made recommendations per specific needs of the residents, that devices be applied 3-5 days a week for so many hours per day per individual resident tolerance. She revealed that Resident #94 was discharged from therapy on 05/14/25 with recommendations for restorative caregivers to apply orthotic to contracted left wrist/hand to maintain current range of motion and prevent further contracture. OT revealed that Resident #16 was discharged from therapy on 01/10/25 with recommendations to continue orthotic/hand roll to the left hand. An interview on 08/26/25 at 4:30 PM with Restorative Licensed Practical Nurse (LPN), revealed that when a resident discharged from therapy for restorative services with a splint or other device, they go by the recommendations. She revealed that she did not put orders into the computer, that they communicated on paper. Restorative LPN confirmed that she did not have Resident #16 or Resident #94 on her current caseload list and was not aware of the prior recommendations for orthotic devices. She agreed that not following the recommendations for orthotics could result in decrease range of motion and worsening contractures.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents' rights to reasonable accommodation of needs by not providing access to oral hydration for two (2) of ninety-six residents reviewed (Resident #38 and Resident #47).Findings IncludeTop of Form Record review of the facility policy titled, Resident [NAME] of Rights undated, revealed, Each resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the Facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life . 10. Reside and receive services in the facility with reasonable accommodation of resident needs. Resident #38 Observation and interview on 8/25/2025 at 10:25 AM, revealed Resident #38 sitting in her room. No water was observed in either a water pitcher or a cup. The resident stated, I'll have to go up the hall to get some water. An observation and interview on 8/25/2025 at 12:05 PM, Resident #38 was propelling herself down the hall. State Agent (SA) stopped to speak with the resident and the resident stated, I need to go get some water. An observation on 8/25/2025 at 4:15 PM revealed no water in Resident #38's room. During an observation and interview on 8/26/2025 at 8:25 AM, it was revealed that Resident #38 was sitting in her room with no water observed. Resident #38 revealed she still has no water; someone took her water pitcher and didn't bring it back. She revealed she has to go up the hall to the nurse's desk and ask for water. An interview on 8/26/2025 at 11:05 AM, Licensed Practical Nurse (LPN) #5 revealed that all residents are to have a water pitcher in their room unless they are on thickened liquids or cannot drink. She revealed that the restorative aides or activities staff are responsible for passing hydration on her shift, usually between 9-10 AM and then again at 2 PM. She revealed that the residents must have accessible hydration at all times. An observation and interview on 8/26/2025 at 11:25 AM, LPN #5 confirmed that Resident #38 had no water in her room. LPN #5 asked Resident #38 where her water pitcher was, and the resident stated, Someone came and got it and never returned it to me. Record review of the admission Record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Atherosclerotic Heart Disease and Major Depressive Disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 7/3/2025 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 13, which indicates that Resident #38 is cognitively intact. Resident #47 During an observation and interview on 8/25/2025 at 12:05 PM, an empty pink plastic water pitcher was sitting across the room on top of Resident #47's chest of drawers. Resident #47 stated, I can't walk over there to get that. She revealed she had no water at her bedside and just the water she had at lunch. Observation of a white 8-oz Styrofoam cup with her lunch meal was noted. An observation on 8/25/2025 at 4:40 PM revealed no water at Resident #47's bedside, and the pink water pitcher remains across the room on top of the chest of drawers and is empty. An observation and interview on 8/26/2025 at 9:05 AM revealed Resident #47 lying in bed, no water is accessible to the resident, and the water pitcher remains across the room on top of the chest of drawers. Resident #47 revealed she hasn't had a pitcher of water at her bedside in a long time and usually gets some water and tea when she eats her meals. During an observation and interview on 8/26/2025 at 11:10 AM with LPN #5 she confirmed Resident #47's water pitcher was inaccessible and should never just be sitting across the room. She revealed that we are supposed to ensure our residents are always offered hydration, and it is accessible to them at their bedside. Record review of the admission Record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Vitamin D Deficiency, Heart Failure and Chronic Kidney Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 7/28/2025 revealed under Section C a BIMS score of 15, which indicates that Resident #47 is cognitively intact.

Based on staff and resident interview, record review and facility policy review, the facility failed to resolve a grievance for one (1) of eight (8) residents present at the resident council meeting. (Anonymous Resident).Findings IncludeReview of the facility policy titled Grievance/Missing Property with a revision date of 8/17 revealed under Purpose .to provide an opportunity for residents, resident representatives and/or family to present concerns or grievance to the proper authorities at the facility and to receive responses to the issue(s) raised. Under Procedure .A.3 .Supervisory personnel shall be responsible for notifying the resident of resolution and so indicate on grievance form .An interview on 8/25/25 at 10:15 AM, Anonymous Resident complained that Certified Nursing Assistant (CNA) #6 jerked his legs when she turned him and it hurt his back. He admitted that he reported this to the staff, but no one had come to ask him about it.An interview and record review on 8/25/25 at 4:00 PM with the Director of Nurses (DON) confirmed that the Anonymous Resident had complained about CNA #6 and she had filled out a grievance form for him. Record review of the grievance that was completed for the Anonymous Resident revealed that the resident had not signed the grievance form and there was no documentation that the grievance had been resolved or discussed with the resident and DON confirmed.Record review of the grievance log revealed a grievance from Anonymous Resident regarding CNA #6 hurting him when they jerked his turn pad but was listed as a complaint regarding customer service and was marked as resolved.An interview with Social Services #2 confirmed that all grievances should be discussed with the residents and signed by the residents before they can be considered resolved.

Based on observation, staff interview and record review, the facility failed to maintain a safe, clean, and comfortable environment as evidenced by a bathroom floor covering that had been removed, leaving bare concrete with a black stained area around the toilet for one (1) of 38 residents on sample. Resident #43 Findings Include: Review of a typed statement on facility letterhead revealed the facility did not have a policy regarding maintenance repairs and was signed by the Administrator. On 8/25/25 at 9:05 AM, an observation revealed Resident #43's bathroom floor covering was removed. The floor was bare concrete with a black substance around the toilet base. During an observation and interview with the Housekeeper #1 on 8/26/25 at 11:06 AM, he stated he mopped the area, but the concrete floor could not be cleaned properly and that it had been that way for some time. On 8/26/25 at 11:30 AM, an interview with the Maintenance Staff #2, revealed that when flooring is torn or damaged, linoleum is sometimes removed down to bare concrete. He stated that the aides, nurses, or housekeepers would let him know when repairs needed to be made. During an interview with the Administrator on 8/26/25 at 2:30 PM, she stated she was unaware Resident #43's bathroom floor covering had been removed and acknowledged the resident should have a floor covering. On 8/27/25 at 9:00 AM, a follow-up observation and interview with the Administrator revealed Resident #43's bathroom had new tile-patterned floor covering installed. She stated she observed the Maintenance Supervisor carrying the flooring earlier that day. Record review of Resident #43 's admission Record revealed the resident was admitted to the facility on [DATE] with a medical diagnosis that included Huntington's Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/02/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #43 is cognitively intact.

Based on resident and staff interviews, record reviews and facility policy review the facility failed to protect a resident's right to be free from verbal abuse for one (1) of five (5) residents reviewed for Abuse and Neglect. Resident #3 Findings IncludeTop of Form Top of Form Top of Form Review of the facility policy titled: Abuse Prevention undated, revealed, The facility is committed to protecting the residents from abuse by anyone, including, but not necessarily limited to: facility staff.Definitions: b) Verbal Abuse: The use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents . Review of the facility policy titled: Resident [NAME] of Rights, with a revision date of 1/23, revealed A. Facility residents shall have the right to: 36 . be free of abuse, neglect, exploitation, misappropriation of resident property . A record review of a written statement dated 2/14/25 and signed by Certified Nurse Aide (CNA) #1 revealed, I, (proper name of CNA #1) was working with Resident #3 on Friday, [DATE]. We put her in the bed, and she went to crying and I asked her what was wrong, and she said her legs were hurting and I just said your legs ain't hurting, she told me to shut up and I said you shut up. During an interview on 8/25/2025 at 11:10 AM, Resident #3 stated, CNA #1 told me to shut up when I complained about my legs hurting when she put me to bed. I told her I would report her, and she said she didn't care who I told about it. She revealed she told the former Administrator about it. During an interview on 8/26/25 at 2:40 PM, the Former Administrator stated, She got a phone call from the Ombudsman on Saturday night, the Ombudsman reported that Resident #3 had called her and said that CNA #1 had told her to shut up. The former administrator revealed that she had immediately called the facility and asked the nurse to put Resident #3 on the phone. She revealed that Resident #3 was talking fast and was upset and told her that CNA #1 was trying to prop a pillow under her legs and that she told the CNA that she was hurting her, and the CNA told her that she wasn't hurting her and to shut up. The former Administrator revealed I immediately sent CNA #1 home pending an investigation. She revealed that when I arrived at the facility on Monday, I went to talk with Resident #3 to see what happened. The former Administrator stated, Resident #3 told me that CNA #1 told her to shut up, and I said Well, what did you say to her? She revealed that Resident #3 told her that she also told CNA #1 to shut up. She revealed that she didn't see that it was abuse because by Monday, Resident #3 said it was okay, but that she didn't want CNA #1 to take care of her anymore. The Administrator revealed she was aware that Resident #3 had a diagnosis of chronic pain. In an interview on 8/26/25 at 3:45 PM, Social Services #2 revealed she remembers the incident of Resident #3 being told to shut up and revealed that when she came into work that Monday, she went and spoke with Resident #3, and she was upset and didn't want CNA #1 back in there to take care of her. During an interview on 8/26/2025 at 4:50 PM, Resident #3 revealed that when the incident happened, it was on a weekend, and CNA #1 and another aide were putting her in bed. I complained that my legs were hurting because she didn't put my legs up on the pillow correctly. I told her my leg was hurting, and she said, Shut up, your legs aren't hurting. Resident #3 stated, She didn't know how I felt. I was hurting. I have Cerebral Palsy. It made me sad and angry that she said that to me. Resident #3 revealed that CNA #1 still works at the facility. She comes in and takes care of her roommate, but doesn't take care of me, and that's how I want it. In a phone interview on 8/26/2025 at 5:40 PM, CNA #1 confirmed that she did tell Resident #3 to shut up. She revealed that she and another CNA were repositioning Resident #3's legs, and she kept saying her leg was hurting. She revealed I didn't think anything about it when I said, you're okay, you're not hurting then Resident #3 told me to shut up, and I told her to shut up back. CNA #1 acknowledged that she should not have spoken to Resident #3 like that. Record review of the admission Record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included Major Depressive Disorder, Anxiety Disorder, Pain, and Cerebral Palsy. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date of June 5, 2025, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicates that Resident #3 is cognitively intact.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure that all alleged abuse violations were reported to the State Survey Agency as required. This deficient practice had the potential to place residents at risk for abuse and/or neglect. For three (3) of the five (5) alleged abuse violations reviewed. Resident #3, Anonymous Resident, and Resident #68. Findings Include Review of the facility policy titled: “Abuse Prevention” dated 10/22, revealed, “The facility is committed to protecting the residents from abuse by anyone, including, but not necessarily limited to: facility staff… under Reporting: Alleged violations involving abuse, neglect, …are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including State Survey Agency…) Under Corrective Action: Any instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies.” Resident #3 A record review of a written statement dated 2/14/25 and signed by Certified Nurse Aide (CNA) #1 revealed, “I, (proper name of CNA #1) was working with Resident #3 on Friday, [DATE]. We put her in the bed, and she went to crying and I asked her what was wrong, and she said her legs were hurting and I just said your legs ain’t hurting, she told me to shut up and I said you shut up.” An interview with Resident #3 on 8/25/2025 at 11:10 AM, she stated, “Certified Nurse Aide (CNA) #1 told me to shut up when I complained about my legs hurting when she put me to bed. I told her I would report her, and she said she didn’t care who I told about it.” She revealed she told the former Administrator about it.” An interview with the Former Administrator on 8/26/25 at 2:40 PM confirmed that Resident #3 had reported that CNA #1 had told her to shut up when she complained of leg pain during repositioning. The former administrator revealed that she had immediately sent CNA #1 home and started her investigation. She confirmed she did not report it to the State Survey Agency because she didn’t see that it was abuse, because by Monday, when I returned to work to talk with Resident #3, she said it was okay, but that she didn’t want CNA #1 to take care of her anymore. She revealed she took CNA #1 off the schedule for a couple of days, did corrective counseling with her, and allowed her to return to work. Record review of the “admission Record” revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included Major Depressive Disorder, Anxiety Disorder, Pain, and Cerebral Palsy. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of June 5, 2025, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicates that Resident #3 is cognitively intact. Anonymous Resident An interview with Anonymous Resident on 8/25/25 at 10:15 AM revealed that he had reported that Certified Nurse Assistant (CNA) #6 and CNA #2 had hurt him during care. He stated that CNA #6 jerked his legs and hurt his back when she turned him and that CNA #2 slapped him in the face with a wet towel when she was bathing him. He admits that no one ever came and talked to him about it, but that neither CNA has returned to his room. An interview on 8/26/25 at 2:30 PM with CNA #6 revealed she recalls the day that the Anonymous Resident complained that they hurt him when they turned him and she was told not to go back to his room. Record review of Anonymous Resident’s “admission Record” revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Paraplegia. Record review of Anonymous Resident’s MDS with an ARD of 7/14/25 revealed in Section C, a BIMS score of 15, indicating that the resident was cognitively intact. Resident #68 An interview on 8/25/25 at 11:00AM with Resident #68 revealed that he reported to the Director of Nurses (DON) that he did not want CNA #2 back in his room. He stated that she hurts him when she tries to turn him and sometimes, she talks ugly to him. He admitted CNA #2 does not come to his room anymore, but that no one had questioned him about why he didn’t want her in his room anymore. A phone interview on 8/26/25 at 3:15PM with CNA #2 recalled that Anonymous Resident complained that she had wiped his bottom too hard when she was cleaning him, so they told her not to go back in his room. She revealed that last week she was told not to go back into Resident #68’s room but was not told why and today she was suspended while they investigated this with Resident #68. Record review of Resident #68’s “admission Record” revealed the resident was admitted on [DATE] with medical diagnoses that included Anxiety, Pain and Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side. Record review of Resident #68's MDS with an ARD of 7/17/25 revealed in Section C a BIMS score of 14, which indicates the resident is cognitively intact. An interview on 8/25/25 at 4:00PM with the DON confirmed that she had a complaint on CNA #2 for Resident #68 and CNA #6 for an Anonymous Resident but admitted that she felt like it was more of a customer service issue and therefore did not report it to the state. She confirmed that she removed both CNA’s from providing care to these residents and should have reported the allegations to the state. An interview on 8/26/25 at 9:30AM with the ADM confirmed that all allegations of abuse should be reported to the state. She stated she was aware of some complaints on CNA #2 but was not aware of any abuse allegations since she had been here and she started in April 2025.

Based on staff and resident interviews, record review and facility policy review the facility failed to investigate allegations of abuse for two (2) of five (5) residents reviewed for abuse. Residents #68 and Anonymous Resident Findings IncludeReview of the facility policy titled, with a revision date of 10/22 revealed under Investigate: .the facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation.An interview on 8/25/25 at 10:15AM with an Anonymous Resident revealed that Certified Nurse Assistant (CNA) #6 and CNA #7 came in to turn him and they jerked his legs and hurt his back. He admitted that he reported it to staff that he thought it was CNA #6 and admits that she hasn't worked with him since. He then stated that he reported to the Administrator that CNA #2 was giving him a bed bath and when he ask her to wash his back, she wet the towel and slapped his face with it as she was reaching over him. He admitted that she had not worked with him since, but that no one had come and talked with him about either report.An interview on 8/25/25 at 11:00AM with Resident #68 revealed that CNA #2 tries to turn him every day by herself. He stated that it needs to be two people because it hurts and sometimes, she talks ugly to him. He admitted that he reported CNA #2 to the Director of Nurses (DON) and now CNA #2 does not come to his room anymore, but that no one had come and questioned him about it.An interview on 8/25/25 at 11:40AM with the DON confirmed that there was a resident that complained about CNA #6 and that Resident #68 had complained about CNA #2 and she had removed them from those resident's care but had not completed an investigation.An interview on 8/25/25 at 2:30PM with CNA #7 confirmed that she was present and assisted CNA #6 on the Anonymous Resident the day he complained that we had hurt him. She stated that they did not feel like they did anything wrong or different, but they reported it to the DON.A follow-up interview on 8/25/25 at 4:00PM with the DON confirmed that she had a complaint on CNA #2 for Resident #68 and CNA #6 for an Anonymous Resident, but admitted that she had not done an investigation, because she felt like it was more of a customer service issue and therefore did not report it to the state. She confirmed that she removed both CNA's from providing care to these residents. She stated that a couple of days after the Anonymous Resident complained on CNA #6, the resident was sent to the emergency room for back pain and admits that an investigation should have been completed. She revealed she would start an investigation now. She stated she does not recall having any complaints from the Anonymous Resident regarding CNA #2.An interview on 8/26/25 at 9:30AM with the ADM confirmed that all allegations of abuse should be investigated. She stated she was aware of some complaints on CNA #2 but was not aware of any abuse allegations since she had been here and she started in April 2025.An interview on 8/26/25 at 2:30PM with CNA #6 revealed she recalls the day that the Anonymous Resident complained that they hurt him when they turned him and she was told not to go back to his room.A phone interview on 8/26/25 at 3:15PM with CNA #2 recalled that Anonymous Resident complained that she had wiped his bottom too hard when she was cleaning him, so they told her not to go back in his room. She revealed that last week she was told not to go back into Resident #68's room but was not told why and today she was suspended while they investigated this with Resident #68. Record review of Anonymous Resident's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Paraplegia.Record review of Anonymous Resident's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/14/25 revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact.Record review of Resident #68's admission Record revealed the resident was admitted on [DATE] with medical diagnoses that included Anxiety, Pain and Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to maintain accurate medical records for one (1) of five (5) medication reviews. Resident #106Findings include: Review of the facility policy titled Medication Administration -General Guidelines revised 8/16 revealed under, Policy: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Also revealed under, Procedure: . 9 . This individual records the administration on the resident's MAR/eMAR (medication administration record) and TAR/eTAR (treatment administration record) after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/TAR to ascertain that all necessary doses were administered and all administered doses were documented . During an interview with Resident #106 on 8/25/2025 at 10:55 AM, he revealed he had a problem with a nurse on 3-11 shift not applying his fentanyl patch and stated he was not getting it like he should be. He explained that he did not get his fentanyl patch correctly four (4) separate times since he had been at the facility. The resident stated, The last time she neglected to apply my patch was on August 5th; I didn't get it until August 6th. Record review of the July 2025 Medication Administration Record (MAR) for Resident #106 revealed an order dated 7/24/25, Fentanyl transdermal patch 72-hour 75 MCG (microgram)/HR (hour) apply 1 patch transdermal every 72 hours for pain unspecified and remove per schedule which was due to be changed 7/30/25 and was initialed on the MAR as administered. Record review of Resident #106's Fentanyl Controlled Drug Record revealed a dose was not signed out on 7/30/25, which indicated he did not receive the fentanyl on this day as ordered. Record review of the August 2025 Medication Administration Record (MAR) for Resident #106 revealed an order dated 7/24/25, Fentanyl transdermal patch 72-hour 75 MCG (microgram)/HR (hour) apply 1 patch transdermal every 72 hours for pain unspecified and remove per schedule which was due to be changed on 8/5 was initialed on the MAR as given. Record review of Resident #106's Fentanyl Controlled Drug Record revealed a dose was not signed out on 8/5/25, which indicated he did not receive the fentanyl on this day as ordered. During an interview with the Director of Nursing (DON) on 8/27/25 at 8:06 AM revealed after reviewing Resident #106's fentanyl narcotic record she confirmed the patch was not given on 7/30 and 8/5 but was signed off on the medication record as given. She stated medications should not be signed as administered if they were not and confirmed this was inaccuracy of the resident's medical record. During an interview with the Administrator on 8/27/25 at 12:02 PM, she revealed her expectations were for the nurses to give the medications as ordered and sign off on the medication record immediately after giving them. She agreed Resident #106's medical record would not be accurate. Record review of the admission Record revealed the facility admitted Resident #106 on 7/18/25 with medical diagnoses that included Unspecified Injury at Unspecified Level of Cervical Spinal Cord, Hereditary and Idiopathic Neuropathy, Chronic Pain, and Polyosteoarthritis. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/25/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #106 was cognitively intact.

Based on observation, staff interview, record review, and facility policy review the facility failed to prevent a resident from being physically restrained with a sheet tied to the wheelchair. The facility also failed to obtain physician orders, consent and failed to assess a resident for the need of restraints (mattress with elevated sides and wedges) for one (1) of six (6) residents reviewed. Resident #1. Findings included: Review of the facility policy titled, Restraint Evaluation & (and) Restraint Reduction, revised 12/23, revealed, Policy: as per OBRA (Omnibus Budget Reconciliation Act) requirements, all residents have the right to be unrestrained. Restraints should be used only as a last alternative and only when other less restrictive measures have been tried and rejected.Definition: Physical Restraints are defined as any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access.Procedure: 2.) All residents using a restraint are to be evaluated utilizing the Restraint Evaluation Form.4.) A specific physician's order is to be entered in the resident's medical record which details the medical reason, type of restraint and when to be used . Record review of the facility occurrence, completed by the Director of Nursing (DON) revealed that an investigation was conducted on 6/10/24, when the DON was informed of a resident possibly having a sheet tied on her wheelchair the previous day. After staff interview which revealed four (4) CNAs stated they saw the resident restrained on 6/9/24 with a sheet tied around the wheelchair, the facility determined that because the resident was recently combative and sliding down in the chair; someone may have tied a sheet loosely around her wheelchair. An observation and interview on 6/25/24 at 8:30 AM, with Certified Nursing Assistant (CNA) #1 revealed Resident #1 was in bed on a mattress with elevated sides that extended the length of the mattress and four (4) - 18 by eight (8) inch foam wedges which were present on either side of her upper and lower body. CNA #1 verified that Resident #1 currently had a mattress with elevated sides and wedges in use in the bed to keep her off of the floor. She stated that the daily care guide lets her know what type of devices the resident should have. An interview with Licensed Practical Nurse (LPN) #1 on 6/25/24 at 8:40 AM, stated that Resident #1 had a history of falls and that the mattress with elevated sides and wedges were to keep the resident from falling. She stated that she has to check the resident about every 30 minutes because she gets up unassisted. A record review of the facilities Daily Care Guide for Resident #1 revealed, under interventions Concave bed with elevated sides . There were no interventions listed for the use of foam wedges. A record review of the Physician's Order List for Resident #1 revealed no physician's orders for a mattress with elevated sides or wedges. Record review of a written statement on company letter head, provided by the Administrator, undated, revealed that the facility did not have physician's orders, consents or assessments for the mattress and wedges that were in place for Resident #1. In a telephone interview with CNA #3 on 6/25/24 at 9:00 AM, she stated when she came on duty a little after 7:00 AM on 6/9/24, she noticed Resident #1 had a sheet tied around her waist tied in a knot behind the wheelchair. She stated that she knew that the resident should not be restrained that way. CNA #3 stated that she brought it to the attention of the resident's nurse LPN #1. CNA #3 stated LPN #1 told her that it was to aid in the resident's safety and for her protection. During an interview with CNA #1 on 6/25/24 at 9:35 AM, she stated that on 6/9/24 after lunch, she saw Resident #1 tied in the wheelchair with a sheet. She stated that CNA #2 told her the nurse put it on. CNA #1 stated she and CNA #2 removed the sheet and showered the resident but did not reapply the sheet. In a telephone interview 6/25/24 at 10:40 AM, with CNA #2 she stated on 6/9/24 at 9:30 AM, while making rounds she saw Resident #1 sitting in the day room restrained in the wheelchair with a sheet with a knot tied in the back. She stated she untied the sheet to take the resident to her room to provide incontinent care. CNA #2 states that she left the sheet off of the resident but when she went to get Resident #1 after lunch, she was restrained with a sheet in the wheelchair again. She stated that one of her co-workers informed her that the nurse said it was for the resident's safety and not to remove it. CNA #2 stated that she and CNA #1 removed the sheet and showered the resident. She stated that they did not reapply the sheet. In an interview with LPN #1 on 6/25/24 at 10:45 AM, she verified that she was assigned to Resident #1 on 6/9/24. LPN #1 denied any knowledge of Resident #1 being restrained in the wheelchair with a sheet. She stated she did not see the resident restrained and she denied anyone bringing to her attention that the resident was restrained. LPN #1 denied restraining the resident or telling staff that it was for the resident's safety and protection. During an interview with the DON on 6/25/24 at 11:00 AM, she verified that based on her investigation it was likely that someone restrained Resident #1 in the wheelchair with a sheet on 6/9/24, because the resident had recently been combative and had slid down in the wheelchair. She stated that she was unable to determine who had restrained the resident. The DON stated that she felt that they had done it for the resident's safety and did not feel that the resident was at risk of any injuries related to being restrained in the wheelchair with a sheet. During further interview the DON verified that there were no wedges listed as interventions on Resident #1's Daily Care Guide and agreed that there were no physician's orders for the use of a mattress with elevated sides or wedges for Resident #1. During an interview with the Unit Manager (UM) on 6/25/24 at 1:16 PM, she revealed that a resident should never have any restraints applied without assessment , physicians' orders, and family consent. She stated restraining a resident places the resident at risk of sliding in the chair and getting choked. Record review of the Face Sheet revealed the facility admitted Resident #1 on 5/6/2024, with diagnoses that include Dementia and Impulse Disorder.

Based on staff interview, record review and facility policy review the facility failed to report an allegation of mistreatment when a resident was physically restrained with a sheet tied to the wheelchair for one (1) of six (6) residents reviewed. Resident #1. Findings Included: Review of the facility policy titled, Abuse Prevention, revealed the definition of mistreatment means inappropriate treatment of a resident. All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than two hours after the allegation is made. Record review of the facility occurrence, completed by the Director of Nursing (DON) revealed that an investigation was conducted on 6/10/24, when the DON was informed of a resident possibly having a sheet tied on her wheelchair the previous day. After staff interview which revealed four (4) Certified Nursing Assistants (CNAs) stated they saw the resident restrained on 6/9/24 with a sheet tied around the wheelchair, the facility determined that because the resident was recently combative and sliding down in the chair; someone may have tied a sheet loosely around her wheelchair. On 6/25/24 at 10:40 AM, a telephone interview with Certified Nursing Assistant (CNA) #2 she stated on 6/9/24 at 9:30 AM, while making rounds she saw Resident #1 sitting in the day room restrained in the wheelchair with a sheet tied in a knot. She states that she took the sheet off of the resident but when she went to shower Resident #1 after lunch, she was restrained with a sheet in the wheelchair again. She stated that one of her co-workers informed her that the nurse said it was for the resident's safety and not to remove it. During an interview with the DON 6/25/24 at 11:45 AM, she stated that the facility did not report the allegation of the resident being restrained in the wheelchair with a sheet because they ran it up the flagpole with corporate and determined that the occurrence did not need to be reported to the State Agency because she knew that it was done for the resident's safety due to her behaviors and falls. She stated the facility was unable to determine who had restrained the resident with a sheet in the wheelchair. In an interview with the Administrator on 6/25/24 at 2:00 PM, he agreed that the use of a sheet to restrain a resident in the wheelchair was an inappropriate treatment to prevent falls, therefore, mistreatment and should have been reported to the State Agency. Record review of the Face Sheet revealed the facility admitted Resident #1 on 5/6/2024, with diagnoses that include Dementia and Impulse Disorder. Record review of an annual Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 5/13/24 revealed under section GG that Resident #1 was dependent for locomotion in the wheelchair.

Based on staff interview, care plan review, record review, and facility policy review, the facility failed to revise a comprehensive care plan related to behaviors for (1) one of 13 residents reviewed for care plans. Resident #1 The facility's failure to revise Resident #1's care plans with appropriate interventions related to his known behavior of getting into bed with other residents resulted in staff not having access to preventative measures to deter this behavior. On [DATE], Resident #1 was found in bed on top of Resident #2 with only his hands visible beneath Resident #1. Resident #2 was unresponsive and did not respond to life sustaining measures and was pronounced dead. This placed the residents residing in the facility at risk, and in a situation that was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) on [DATE], which began on [DATE] when the facility failed to revise Resident #1's behavior care plan. On [DATE] at 10:30 AM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and provided the IJ Template. The facility submitted a credible Removal Plan on [DATE], in which the facility alleged all corrective actions to remove the IJ were completed on [DATE] and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CFR(s) 483.21(b)(2)(iii) Care plan Timing and Revision Care Plans (F657) - Scope and Severity - J, was lowered from an J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled, Comprehensive Person Centered Care Plans, revised ,d+[DATE], revealed: Policy: 9.) Upon a change in condition, the comprehensive person-centered care plan will be updated .' Record review of the Care Plan for Resident #1 with a problem onset date of [DATE] revealed, Problem/Need I am delusional, easily agitated, verbally/physically aggressive at times, refuses care (showers, shaves, and personal hygiene) and socially inapp. (inappropriate) with females staff (touching and remarks). Takes mattress off bed puts mattress on floor and sleeps on it . The care plan did not include a revision to the problem/need or approaches to address the behavior of Resident #1 getting into other resident's beds. Record review of the Departmental Notes for Resident #1 revealed a note by Licensed Practical Nurse (LPN) #3 on [DATE] at 2:25 AM revealed CNA #4 reported while she was making rounds Resident #1 was noted lying in bed bedside his roommate. Record review of the Departmental Note for Resident #1 revealed a note written by LPN #2 on [DATE] at 1:22 AM that Resident #1 was observed in Resident #3's bed unclothed, refusing to get in his bed stating, there are rats over there, after multiple failed attempts to redirect Resident #1 he finally put his mattress on the floor and laid down. In an interview and record review with Social Service #1 assigned to the [NAME] wing on [DATE] at 1:00 PM, she revealed she did not update Resident #1's plan of care or increase monitoring. Social service #1 also confirmed that by not updating Resident #1's plan of care and the Interdisciplinary team not putting interventions in place to alert staff and potentially protect the residents in the facility, all residents were at risk because Resident # 1 did not have increased monitoring and was ambulatory, very obese, and could have gotten into to any residents bed placing them at risk to be accidentally hurt or abused. Social Service #1 confirmed after review of Resident #1's behavior plan of care that it had never been updated to reflect the behavior of Resident #1 getting into other resident's beds and confirmed by not increasing monitoring and supervision of Resident #1's behaviors the facility did not protect the other residents from harm. Social Service #1 revealed the purpose of the care plan is to aid staff to provide person-centered care and treatment to meet the resident's specific needs. In an interview with the current Director of Nurses (DON) on [DATE] at 9:30 AM, she confirmed Resident #1 should have been placed on 1-on-1 observation and the plan of care should have been updated for staff to be aware of the behavior to possibly intervene. In an interview with the current Administrator on [DATE] at 8:00 AM, he revealed all the incidents related to Resident #1's behavior of getting into his roommate's bed should have been updated in the plan of care. Record review of the Face Sheet revealed the facility admitted Resident #1 on [DATE] with diagnoses that included Unspecified mood affective disorder, Unspecified psychosis, and Anxiety Disorder. Record review of the quarterly Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) on [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated that he was severely cognitively impaired. Section E- Mood revealed no behaviors were checked. Section GG-Functional Abilities and Goals revealed the resident was independent with walking. Section K-Swallowing/Nutritional Status revealed a height of 76 inches and weight of 486 pounds. The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Summary of events: The facility was informed by the state agency on [DATE] at 10:30 AM of five immediate jeopardies. The state agency provided the facility with IJ template for F600, F609, F657, F689 and F742. On [DATE], Resident #1 was clothed and observed in bed with Resident # 3. Resident # 3 was a vulnerable, deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident # 1's care plan for this behavior. [DATE], Resident # 1 was observed in Resident #3 bed unclothed. Resident # 3 was a vulnerable deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident #1's care plan for the behavior. On [DATE], at approximately 3:30 AM, the staff responded to the call light in Resident # 1's room, and he was observed unclothed and lying on top of Resident # 2. Licensed nurses and certified nursing assistants intervened. Resident # 2's body fell to the floor and cardiopulmonary resuscitation measures (CPR) were initiated. The emergency management services (EMS), and police department were notified. EMS arrived at the facility at approximately 3:50 AM. The emergency management services continued cardiopulmonary resuscitation measures until 4:12 AM and discontinued life resuscitating measures. The local police arrived at the facility at approximately 3:50 AM and interviewed Resident # 1, licensed nurses and certified nursing assistants (CNA). The local police took statements and confirmed Resident # 2 was deceased . The local coroner arrived to examine Resident # 2's body and removed the body from the facility with the understanding that an autopsy would be completed to determine the final cause of death. Corrective Actions: 1. On [DATE] Resident # 1 was placed on one-on- one (,d+[DATE]) supervision immediately. Psychiatric placement was initiated on [DATE] at approximately 8:00 am, but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner on [DATE] at approximately 12:00 PM. Resident #1 remained on ,d+[DATE] supervision until he was discharged to the custody of the local police department on [DATE] at 3:45 PM. 2. The Administrator presented to the facility on [DATE] at approximately 4:40 AM and initiated an investigation with assigned licensed nurses and certified nursing assistants. 3. On [DATE] The Administrator notified the MS State Department of Health at 5:50 AM, Attorney General Office at 9:00 PM and Ombudsman on [DATE] at 11:08 AM. 4. An in-service was initiated for all staff on [DATE] at approximately 5:30 AM regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors. 5. A special resident council meeting was conducted on [DATE] 11:30 AM by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility. 6. On [DATE] at approximately 3:30 PM, the social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates. 7. On [DATE] an in-service was initiated at approximately 10:00 am by the [NAME] President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining 1-on-1 supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses were instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received. 8. On [DATE] at 9:00 AM, the [NAME] President of Operations in serviced the Administrator and Director of Nurses at 9:00 AM on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies. 9. On [DATE] at 10:15 AM, the [NAME] President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored. 10. On [DATE] at approximately 11:30 AM, an interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns. 11. A 100% audit was initiated on [DATE] at 1:30 PM by the social services department to ensure that all Residents had compatible roommates. No issues identified. 12. A 100% audit was conducted on [DATE] at 2:00 PM by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place. 13. The Administrator reported the [DATE] incident involving Resident # 1 and Resident # 3 to the MS State Department of Health at 2:13 PM on [DATE]. 14. An emergency quality assurance committee met on [DATE] at 2:50 PM. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional [NAME] President. The facility discussed the current survey IJ outcomes. 5 IJ cites for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident # 1 had previous behavioral issues on [DATE] with Resident # 3. Resident # 1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified as of [DATE] to include protecting residents from others who get into their beds by intervening and providing 1-on-1 supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required. 14. The Ombudsman was notified of the [DATE] on [DATE] at 3:27 PM by the Administrator. 15. The Administrator reported the [DATE] incident involving Resident # 1 and Resident # 3 to the Attorney General Office online system on [DATE] at 3:40 PM. The facility is alleging that all activities to remove the Immediate Jeopardy were completed as of [DATE] and the Immediate Jeopardy was removed on [DATE]. Validation: SA Validations were made onsite during the complaint investigation CI MS #25192. On [DATE], the SA surveyor verified through staff and resident interview, record review, sign-in sheets, and in-service reviews that all corrective actions had been taken by the facility to remove the IJ during the survey on [DATE] and the IJ was removed on [DATE].

Based on staff interviews, record review, and facility policy review the facility failed to protect one (1) of 108 residents right to be free from neglect as evidenced by [DATE] Resident #3 being unwilling to sleep in his room with his roommate due to Resident #1 getting in the bed with Resident #3. This resulted in the death of another resident (Resident #2) when Resident #1 laid on top of Resident #2 who was placed in the room with Resident #1. The facility's neglect to identify roommate incompatibility and provide appropriate person-centered behavioral interventions from [DATE]-[DATE] placed Resident #2 at risk, caused his death and placed other residents in a situation which was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE], which began on [DATE], when the facility neglected to ensure appropriate services for residents with behavioral needs. The facility's failure to provide appropriate person-centered behavioral interventions resulted in Resident #1 lying on Resident #2 until death on [DATE]. On [DATE] at 10:30 AM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the IJ Templates. The facility submitted a credible Removal Plan on [DATE], in which the facility alleged all corrective actions to remove the IJ were completed on [DATE] and the IJ removed as [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed before exit. Therefore, the scope and severity for 42 CFR(s) 483.12(a)(1) - Abuse and Neglect (F600) was lowered from a J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled, Abuse Prevention, dated ,d+[DATE] revealed: Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents .Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish Abuse may be resident -to -resident .Neglect: A failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain .Identification: Identify events, such as occurrences, pattens and trends that may constitute abuse; and determine the direction of the investigation . Review of the facility policy titled, Resident [NAME] of Rights revealed a facility resident shall have the right to a safe environment and the right to be free of abuse and neglect. Record review of the facility reported incident report that occurred on [DATE], at approximately 3:30 AM, the following information was found: the staff responded to the call light in Resident #1's room, and he was observed unclothed and lying on top of Resident #2. Licensed nurses and Certified Nursing Assistants (CNA) intervened. Resident #2's body fell to the floor and cardiopulmonary resuscitation (CPR) measures were initiated. The emergency management services (EMS), and police department were notified. EMS arrived at the facility at approximately 3:50 AM. The EMS continued CPR measures until 4:12 AM when they discontinued life resuscitating measures. The local police arrived at the facility at approximately 3:50 AM and interviewed Resident #1, licensed nurses and CNAs. The local police took statements and confirmed Resident #2 was deceased . The local coroner arrived to examine Resident #2's body and then removed the body from the facility. A phone interview with CNA #1 on [DATE] at 3:30 PM, revealed on the early morning of [DATE] at approximately 3:30 AM she responded to the call light going off and went into the room and observed Resident #1 naked and lying on top of Resident #2 in Resident #2's bed. She stated she instructed Resident #1 to get off of Resident #2 several times, but he would not get up, so she immediately went out into the hall and yelled for the nurse to come now, and Registered Nurse (RN) #1 came in and took over. CNA #1 revealed she had not heard any noises coming from the room that night. A phone interview with CNA #2 on [DATE] at 5:36 PM revealed she was assigned to Resident #1 and Resident #2 on the early morning of [DATE]. She stated at approximately 1:30 AM she was making rounds and observed Resident #1 was lying in bed listening to music and talking to himself which was normal behavior for both residents to have conversations with themselves, and Resident #2 was asleep in his bed. CNA #2 revealed around 3:00 AM she was making rounds and walked by the room and saw Resident #1 standing naked in front of his window but did not find that uncommon because Resident #1 often slept naked, and Resident #2 was in his bed on his side and appeared asleep. She stated that around 3:30 AM she was in an adjacent room and could hear one of the staff calling for the nurse to come help because Resident #1 was on top of Resident #2. A phone interview with RN #1 on [DATE] at 7:30 AM, revealed on the morning of [DATE] at approximately 3:30 AM he was called to the room of Resident #1 and Resident #2. As he entered the room he observed Resident #1 lying naked on top of Resident #2 with only the hands of Resident #2 could be seen. Resident #1 was severely obese weighing 489 pounds and was covering his entire torso and head area. He stated he instructed Resident #1 to get up several times and when he did Resident #2 fell off the bed, on to the floor on his back and was not breathing. Resident #2 was a full code and CPR was immediately started, EMS was called and CPR was continued but was unable to revive Resident #2. RN #1 stated he asked Resident #1 what his date of birth and social security number were and Resident #1 answered correctly. When asked what he was doing, Resident #1 said, we were arguing and fighting I went to the nurses station and asked to call the police but we would not let him, he went back to his room and continued to argue and said Resident #2 said I am going to kill you, I took offense to that so I hit him and got on top of him. RN #1 confirmed at no time during the shift did he see Resident #1 come to the nurse's station asking to call police but stated at some point Resident #1 stated he put the call light on when Resident #2 stopped fighting him. RN #1 then stated he interviewed Resident #1 after the incident and he was alert and oriented, and answered questions appropriately. He followed RN #1's command when he asked Resident #1 to go in the bathroom and he stayed when the CPR was started. RN #1 stated Resident #1 is alert and oriented most of the time, with frequent episodes of delusional episodes. He also revealed Resident #2 had frequent episodes of delusions and talking to himself. He stated he was not made aware of concerns that night, related to the residents. RN #1 then stated he has observed Resident #1 in bed with his roommates on two other occasions in the past but was not sure of the dates and confirmed it was reported to Administration by the nurses assigned to Resident #1 immediately. RN #1 revealed that the female nursing staff call him to help when some of the male residents will not respond to them. RN #1 confirmed Resident #1 was placed on one-on-one supervision after the incident but was not on any special monitoring before the incident. Review of the facility investigation interview summary with Resident #1 under facility events for the incident that occurred on [DATE] revealed, Resident #1 was interviewed but his statement was disorganized speech, delusional, and at times nonsensical. Resident #1 told the nurse that he tried to use the phone at the nurses' station to call police before the incident but, the staff denied that he was at the nurse's station or requested to use the phone. During an interview with the Executive Director/Administrator, Director of Nursing (DON), and Regional Nurse Consultant they revealed that Resident #1 did not verbalize that he had called or tried to call the police before the incident. The information gathered from Resident #1 was that Resident #2 was tormenting him. Resident #1 said he got scared and went into the bathroom where he waited. After some time waiting in the bathroom, he said he wasn't going to wait for Resident #2 to Choke my neck. According to Resident #1 he came out of the bathroom, then he said he hit Resident #2 multiple times on the head area. Initially, Resident #1 stated he hit Resident #2 once in the back of the head when he came out of bathroom before grabbing him. Resident #1 stated they tussled and wrestled for a while on the bed where Resident #2 was bear hugging him and scratching and biting him. Resident #1 said as he was holding Resident #2 on the bed, and then Resident #2 gave up after he got on top of him. Resident #1 stated that he pressed the intercom for (staff) help. He stated that he held him down until staff could come to the room. Resident #1 also stated that he had called his dad who was working and that the police came and got his body. The resident at times rambled with disorganized speech and delusions. Resident #1 had increased delusions every time he was asked to recall the event even though there were times when his statements were consistent. An interview with the Attorney General officer on [DATE] at 1:40 PM revealed he interviewed Resident #1 on [DATE] while Resident #1 was sitting in his chair in his room and he pointed to Resident #2's bed and stated, I killed him right over there on that bed I smothered his nose. The Attorney General officer also revealed he notified the facility on [DATE] that the sheriff's office would be picking Resident #1 up to meet with mental health services. Record review of an incident report dated [DATE] at 3:30 AM by Licensed Practical Nurse (LPN) #1 for Resident # 1 revealed, Incident description: Resident was observed lying on top of his roommate Resident #2, Resident #1 was redirected by RN #1 to go to the restroom. Resident #1 was assessed to have a scratch to his right interior shoulder measuring five inches by 0.4 inches and an abrasion to the last digit on his left hand measuring 0.2 inches by 0.2 inches. Immediate actions: Resident placed on ,d+[DATE] supervision. Mobility: Ambulates independently. Record review of the incident report dated [DATE] at 3:30 AM by LPN #1 for Resident #2 revealed Resident #1 was found on top of Resident #2. Resident #2 was not responding to name being called loudly, no movement, CPR was started until the EMT arrived and continued CPR. Unable to obtain vital signs, no pulse noted, code call stopped at 4:12 AM. Resident #2 was observed to have ,d+[DATE] inch circular abrasion to his lower right eye and his nose was misshapen. Coroner was on site and pronounced Resident #2 expired at 4:12 AM and the body was released to the Coroner. Family, responsible party, medical provider, DON and Executive Director were notified. Record review of the Behavior/Intervention Monthly Flow record for [DATE] for Resident #1 revealed behaviors to be monitored were physically/fighting aggressive, verbally aggressive (cursing), delusional, easily agitated, refusing care, and socially inappropriate with females (touching and remarks) with only one day of documentation of monitoring for the month of May which was on [DATE] and revealed no behavior noted. There was no behavior monitoring for the behavior of getting into other resident's beds. Record review the departmental note for Resident #1 revealed a note by LPN #3 dating back to [DATE] at 2:25 AM that read CNA #4 who was assigned to Resident #1 reported during her rounds Resident #1 was noted lying in bed bedside his roommate, Resident #3. Resident #1 stated he was trying to keep his roommate warm. CNA #4 reported she did not see Resident #1 do anything wrong. LPN #1 informed Resident #1 he could not get into bed with other residents. Resident #1 stated okay I was just trying to help him. The (ED) Executive Director/ Administrator, social services, and DON were notified. A phone interview with LPN #3 on [DATE] at 7:00 AM revealed she was assigned to Residents #1 and #3 on the early morning of [DATE]. She revealed CNA #4 was working the hall that night and informed her that while she was making rounds, she observed Resident #1 lying in bed with his roommate Resident # 3. Resident #3 is a deaf mute, she stated CNA #4 told her that both residents were fully clothed. LPN #3 stated that she did not think anything about it because when she asked Resident #1 why he was in the bed with Resident #3 he told her he thought that was his son and wanted to keep him warm. She stated she and CNA #4 made statements and notified the Director of Nursing and the Social Services, but she was unaware if the incident was reported and confirmed that Resident #3 was assessed and had no visible injuries. She also confirmed she did not increase monitoring of Resident #1 or notify the provider because it just did not cross her mind that Resident #1 could have attempted to abuse Resident #3 and stated, I see now why I should have recognized that. Record review of the departmental note for Resident #1 by Social Service #1, dated [DATE] at 2:14 PM revealed the writer was informed by a nurse that a CNA reported to her she observed resident lying in bed with his roommate: resident stated he was trying to keep his room-mate warm. CNA reported she did not see the resident doing anything. Resident #1 was counseled by social services and Resident #1 voiced understanding and will observe for any further behaviors. Record review of the progress notes for Resident #1 revealed a note by LPN #2 on [DATE] at 1:22 AM that Resident #1 was observed in Resident #3's bed unclothed, refusing to get in his bed stating, there are rats over there, after multiple failed attempts to redirect resident, he finally put his mattress on the floor and laid down. A phone interview with LPN #2 on [DATE] at 5:00 PM, revealed she was assigned to Resident #1 and Resident #3 on the early morning of [DATE]. During rounds she found Resident #1 lying naked in the bed with his roommate, Resident #3, and confirmed Resident #1 had to be instructed several times to get up before he would, stating there were rats on his side of the room. She stated he finally got up and put his mattress on the floor and settled down. She revealed Resident #3 was severely cognitively impaired, a deaf mute and would not be able to call for assistance. She stated Resident #3 had a shirt and brief on at the time of the incident and was assessed to have no visible injuries. LPN #2 confirmed she notified the social worker, Administrator, the DON and confirmed she did not increase monitoring or supervision of either Resident #1 or #3 and did not notify the provider of the behavior. LPN #2 also revealed on the early morning of [DATE] she observed Resident #1 in another bed with no resident in the room and stated he did not want to go to his room because there were spiders in the room. A document provided by Social Services #1 revealed Resident #3 resided with Resident #1 from [DATE]-[DATE]. Record review of the departmental notes for Resident #3 revealed a note by LPN #3 dated [DATE] at 12:25 AM that CNA #4 had reported Resident #3's roommate was noted lying in the bed with him. Record review of the departmental notes for Resident #3 revealed a note by Social Service #1 a follow up visit related to roommate lying in bed with him. Resident is a deaf-mute unable to interview due to cognitive impairment but has not had any changes in mood, behavior, cognition or daily routine. Record review of the Face Sheet revealed the facility admitted Resident #3 on [DATE] with the diagnoses of Deaf non-speaking and Autistic disorder. Review of the departmental notes for Resident #3 revealed a note by Social Service #1 dated [DATE] at 11:09 AM that Resident #3 is being moved to another room related to roommate incompatibility. An interview with the Social Service #1 assigned to the [NAME] wing on [DATE] at 1:00 PM, revealed she was informed of the incident on [DATE] when Resident #1 was observed in Resident #3's bed. She stated that Resident #1 was clothed at the time of the incident, and she counseled him not to do that again. She stated she felt Resident #1 meant no harm because he said he thought Resident #2 was his son and was trying to keep him warm and was at times delusional. She stated she did not update Resident #1's plan of care or increase monitoring and confirmed she did not recognize this as a behavior. Social service #1 also confirmed that by not updating Resident #1's plan of care, the Interdisciplinary team not putting interventions in place to alert staff and potentially protect the residents in the facility. All residents were at risk. Resident #1 did not have increased monitoring, was ambulatory, very obese, and could have gotten into to any resident's bed, placing them at risk to be accidentally hurt or abused. Social Service #1 revealed she was not aware of the incident that occurred on [DATE], in the early morning hours, when Resident #1 was observed unclothed in Resident #3's bed. When asked if increased monitoring or treatment was put in place she stated she did not put any new interventions or monitoring in place because that was nursing's responsibility. An interview with the [NAME] President of Operations on [DATE] at 2:00 PM, revealed that the previous DON and Administrator were let go from the company on [DATE] and she was not able to find any investigations for the Resident #1 related incidents in November and December. She revealed she was unable to find any ,d+[DATE] supervision/ monitoring for Resident #1 for the Month of November and [DATE]. She provided one document of ,d+[DATE] supervision for Resident #1 that was initiated after the death of Resident #2 on the morning of [DATE]. She also confirmed that she could not find evidence were Resident #1's behavior interventions or increased monitoring were ever updated after the incidents in November and [DATE] and confirmed that the potential was there for the other residents in the facility to be at risk for harm such as being smothered if Resident #1 got into their bed. She also confirmed after review of Resident #1's Behavior/Intervention Monthly Flow Record that staff were not completing the forms correctly and it appeared the resident was not monitored for behaviors. No increased monitoring forms were provided to the SA from the facility for Resident #2 or Resident #3. An interview on [DATE] at 8:00 AM, with the previous Administrator whose last date of employment was [DATE] revealed she was not aware of any incidents of Resident #1 getting in the bed with another resident naked or clothed. She stated she would have reported and investigated it immediately because it could have been abuse and the residents in the facility are all vulnerable adults. An interview on [DATE] at 8:30 AM, with the previous DON whose last date of employment was [DATE] revealed no one had ever reported Resident #1 getting into bed with his roommate. She stated if she had that information, she would have reported it immediately and measures in place to protect both residents. An interview with the current DON on [DATE] at 9:30 AM, revealed she was not aware of Resident #1's behavior of getting into other residents' beds and was not employed at the facility during the time of the first two incidents. She confirmed the incident on ,d+[DATE] and ,d+[DATE] should have been thoroughly investigated, and interventions put in place to protect the residents. She went on to say that if after the first incident on ,d+[DATE] Resident #3, should have been moved, interventions put in place and there may not have been another incident with Resident #1 getting into resident's beds. The DON also confirmed Resident #1 should have been placed on ,d+[DATE] observation and the plan of care should have been updated for staff to be aware of the behavior to possibly intervene. An interview with the Medical Director on [DATE] at 3:00 PM revealed the facility notified him of the incident on [DATE] related to the resident-on-resident death, but confirmed he was never notified of Resident #1 ever getting into any other residents' bed clothed or unclothed. An interview with the psychiatric Nurse Practitioner (NP) on [DATE] at 3:30 PM, confirmed she was informed of the incident on [DATE] related to the death of Resident #2 but revealed she was not aware of Resident #1 getting into another resident's bed. She stated that she was aware of Resident #1's delusional/hallucinations. Record review of the psychiatric encounter notes for Resident #1 dated [DATE], [DATE], and [DATE] revealed no mention of the behavior of getting into other resident beds. An interview with the current Administrator/Executive Director on [DATE] at 8:00 AM, revealed all the incidents related to Resident #1 getting into his roommate's bed should have been thoroughly investigated. Record review of the Face Sheet the facility admitted Resident #1 on [DATE] with the diagnoses of Unspecified Mood Affective Disorder, Unspecified Psychosis, and Anxiety disorder Record review of the quarterly Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) on [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated that he was severely cognitively impaired. Section E- Mood revealed no behaviors checked. Section GG-Functional Abilities and Goals revealed resident was independent with walking. Section K-Swallowing/Nutritional Status revealed a height of 76 inches and weight of 486 pounds. Record review of the Face Sheet revealed the facility admitted Resident #2 on [DATE] with the diagnoses of Unspecified mood affective disorder, Unspecified psychosis, and Generalized anxiety disorder. Record review of the quarterly MDS Section C with an ARD on [DATE], revealed that Resident #2 had a BIMS score of 9 which indicated that he was moderately cognitively impaired. Review of the Mortician Record/Record of Death for Resident #2 dated [DATE] time of death was 4:12 AM, body was released to local Coroner's office. The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Summary of events: The facility was informed by the state agency on [DATE] at 10:30 AM of five immediate jeopardies. The state agency provided the facility with IJ template for F600, F609, F657, F689 and F742. On [DATE], Resident #1 was clothed and observed in bed with Resident #3. Resident #3 was a vulnerable, deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident #1's care plan for this behavior. [DATE], Resident #1 was observed in Resident #3 bed unclothed. Resident #3 was a vulnerable deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident #1's care plan for the behavior. On [DATE], at approximately 3:30 AM, the staff responded to the call light in Resident #1's room, and he was observed unclothed and lying on top of Resident #2. licensed nurses and certified nursing assistants intervened. Resident #2's body fell to the floor and cardiopulmonary resuscitation measures (CPR) were initiated. The emergency management services (EMS), and police department were notified. EMS arrived at the facility at approximately 3:50 AM. The emergency management services continued cardiopulmonary resuscitation measures until 4:12 AM and discontinued life resuscitating measures. The local police arrived at the facility at approximately 3:50 AM and interviewed Resident # 1, licensed nurses and certified nursing assistants (CNA). The local police took statements and confirmed Resident # 2 was deceased . The local coroner arrived to examine Resident # 2's body and removed the body from the facility with the understanding that an autopsy would be completed to determine the final cause of death. Corrective Actions: 1. On [DATE] Resident #1 was placed on one-on- one (,d+[DATE]) supervision immediately. Psychiatric placement was initiated on [DATE] at approximately 8:00 am but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner on [DATE] at approximately 12:00 PM. Resident #1 remained on ,d+[DATE] supervision until he was discharged to the custody of the local police department on [DATE] at 3:45 PM. 2. The Administrator presented to the facility on [DATE] at approximately 4:40 AM and initiated an investigation with assigned licensed nurses and certified nursing assistants. 3. On [DATE] The Administrator notified the MS State Department of Health at 5:50 AM, Attorney General Office at 9:00 PM and Ombudsman on [DATE] at 11:08 AM. 4. An in-service was initiated for all staff on [DATE] at approximately 5:30 AM regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors. 5. A special resident council meeting was conducted on [DATE] 11:30 AM by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility. 6. On [DATE] at approximately 3:30 PM, the social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates. 7. On [DATE] an in-service was initiated at approximately 10:00 am by the [NAME] President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining 1-on-1 supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses was instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received. 8. On [DATE] at 9:00 AM, the [NAME] President of Operations in serviced the Administrator and Director of Nurses on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies. 9. On [DATE] at 10:15 AM, the [NAME] President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored. 10. On [DATE] at approximately 11:30 AM, an interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns. 11. A 100% audit was initiated on [DATE] at 1:30 PM by the social services department to ensure that all Residents had compatible roommates. No issues identified. 12. A 100% audit was conducted on [DATE] at 2:00 PM by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place. 13. The Administrator reported the [DATE] incident involving Resident #1 and Resident #3 to the Mississippi State Department of Health at 2:13 PM on [DATE]. 14. An emergency quality assurance committee met on [DATE] at 2:50 PM. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional [NAME] President. The facility discussed the current survey IJ outcomes. 5 IJ were cited for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident #1 had previous behavioral issues on [DATE] with Resident #3. Resident # 1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified as of [DATE] to include protecting residents from others who get into their beds by intervening and providing 1-on-1 supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required. 14. The Ombudsman was notified of the [DATE] on [DATE] at 3:27 PM by the Administrator. 15. The Administrator reported the [DATE] incident involving Resident #1 and Resident # 3 to the Attorney General Office online system on [DATE] at 3:40 PM. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of [DATE] and the Immediate Jeopardy was removed [DATE]. Validation: The SA Validations were made onsite during the complaint investigation CI MS #25192. On [DATE], the SA validated through interviews and record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on [DATE].

Based on record review, staff interviews, and facility policy review, the facility failed to provide adequate supervision to reduce the risk of an accident/hazards when a resident with behaviors got into other resident's beds and did not have any increased supervision/monitoring put in place resulting, in the physical assault and death of a resident for (1) one of (4) four residents reviewed for accidents. (Resident #2) The facility's failure to provide adequate supervision and monitoring, placed Resident #2 and other residents residing in the facility at risk, and in a situation which caused Resident #2's death and was likely to cause serious injury, serious harm, serious impairment, or death for others. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE], which began on [DATE], when the facility failed to provide increased supervision/monitoring and ensure appropriate services for residents with behavioral needs. The facility's failure to provide supervision/monitoring, resulted in the physical assault and death of a resident on [DATE]. On [DATE] at 10:30 AM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the IJ Templates. The facility submitted a credible Removal Plan on [DATE], in which the facility alleged all corrective actions to remove the IJ were completed on [DATE] and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed before exit. Therefore, the scope and severity for 42 CFR(s) 483.25(d)(1)(2)- Free of accidents/hazards/supervision/devices (F689) Scope and Severity -J, was lowered from a J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy Accident & Incident Documentation & Investigation Resident Incident reviewed ,d+[DATE] revealed POLICY: Accidents and/or incidents involving resident care will .be analyzed for trends or patterns to enable the facility to enhance preventative measures to reduce the occurrence of incidents . Record review of an incident report dated [DATE], at approximately 3:30 AM, the staff responded to the call light in Resident # 1's room, and he was observed unclothed and lying on top of Resident #2. Licensed nurses and Certified Nursing Assistants (CNAs) intervened. Resident #2's body fell to the floor and cardiopulmonary resuscitation measures (CPR) was initiated. The emergency management services (EMS) and the police department were notified. EMS arrived at the facility at approximately 3:50 AM. EMS continued CPR until 4:12 AM and then discontinued life resuscitating measures. The local police arrived at the facility at approximately 3:50 AM and interviewed Resident #1, licensed nurses and CNAs. The local police took statements and confirmed Resident #2 was deceased . The local coroner arrived to examine Resident # 2's body and then removed the body. Record review of the Face Sheet revealed the facility admitted Resident #1 on [DATE] with the diagnoses that included Unspecified mood affective disorder, Unspecified psychosis, and Anxiety Disorder. Record review of the quarterly Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated that he was severely cognitively impaired. Section E- Mood revealed no behaviors checked. Section GG-Functional Abilities and Goals revealed the resident was independent with walking. Section: K-Swallowing/Nutritional Status revealed a height of 76 inches and weight of 486 pounds. Record review of the Face Sheet revealed the facility admitted Resident #2 on [DATE] with the diagnoses of Unspecified Mood Affective disorder, Unspecified Psychosis, and Generalized Anxiety disorder. Record review of the quarterly MDS Section C with an ARD on [DATE], revealed that Resident #2 had a BIMS score of 9 which indicated that he was moderately cognitively impaired. On [DATE] at 7:30 AM, during a phone interview with Registered Nurse (RN) #1 revealed on the morning of [DATE] at approximately 3:30 AM he was called to the room of Resident #1 and Resident #2 and observed Resident #1 lying naked on top of Resident #2 with only the hands of Resident #2 could be seen. RN #1 revealed Resident #1 was severely obese, weighing 489 pounds, covering Resident #2's entire torso and head. RN #1 confirmed Resident #1 was placed on one-on-one monitoring after the incident, but was not on any special monitoring before the incident. Record review of the coroner report, revealed Resident #2 was pronounced deceased on [DATE] at 4:12 AM and then released to the coroner's office. Review of the Departmental Notes for Resident #1 revealed a note by Licensed Practical Nurse (LPN) #3 on [DATE] at 2:25 AM, CNA #4 reported while she was making rounds Resident #1 was noted lying in bed bedside roommate, Resident #3. Resident #1 stated he was trying to keep his roommate warm. LPN #2 informed Resident #1 he could not get into bed with other residents. Resident #1 stated, okay, I was just trying to help him. On [DATE] at 7:00 AM, in a phone interview LPN #3 revealed on the early morning of [DATE] CNA #4 that was working the hall that night informed her that while she was making rounds, she observed Resident #1 lying in bed with his roommate Resident # 3, who is a deaf mute. She also confirmed she did not increase monitoring of Resident #1 because it just did not cross her mind that Resident #1 could have attempted to abuse Resident #3 stating I see now why I should have recognized that. Record review of the Departmental Note for Resident #1 revealed a note by Social Service #1 dated [DATE] at 2:14 PM revealed the writer was informed by a nurse that a CNA reported to her, she observed Resident #1 lying in bed with his roommate: Resident #1 stated he was trying to keep his roommate warm. The CNA reported she did not see the resident doing anything. The resident was counseled by social services and the resident voiced understanding and will observe for any further behaviors. Record review of the Departmental Note for Resident #1 revealed a note by LPN #2 on [DATE] at 1:22 AM Resident #1 was observed in roommate's bed unclothed, refusing to get in his bed stating, there are rats over there, after multiple failed attempts to redirect he finally put his mattress on the floor and laid down. On [DATE] at 5:00 PM, a phone interview with LPN #2 revealed on the early morning of [DATE] she found Resident #1 lying naked in the bed with Resident #3. She confirmed she did not increase monitoring of either Resident #1 or Resident #3. On [DATE] at 1:00 PM, in an interview with the Social Service staff #1 assigned to the [NAME] wing on [DATE] revealed she was informed of the incident on [DATE] early in the morning hours when Resident #1 was observed in Resident #3's bed. Social Service #1 stated she did not update Resident #1's increase monitoring and confirmed she did not recognize this as a behavior. Social Service #1 also confirmed that by not putting interventions/increased monitoring in place to alert staff and potentially protect the residents in the facility, all residents were at risk. Due to Resident #1 was ambulatory, very obese, and could have gotten into to any resident's bed placing them at risk to be accidentally hurt. When asked if increased monitoring or treatment was put in place after the incident on [DATE], she stated she did not put any new interventions or monitoring in place because that was nursing's responsibility. Record review of the Departmental Notes for Resident #3 revealed a note by Social Service #1 dated [DATE] at 11:09 AM, that resident is being moved related to roommate incompatibility. Record review of the Face Sheet revealed the facility admitted Resident #3 on [DATE] with the diagnoses of Deaf non-speaking and Autistic disorder. On [DATE] at 2:00 PM, an interview with the [NAME] President of Operations, revealed she was unable to find any ,d+[DATE] supervision/monitoring for Resident #1 related to the incidents in November and [DATE]. She provided a document of ,d+[DATE] supervision for Resident #1 that was initiated after the death of Resident #2 on the morning of [DATE]. She also confirmed that she could not find evidence where Resident #1's behavior interventions/ monitoring were updated after the incidents in November and [DATE]. She also confirmed that the potential was there for the other residents in the facility to be at risk of harm, such as being smothered if Resident #1 got into their bed. No increased monitoring forms were provided to the SA from the facility for Resident #2 or Resident #3. Record review of the Resident Location Monitoring form for Resident #1 provided by the facility, revealed resident to only be on increased monitoring 1-on 1 supervision starting at 3:45 AM on [DATE] -3:45 PM on [DATE] when Resident #1 was released to the Sheriff's department. The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Summary of events: The facility was informed by the state agency on [DATE] at 10:30 AM of five immediate jeopardies. The state agency provided the facility with IJ template for F600, F609, F657, F689 and F742. On [DATE], Resident #1 was clothed and observed in bed with Resident # 3. Resident # 3 was a vulnerable, deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident #1's care plan for this behavior. [DATE], Resident # 1 was observed in Resident #3 bed unclothed. Resident # 3 was a vulnerable deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident #1's care plan for the behavior. On [DATE], at approximately 3:30 AM, the staff responded to the call light in Resident # 1's room, and he was observed unclothed and lying on top of Resident # 2. Licensed nurses and certified nursing assistants intervened. Resident # 2's body fell to the floor and cardiopulmonary resuscitation measures (CPR) were initiated. The emergency management services (EMS), and police department were notified. EMS arrived at the facility at approximately 3:50 AM. The emergency management services continued cardiopulmonary resuscitation measures until 4:12 AM and discontinued life resuscitating measures. The local police arrived at the facility at approximately 3:50 AM and interviewed Resident # 1, licensed nurses and certified nursing assistants (CNA). The local police took statements and confirmed Resident # 2 was deceased . The local coroner arrived to examine Resident # 2's body and removed the body from the facility with the understanding that an autopsy would be completed to determine the final cause of death. Corrective Actions: 1. On [DATE] Resident # 1 was placed on one-on- one (,d+[DATE]) supervision immediately. Psychiatric placement was initiated on [DATE] at approximately 8:00 am but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner on [DATE] at approximately 12:00 PM. Resident #1 remained on ,d+[DATE] supervision until he was discharged to the custody of the local police department on [DATE] at 3:45 PM. 2. The Administrator presented to the facility on [DATE] at approximately 4:40 AM and initiated an investigation with assigned licensed nurses and certified nursing assistants. 3. On [DATE] The Administrator notified the MS State Department of Health at 5:50 AM, Attorney General Office at 9:00 PM and Ombudsman on [DATE] at 11:08 AM. 4. An in-service was initiated for all staff on [DATE] at approximately 5:30 AM regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors. 5. A special resident council meeting was conducted on [DATE] 11:30 AM by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility. 6. On [DATE] at approximately 3:30 PM, the social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates. 7. On [DATE] an in-service was initiated at approximately 10:00 am by the [NAME] President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining 1-on-1 supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses was instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received. 8. On [DATE] at 9:00 AM, the [NAME] President of Operations in serviced the Administrator and Director of Nurses at 9:00 AM on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies. 9. On [DATE] at 10:15 AM, the [NAME] President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored. 10. On [DATE] at approximately 11:30 AM, an interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns. 11. A 100% audit was initiated on [DATE] at 1:30 PM by the social services department to ensure that all Residents had compatible roommates. No issues identified. 12. A 100% audit was conducted on [DATE] at 2:00 PM by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place. 13. The Administrator reported the [DATE] incident involving Resident # 1 and Resident # 3 to the MS State Department of Health at 2:13 PM on [DATE]. 14. An emergency quality assurance committee met on [DATE] at 2:50 PM. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional [NAME] President. The facility discussed the current survey IJ outcomes. 5 IJ cites for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident # 1 had previous behavioral issues on [DATE] with Resident # 3. Resident # 1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified as of [DATE] to include protecting residents from others who get into their beds by intervening and providing 1-on-1 supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required. 14. The Ombudsman was notified of the [DATE] on [DATE] at 3:27 PM by the Administrator. 15. The Administrator reported the [DATE] incident involving Resident # 1 and Resident # 3 to the Attorney General Office online system on [DATE] at 3:40 PM. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of [DATE] and the Immediate Jeopardy was removed [DATE]. Validation: SA Validations were made onsite during the complaint investigation (CI) MS #25192. On [DATE], the SA surveyor verified through staff and resident interview, record review, sign-in sheets, and in-service reviews that all corrective actions had been taken by the facility to remove the IJ during the survey on [DATE] and the IJ was removed on [DATE].

Based on staff interviews, record review, and facility policy review, the facility failed to recognize behaviors and provide appropriate person-centered behavioral interventions for one (1) of three (3) residents with documented behaviors resulting in the physical assault and death of a resident. (Resident #1) The facility's failure to identify behaviors and failure to provide appropriate person-centered behavioral interventions and supervision, from [DATE] through [DATE] resulted in the death of Resident #2 and placed other residents at risk, and in a situation which was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE], which began on [DATE], when the facility failed to identify behaviors, and ensure appropriate services for residents with behavioral needs. The facility's failure to identify potential abuse, failure to provide appropriate person-centered behavioral interventions and supervision resulted in the physical assault and death of a resident on [DATE]. On [DATE] at 10:30 AM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the IJ Templates. The facility submitted a credible Removal Plan on [DATE], in which the facility alleged all corrective actions to remove the IJ were completed on [DATE] and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed before exit. Therefore, the scope and severity for 42 CFR(s) 483.40 (b)(1) Treatment/services Mental/Psychosocial (F742) - Scope and Severity - J, was lowered from an J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility policy titled, Behavior Management and Psycho-pharmacological Medication Monitoring Protocol, reviewed ,d+[DATE], revealed: Behavioral Interventions: are individualized non-pharmacological approaches to care as a part of a supportive physical and psychosocial environment, and are directed toward understanding, preventing, relieving, and or accommodating a resident's distress or loss of abilities as well as maintaining or improving a resident's mental, physical or psychosocial well being . Record review of an incident report dated [DATE], at approximately 3:30 AM, revealed the staff responded to the call light in Resident # 1's room, and he was observed unclothed and lying on top of Resident #2. Licensed nurses and Certified Nursing Assistants (CNAs) intervened. Resident #2's body fell to the floor and cardiopulmonary resuscitation measures (CPR) was initiated. The emergency management services (EMS) and the police department were notified. EMS arrived at the facility at approximately 3:50 AM. EMS continued CPR until 4:12 AM and then discontinued life resuscitating measures. The local police arrived at the facility at approximately 3:50 AM and interviewed Resident #1, licensed nurses and CNAs. The local police took statements and confirmed Resident #2 was deceased . The local coroner arrived to examine Resident # 2's body and then removed the body. Record review of the Behavior/Intervention Monthly Flow record for [DATE] for Resident #1 revealed behaviors to be monitored were physically/fighting aggressive, verbally aggressive (cursing), delusional, easily agitated, refusing care, and socially inappropriate with females (touching and remarks). There was no documentation of Residents #1's behavior of getting into other resident's beds listed to be monitored on the flow record. There was only one day of monitoring documentation on [DATE] for the month of May. Record review of the Face Sheet revealed the facility admitted Resident #1 on [DATE] with diagnoses that included Unspecified Mood Affective disorder, Unspecified Psychosis, and Anxiety disorder. Record review of the quarterly Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated that he was severely cognitively impaired. Section E- Mood revealed no behaviors checked. Section GG-Functional Abilities and Goals revealed the resident was independent with walking. Section: K-Swallowing/Nutritional Status revealed a height of 76 inches and weight of 486 pounds. Record review of the quarterly MDS Section C with an ARD on [DATE], revealed that Resident #2 had a BIMS score of 9 which indicated he had moderate cognitive impairment During a telephone interview with Registered Nurse (RN) #1 on [DATE] at 7:30 AM, confirmed on the morning of [DATE] at approximately 3:30 AM Resident #1 was placed on one-on-one monitoring but confirmed the resident was not on any special monitoring before the incident. Record review of the Departmental Note for Resident #1 revealed a note written by Licensed Practical Nurse (LPN) #3 on [DATE] at 2:25 AM, CNA #4 reported while she was making rounds that Resident #1 was noted lying in bed bedside roommate Resident #3. Resident #1 stated he was trying to keep his roommate warm. LPN #3 informed Resident he could not get into bed with other residents. Resident #1 stated, okay, I was just trying to help him. Record review of the Face Sheet revealed the facility admitted Resident #3 on [DATE] with diagnoses that included Deaf non-speaking and Autistic disorder. During a phone interview on [DATE] at 7:00 AM, LPN #3 revealed she was assigned to Resident #1 and #3 on the early morning of [DATE] and confirmed she did not increase monitoring of Resident #1 because it just did not cross her mind that Resident #1 could have attempted to abuse Resident #3. LPN #3 stated I see now why I should have recognized that. Record review of the Departmental Note for Resident #1by Social Service (SS) #1 dated [DATE] at 2:14 PM revealed, the writer was informed by a nurse that a CNA reported to her, she observed Resident #1 lying in bed with his roommate. Resident #1 stated he was trying to keep his roommate warm. The CNA reported she did not see the resident doing anything. Resident #1 was counseled by SS and the resident voiced understanding and will observe for any further behaviors. Record review of the Progress Notes for Resident #1 revealed a note by LPN #2 on [DATE] at 1:22 AM Resident #1 was observed in roommate's bed unclothed, refusing to get in his bed stating, there are rats over there, after multiple failed attempts to redirect Resident #1 finally put his mattress on the floor and laid down. During a telephone interview with LPN #2 on [DATE] at 5:00 PM, she revealed she was assigned to Resident #1 and Resident #3 on the early morning of [DATE] and confirmed she did not increase monitoring of either Resident #1 or #3 and did not notify the provider of the behavior. During an interview with the Social Service #1 on [DATE] at 1:00 PM, she revealed she was informed of the incident on [DATE], and she counseled Resident #1 not to do that again. She stated she felt Resident #1 meant no harm because he said he thought Resident #3 was his son and trying to keep him warm and was at times delusional. During a record review and interview with the [NAME] President of Operations on [DATE] at 2:00 PM, she revealed she was unable to find any 1:1 supervision monitoring for Resident #1 for the months of November and [DATE] at the time of the incidents. She provided only one document of 1:1 supervision for Resident #1 that was initiated after the death of Resident #2 on the morning of [DATE]. She also confirmed after review of Resident #1's behavior monitoring forms that staff were not completing the forms correctly, and it appeared the Resident was not monitored for behaviors. During an interview with the current Director of Nursing (DON) on [DATE] at 9:30 AM, she confirmed interventions should have been put in place for the incidents that occurred in November and [DATE] to protect the residents. She went on to say that if after the first incident on [DATE] Resident #3 was moved and interventions were put in place there may not have been another incident with Resident #1 getting into resident's beds. She confirmed Resident #1 should have been placed on 1-on-1 observation and the plan of care should have been updated for staff to be aware of the behavior to possibly intervene. The facility submitted an acceptable Removal Plan for the IJ on [DATE]. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Summary of events: The facility was informed by the state agency on [DATE] at 10:30 AM of five immediate jeopardies. The state agency provided the facility with IJ template for F600, F609, F657, F689 and F742. On [DATE], Resident #1 was clothed and observed in bed with Resident # 3. Resident # 3 was a vulnerable, deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident # 1's care plan for this behavior. [DATE], Resident # 1 was observed in Resident #3 bed unclothed. Resident # 3 was a vulnerable deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident #1's care plan for the behavior. On [DATE], at approximately 3:30 AM, the staff responded to the call light in Resident # 1's room, and he was observed unclothed and lying on top of Resident # 2. Licensed nurses and certified nursing assistants intervened. Resident # 2's body fell to the floor and cardiopulmonary resuscitation measures (CPR) were initiated. The emergency management services (EMS), and police department were notified. EMS arrived at the facility at approximately 3:50 AM. The emergency management services continued cardiopulmonary resuscitation measures until 4:12 AM and discontinued life resuscitating measures. The local police arrived at the facility at approximately 3:50 AM and interviewed Resident # 1, licensed nurses and certified nursing assistants (CNA). The local police took statements and confirmed Resident # 2 was deceased . The local coroner arrived to examine Resident # 2's body and removed the body from the facility with the understanding that an autopsy would be completed to determine the final cause of death. Corrective Actions: 1. On [DATE] Resident # 1 was placed on one-on- one (,d+[DATE]) supervision immediately. Psychiatric placement was initiated on [DATE] at approximately 8:00 am but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner on [DATE] at approximately 12:00 PM. Resident #1 remained on ,d+[DATE] supervision until he was discharged to the custody of the local police department on [DATE] at 3:45 PM. 2. The Administrator presented to the facility on [DATE] at approximately 4:40 AM and initiated an investigation with assigned licensed nurses and certified nursing assistants. 3. On [DATE] The Administrator notified the MS State Department of Health at 5:50 AM, Attorney General Office at 9:00 PM and Ombudsman on [DATE] at 11:08 AM. 4. An in-service was initiated for all staff on [DATE] at approximately 5:30 AM regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors. 5. A special resident council meeting was conducted on [DATE] 11:30 AM by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility. 6. On [DATE] at approximately 3:30 PM, the social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates. 7. On [DATE] an in-service was initiated at approximately 10:00 am by the [NAME] President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining 1-on-1 supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses was instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received. 8. On [DATE] at 9:00 AM, the [NAME] President of Operations in serviced the Administrator and Director of Nurses at 9:00 AM on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies. 9. On [DATE] at 10:15 AM, the [NAME] President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored. 10. On [DATE] at approximately 11:30 AM, an interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns. 11. A 100% audit was initiated on [DATE] at 1:30 PM by the social services department to ensure that all Residents had compatible roommates. No issues identified. 12. A 100% audit was conducted on [DATE] at 2:00 PM by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place. 13. The Administrator reported the [DATE] incident involving Resident # 1 and Resident # 3 to the MS State Department of Health at 2:13 PM on [DATE]. 14. An emergency quality assurance committee met on [DATE] at 2:50 PM. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional [NAME] President. The facility discussed the current survey IJ outcomes. 5 IJ cites for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident # 1 had previous behavioral issues on [DATE] with Resident # 3. Resident # 1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified as of [DATE] to include protecting residents from others who get into their beds by intervening and providing 1-on-1 supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required. 14. The Ombudsman was notified of the [DATE] on [DATE] at 3:27 PM by the Administrator. 15. The Administrator reported the [DATE] incident involving Resident # 1 and Resident # 3 to the Attorney General Office online system on [DATE] at 3:40 PM. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of [DATE] and the Immediate Jeopardy was removed [DATE]. Validation: SA Validations were made onsite during the complaint investigation CI MS #25192. On [DATE], the SA surveyor verified through staff and resident interview, record review, sign-in sheets, and in-service reviews that all corrective actions had been taken by the facility to remove the IJ during the survey on [DATE] and the IJ was removed on [DATE].

Based on observation, interview, policy review, and record review, the facility failed to ensure controlled medications were stored in a secure locked container for two (2) of six (6) narcotic storage containers. Findings Include: Review of the facility policy, Medication Storage revealed, Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy. Observation on 11/28/23 11:03 AM, of the [NAME] Wing Nurses Station medication room revealed a medication refrigerator with a red lock box for controlled drugs. The medication box was not locked but was secured to the refrigerator shelf. The box contained 12 single dose vials of Lorazapam and one (1) multidose vial of Lorazapam. The observation was confirmed by Licensed Practical Nurse (LPN ) #3 and LPN #4. Neither LPN had a key to lock the box. LPN #3 said the box is never locked but confirmed the medications are counted at shift change. Observation on 11/28/23 11:20 AM, of East Wing Nurses Station medication room with LPN #2 revealed a medication refrigerator with a red controlled medication lock box containing 17 Lorazapam single use vials and 2 multidose vials of Lorazapam. This box was locked but was not secured to the refrigerator. LPN #2 stated the refrigerator controlled medication box had never been secured to the refrigerator since he had worked here. Observation on 11/29/23 at 10:27 AM revealed East Wing controlled medication lock box remained unsecured to the refrigerator and [NAME] Wing box remained unlocked. On 11/29/23 01:00 PM, a phone interview with the Pharmacy Consultant revealed the narcotic lock box is located behind two locked doors; the med room door and the refrigerator door. The pharmacy consultant stated the lock box must be attached to the refrigerator. He was not aware of the box not being attached to the refrigerator on the East Wing. Interview on 11/29/23 01:03 PM with the Administrator, revealed she was unaware of the controlled medication boxes in the medication rooms on [NAME] Hall being unlocked or that the controlled medication box was not secured on the East Wing. She stated she was going to take care of the boxes being unlocked and unattached immediately.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to maintain clean ice machines, as evidenced by observations during the annual survey of two (2) of two (2) unclean ice machines, for 96 of 105 residents in the nursing facility who use ice. Findings Include: Review of the facility policy titled, Ice Handling and Cleaning, for the Guideline and Procedure Manual . 2020, revealed Guideline: Ice will be stored and served to residents in a sanitary manner. Procedure: . 6. Ice machine will be emptied at least quarterly and thoroughly cleaned with an approved sanitizer to remove any settlement or mineral build-up . An observation on 11/28/23 at 10:35 AM, of the ice machine in the kitchen, revealed a black buildup that was located on the upper right side of the opening of the ice container under the door to the ice storage bin. An observation and interview on 11/28/23 at 10:38 AM, with the Kitchen Aide #2, revealed her use of a wet white paper towel to wipe over the black buildup that was located on the upper right side of the opening of the ice container under the door to the ice storage bin and the black residue was observed to come off on the paper towel. She confirmed the ice machine was not clean. During an observation of the kitchen ice machine and interview with Maintenance #1 on 11/28/23 at 10:42 AM, he confirmed the black buildup that was located on the upper right side of the opening of the ice container under the door to the ice storage bin. The observation also revealed there was black mucus consistency buildup inside the top of the ice machine, that was observed on the bottom of the white side cover panel located over the right side of the door of the ice bin. Also, the observation revealed black and yellow buildup on the white panel that covered the element of the ice machine that freezes the ice cubes, black mucus consistency buildup that covered the white panel above the ice freezing element and the water that ran through the ice machine was observed to flow over the black mucus consistency buildup, and flowed down over the ice freezing element. The outer edges of the white plastic case that surrounded the ice freezing element were observed to have a black mucus consistency buildup. He confirmed the ice machine needed to be cleaned, revealed he was aware there was buildup collecting in the ice machine at a faster pace, and had changed his schedule to clean the ice machine every three (3)months. He revealed he was originally cleaning the ice machine every 6 months. Maintenance #1 noted he would complete a task check off in the computer, for each ice machine, and was not able to document cleaning details. State Agency and Maintenance #1 completed a second observation of the ice machine located in the East Wing nurse's station. Maintenance #1 revealed he cleaned the East Wing ice machine three (3) weeks prior to survey, because it was broken. There was black residue observed in the top/inside of the machine located on the top and bottom white plastic case that surrounded the ice making element of the ice machine. The observation revealed that the water flowed over the black residue at the bottom of the white plastic case. Maintenance #1 confirmed there was black residue observed in the top/inside of the machine located on the top and bottom white plastic case that surrounded the ice making element of the ice machine. The observation revealed that the water flowed over the black residue at the bottom of the white plastic case. He confirmed that he did not completely clean the East Wing ice machine. An observation and interview on 11/28/23 at 10:51 AM with the Administrator confirmed the black buildup that was located on the upper right side of the opening of the kitchen ice container under the door to the ice storage bin. She also confirmed there was black mucus consistency buildup inside the top of the kitchen ice machine, that was observed on the bottom of the white side cover panel located over the right side of the door of the ice bin. The Administrator further confirmed the observation of the black and yellow buildup on the white panel that covered the element of the kitchen ice machine that freezes the ice cubes, confirmed the observation of the black mucus consistency buildup that covered the white panel above the ice freezing element and the water that ran through the kitchen ice machine was observed to flow over the black mucus consistency buildup, and flowed down over the ice freezing element. The Administrator also confirmed the outer edges of the white plastic case that surrounded the ice freezing element, of the kitchen ice machine, had a black mucus consistency buildup. She further confirmed there was black residue in the top/inside of the East Wing ice machine located on the top and bottom white plastic case that surrounded the ice making element of the East Wing ice machine and confirmed that the water flowed over the black residue at the bottom of the white plastic case. The Administrator confirmed that Maintenance #1 was not adequately cleaning the ice machines and there was a possibility of sickness for the residents due to drinking fluids off the ice that was made in the unclean ice machines. Record review of the Work History Report, revealed The record review revealed there was one (1) ice machine cleaning task completed in the months of October 2023, August 2023, and July 2023. The record review did not reveal which ice machine was cleaned.

Based on observation and interview, the facility failed to maintain a dining experience that promotes dignity as evidenced by staff standing while providing feeding assistance to one (1) of three (3) residents who required feeding assistance in the dining room. Resident #38. Findings Include: An observation of the lunch meal service in the west dining room for Resident #38 on 11/28/23 at 12:48 PM, revealed that the resident was sitting in his wheelchair at the table and Certified Nursing Assistant (CNA) #2 was standing beside the resident feeding him lunch. Upon interview with CNA #2 on 11/28/23 at 12:50 PM, she stated that she should not be standing while feeding Resident #38. She stated that she should be sitting at eye level while feeding so the resident does not feel intimidated with staff standing over him. CNA #2 stated that she only stands when there are not enough chairs in the dining area to sit in. An observation of the breakfast meal service in the west dining area for Resident # 38 on 11/29/23 at 8:13 AM, revealed that the resident was sitting in his wheelchair at the table with CNA #5 standing beside the resident feeding him breakfast. Upon interview with CNA #5 on 11/29/23 at 8:14 AM, she agreed that she should not be standing to feed the resident. CNA #5 stated that she only stands while feeding residents if they do not have chairs to sit in. During an interview with CNA #4 on 11/29/23 at 8:16 AM, she stated that they frequently do not have chairs in the west dining room sit to in and have to stand to feed residents. During an interview with the Director of Nursing (DON) and Administrator on 11/29/23 at 8:40 AM, they both agreed that staff should not be standing while feeding residents as it does not promote the resident's dignity. An interview with the Administrator on 11/30/23 at 1:00PM, and review of the statement provided on facility letterhead and signed by the Administrator on 11/30/23 revealed, (Proper Name of Facility) does not have an applicable policy in relation to dining and feeding. Record review of the Face Sheet for Resident #38 revealed that he was admitted to the facility on [DATE] with diagnoses that include Dementia and Neurofibromatosis. Record review of Resident #38 's Annual Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 9/1/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact.

Based on record review, interviews and facility policy/procedure review the facility failed to transition a Resident to post-discharge care for one (1) of five (5) discharged residents sampled. Resident #1 The facility failed to ensure Resident #1 had available caregiver support and a safe post-discharge destination, failed to notify the Resident Representative (RR) of Resident #1's discharge, and failed to provide instructions on post discharge care and medications. The SA identified an Immediate Jeopardy (IJ) that began on 12/29/22 when the facility failed to ensure a safe discharge for Resident #1. Two (2) staff members transported Resident #1 to his RR's home per the facility van. The staff members did not see a person at the home. Both staff members stated that Resident #1 had medications in a bag. There was a Ring doorbell system and a female voice said to facility staff that no one was at home. The facility staff left Resident #1 sitting in a chair on the front porch of the RR's home. On 1/17/23 at 1:30 PM, the SA notified the Administrator, Director of Nurses and Regional [NAME] President of the IJ and provided the facility with the IJ template. The IJ existed at: CFR 483.21 (c) (1) Discharge Planning (F660)-Scope and Severity J. The facility submitted an acceptable Removal Plan on 1/19/23, in which the facility alleged all corrective action to remove the IJ were completed on 1/19/23 and IJ removed on 1/19/23. The SA validated the Removal Plan on 1/21/23, and determined the IJ was removed on 1/19/23, prior to exit. Therefore, the scope and severity for CFR 483.21 (c) (1) Discharge Planning (F660) was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review on of the facility's Discharge and transfer policies-Involuntary policy/procedure, last revised 7/18 revealed the Responsibility: All staff, monitored by the Director of Nursing and Executive Director. The Procedure: 4. The facility will provide sufficient orientation to residents to ensure safe and orderly transfer or discharge from the facility including an opportunity to participate in deciding where to go. Record review of the Policy/procedure of the facility's Discharge Medications last revised 8/16 revealed the policy. Discharge Medications Policy: Medications are sent with the resident upon discharge only under conditions that protect the resident and ensure compliance with the law. Record review of the Care Plan with a problem onset date of 06/17/2019 revealed, Problem/Need: I/Rp (Responsible party) desired length of stay is long term. I/Rp and care planning team have determined that d/c (discharge) to community is not feasible. Goal and Target Date: Resident/Rp goal/desire: Plan/desire is to remain in this facility through NRD (next review date) .10/22 CPOC (continue Plan of Care) thru 1/23 . Record review of the facility investigation revealed, .Facility will utilize appropriate action to discharge (formal name of resident) to another institution to meet his needs . Record review of the Face Sheet revealed Resident # 1 was readmitted to the facility on [DATE]. His admitting diagnosis included Schizophrenia, Bipolar Disorder, Other Seizures, Hypothyroidism. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) was 10/4/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was cognitively intact. Record review of the care plan revealed for behaviors of suicidal ideation, pacing, easily agitated, verbally/physically aggressive, hallucinations, paranoid thinking. His Responsible Party (RP) was his sister. Record review of the medical record revealed Resident #1 had returned to the facility on [DATE] from a Geri-psych unit admission on 12/26/22. He was discharged from the Geri-psych unit on 12/29/22 due to refusal to take medications and participate in his treatment. He arrived at the nursing home and refused to go to his room. He was requesting to discharge from the nursing home and go to his RR's home in [NAME], Ms. The facility attempted three (3) times to contact the RR with no success. Resident #1 was transported in the nursing homes van by 2 staff members to the RR's home and left outside the home, unattended. Review of Internet site www.wunderground.com on 1/12/23 for the weather in [NAME], MS on 12/29/22 revealed the temperature high-73 degrees Fahrenheit (F), low temperatures 58 degrees F, zero (0) rain and the maximum winds were 20 Miles Per Hour (MPH). Record review of Resident #1's Discharge Summary/Instructions dated 12/29/22, revealed there are no medications listed as being sent home with the resident and there is nothing listed under the Education regarding medications/treatments, exercises, or other services sections of the Discharge Summary. Interview with the Administrator on 1/11/23 at 11:44 AM, revealed that when Resident #1 was sent to the Geri-psych for evaluation and treatment on 12/26/22. The Administrator stated We sent him with his medications to senior care. He returned with his same medications. I saw the meds with him when he returned here. The facility did not send him home with any medications. That's why there were no meds on the discharge summary. Interview with the Facility Transporter on 1/11/23 at 10:40 AM, revealed that the Maintenance Assistant went with him to transfer Resident #1 to his RR's home in Bryam, MS which is located approximately 2 to 2 1/2 hours from the nursing facility on 12/29/22 in the facility van. He stated We didn't take any paperwork. Resident #1 had a bag of meds with him. He stated after arriving at the RR's home a female talked through the Ring camera. She said a name, but I never understood it. No, he didn't go inside. He sat on the porch in front of the camera. The nursing home Administrator gave me the address of where to take him. I did call the facility saying there was no one coming to the door. I told the facility staff that someone was talking to me through the door Ring camera. He was unable to recall who he spoke to at the nursing home when he called to inform the facility that no one was coming to the door. Interview with the Maintenance Assistant on 1/11/23 at 10:55 AM, revealed he was with the Facility Transporter transferring Resident #1 to his RR's home. He stated the Facility Transporter was talking to someone through the Ring doorbell. Yes, there was a zip-lock bag with medications. They were his meds from the nursing home. Yes, I saw pills. The person speaking on the Ring camera said his sister was not there. He stated that Resident #1 was wearing a shirt, pants, shoes, socks, jacket, and hat. He stated that Resident #1 was sitting in a chair on the front porch in front of the door when we left. His belongings were beside him. The SA conducted an interview with the RR of Resident #1 on 1/12/23 at 8:31 AM, revealed that she was not home when the nursing home van dropped Resident #1 off at her house. She stated she was out of state at the time. She stated, I had to call 911 and the police and ambulance had to come. There was no one home when they left him. The house was locked. I had not been contacted by the nursing home prior to him coming home. She did state that there had been a family conference 24 days earlier and discharge of Resident #1 was discussed. She stated, the administrator said 'well, he's got to go. She said Resident #1 does have behaviors if provoked. She revealed that the police contacted an ambulance service and Resident #1 was admitted to the hospital and remains there at this time. She stated it took the police 2 hours to get to her residence to make initial contact with Resident #1. Interview with the facility Housekeeping Supervisor on 1/12/23 at 1:55 PM, revealed he was in the BOM's office on 12/29/22 when Resident #1 said he wanted to go home. He stated he was agitated, saying he wanted to go home. (Name of BOM) tried to call the (RR) with no answer a couple of times. They offered to take him to his room. The Administrator said for him to let her read a paper to him about leaving AMA. He signed it, said he understood it. He left in the facility van to go home. In an interview with Licensed Practical Nurse (LPN) #2 on 1/12/23 at 3:18 PM, revealed that she contacted the Medical Director/Resident #1's primary physician to let him know that Resident #1 wanted to go home. I called (name of Medical Director/Primary Physician) and let him know Resident #1 wanted to go home to his sister's home and needed an order for Home Health and the discharge. He said Ok. Resident #1 had already left when I called (name of Medical Director/Primary Physician). Interview with the Medical Director and Primary Physician at 1:20 PM on 1/12/23, revealed that he was unaware the facility van left Resident #1 on his RR's front steps without anyone at home. Interview with the Administrator on 1/13/23 at 12:10 PM, revealed We never sent a 30 day discharge letter related to Resident #1. We discussed it after a meeting with his RR/sister but decided against it. We wanted to wait on that. Removal Plan: Failure Statement: Facility failed to ensure residents were protected from physical abuse when Resident #1, who had a pattern and history of aggression, assaulted Resident #2 and #8 causing injury. The facility failed to ensure Resident #1 was transferred/discharged in a safe orderly manner with sufficient instruction related to medications. Facility failed to ensure Resident #1 Responsible Representative was notified of detailed discharge planning, and arrangements for post-discharge care including medication instruction. Summary: On 09/08/2022 Resident #1 began having episodes of aggression. Resident #1 was involved in a physical altercation with resident #8 who was the aggressor. Resident #8 sustained a laceration to the right eyebrow. Resident #1 was transferred to Geri-psych #1 and Resident #8 was transferred to Geri-psych #2. Resident #8 was assessed by Charge Nurse #3. First aide was provided by Charge Nurse #3 prior to transfer to Geri-psych #2. On 12/22/2022 Resident #1 was involved in an altercation with Resident #2 resulting in injury to nose and face. Resident #1 and #2 were assessed by Director of Nursing and Charge Nurse #1 prior to sending to Hospital for evaluation. Resident #1 was returned to facility on 12/23/22 and placed on one on one observation. Resident #2 was treated at hospital for nasal fracture and facial swelling and returned to facility on 12/22/2022 at 9:09 p.m. Resident #1 remained on one on one observation at facility until discharged to Geri-psych #1 on 12/26/2022 for evaluation and treatment. He returned to facility on 12/29/2022 at which time he refused to be readmitted to facility and signed himself out Against Medical Advice. Facility transported resident to sisters home at his request on 12/29/2022 at 1:30 p.m. by facility transporters in the facility van with two attendants. Resident #1 was left unattended. Resident #1 had a zip lock bag with medication on his person when returned from Geri-Psych #1. Resident #1 medications were not reconciled by facility due to resident #1 refusal to readmit to facility. Medical Director was notified of Resident #1 leaving facility Against Medical Advice on 12/29/2022 at 2:36p.m. by Staff Development Coordinator. Ombudsman notified of Resident #1 leaving facility Against Medical Advice on 12/29/2022 at 5:52 p.m. by Administrator. Facility's action: 1.Abuse and neglect in-service for all staff completed by Staff Development Coordinator in-servicing starting on 12/22/22 through 12/25/22. The staff verbalized understanding the importance of protecting all residents from abuse to include resident to resident abuse and how to deal with combative residents. No staff will be allowed to work until completion of in-service. 2. Licensed nurses, and Social Services in-serviced on safe and orderly discharge with sufficient instruction related to medications will be completed by 01/17/23 by Staff Development, Director of Nursing and Administrator. Social Services or licensed nursing staff will not be allowed to work until in-serviced. On 01/12/2023 through 1/14/2023 an Staff Development Nurse in-serviced Minimum Data Set Nurse, Social Services, and Nursing Service on baseline care plan policy. 3. Resident #1 was placed on one on one observation starting 12/22/22 while in facility until transferred to Geri-psych hospital for evaluation 12/26/22. Then returned from Geri-psych #1 on 12/29/22 and Resident #1 left Against Medical Advice prior to readmission. 4. Head to toe assessment was completed on Resident #8 by Charge Nurse #3 on 09/08/2022. Head to toe assessments of Residents #1 and #2 was completed by Charge Nurse #1 and Director of Nursing on 12/22/22 . On 09/08/22, Resident #8 received in-house treatment of injury to right eyebrow and was later transferred to Geri-psych #2 for psych evaluation on 09/08/22 at 7:11 a.m. Residents #1 and #2 were sent to hospital for evaluation and treatment 12/22/22. 5. All residents were assessed for post traumatic issues related to abuse or neglect by Social Services, this was completed on 12/23/2022. No other residents were identified. 6. On 1/17/23, Staff Development Coordinator, Director of Nursing, and Administrator in-serviced Licensed nurses to ensure sufficient instruction will be given to resident or their representative related to discharge medications. 7. Administrator and Director of Nursing in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident by Regional [NAME] President on 01/13/2023. 8. Social Services and facility van transporters in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident. Staff Development Coordinator completed an in-service 1/17/23 by 5 p.m. Social Service or van drivers will not be allowed to transport or transfer any resident until in-service is completed. 9. Disciplinary counseling completed on Administrator for failure to ensure Resident Representative was notified of discharge of Resident #1. Failure to ensure safe discharge of Resident #1 with medication reconciliation. Completed by Regional [NAME] President on 01/13/2023. 10. All residents discharged home was audited from July 15, 2022 through 12/29/2022 to ensure safe discharge with medication and care instruction. Only 1 resident was discharged home during this time frame, there were no issues noted. This audit was completed by Director of Nursing on 01/13/2023. Quality Assurance: 1. An emergency Quality Assurance Performance Improvement Committee meeting was held on 12/22/2022 at 9:30 a.m. until 10:30 a.m. to review the resident to resident abuse between Resident #1 and #2. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, RN Unit Manager, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. 2. Facility held a second emergency Quality Assurance Performance Improvement Committee meeting on 01/17/2023 4:00p.m. to review immediate jeopardy F-tag .600, F623, F660. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed discharge look back from 07/15/2022 through 12/29/22 audit was performed Director of Nursing. One issues noted. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. 3. Facility held a third emergency Quality Assurance Performance Improvement Committee was held on 01/18/2023 at 3:30 p.m. to review immediate jeopardy F-tag 835. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed Safe Discharge policies and medications. No issues or concerned voiced. There were no new recommendations. The facility alleges compliance as reported to the Department of Health on 1/19/2023. VALIDATION: 1. Record review and staff interviews on 1/21/23 confirmed the facility had conducted Abuse and neglect in-service for all staff completed by Staff Development Coordinator in-servicing starting on 12/22/22 through 12/25/22. During staff interviews on 1/21/23, staff verbalized understanding the importance of protecting all residents from abuse to include resident to resident abuse and how to deal with combative residents. No staff will be allowed to work until completion of in-service. 2. Record review and staff interviews on 1/21/23 confirmed that Licensed nurses, and Social Services were in-serviced on safe and orderly discharge with sufficient instruction related to medications completed by 01/17/23 by Staff Development, Director of Nursing and Administrator. Social Services or licensed nursing staff will not be allowed to work until in-serviced. On 01/12/2023 through 1/14/2023 an Staff Development Nurse in-serviced Minimum Data Set Nurse, Social Services, and Nursing Service on baseline care plan policy. 3. Record review and interview on 1/21/23 confirmed that Resident #1 was placed on one on one observation starting 12/22/22 while in facility until transferred to Geri-psych hospital for evaluation 12/26/22. Then returned from Geri-psych #1 on 12/29/22 and Resident #1 left Against Medical Advice prior to readmission. 4. Record review and staff interview on 1/21/23 confirmed that a Head to toe assessment was completed on Resident #8 by Charge Nurse #3 on 09/08/2022. Head to toe assessments of Residents #1 and #2 was completed by Charge Nurse #1 and Director of Nursing on 12/22/22 . On 09/08/22, Resident #8 received in-house treatment of injury to right eyebrow and was later transferred to Geri-psych #2 for psych evaluation on 09/08/22 at 7:11 a.m. Residents #1 and #2 were sent to hospital for evaluation and treatment 12/22/22. 5. Record review and staff interviews on 1/21/23 confirmed that all residents were assessed for post traumatic issues related to abuse or neglect by Social Services, this was completed on 12/23/2022. No other residents were identified. 6. Staff interviews and record review on 1/21/23 confirmed that on 1/17/23, Staff Development Coordinator, Director of Nursing, and Administrator in-serviced Licensed nurses to ensure sufficient instruction will be given to resident or their representative related to discharge medications. 7. Record review and staff interviews on 1/21/23 confirmed that the Administrator and Director of Nursing in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident by Regional [NAME] President on 01/13/2023. 8. Staff interview and record review on 1/21/23 confirmed that Social Services and facility van transporters were in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident. Staff Development Coordinator completed an in-service 1/17/23 by 5 p.m. Social Service or van drivers will not be allowed to transport or transfer any resident until in-service is completed. 9. Staff interview and record review on 1/21/23 confirmed that Disciplinary counseling completed on Administrator for failure to ensure Resident Representative was notified of discharge of Resident #1. Failure to ensure safe discharge of Resident #1 with medication reconciliation. Completed by Regional [NAME] President on 01/13/2023. 10. Record review and staff interviews on 1/21/23 confirmed that all residents discharged home was audited from July 15, 2022 through 12/29/2022 to ensure safe discharge with medication and care instruction. Only 1 resident was discharged home during this time frame, there were no issues noted. This audit was completed by Director of Nursing on 01/13/2023. Record review and staff interviews on 1/21/23 confirmed that an emergency Quality Assurance Performance Improvement Committee meeting was held on 12/22/2022 at 9:30 a.m. until 10:30 a.m. to review the resident to resident abuse between Resident #1 and #2. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, RN Unit Manager, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. Staff interviews and record review on 1/21/23 confirmed that the facility held a second emergency Quality Assurance Performance Improvement Committee meeting on 01/17/2023 4:00p.m. to review immediate jeopardy F-tag .600, F623, F660. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed discharge look back from 07/15/2022 through 12/29/22 audit was performed Director of Nursing. One issues noted. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. Record review and staff interviews on 1/21/23 confirmed that the facility held a third emergency Quality Assurance Performance Improvement Committee was held on 01/18/2023 at 3:30 p.m. to review immediate jeopardy F-tag 835. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed Safe Discharge policies and medications. No issues or concerned voiced. There were no new recommendations. Staff interviewed on 1/21/23 were seven (7) Certified Nurse Aides (CNA), two (2) Registered Nurses (RN), three (3) Licensed Practical Nurses (LPN), one (1) Business Office Manager (BOM), 1 Social Worker (SW), 1 Minimum Data Set LPN, 1 Administrator, 1 Director of Nurses, 2 Covid Screeners.

Based on record review, interviews and policy/procedure review the facility failed to notify the Resident Representative (RR) of Resident #1's discharge and failed to provide the reasons in writing and in a language and manner they understand for one (1) of five (5) discharged residents sampled. The facility's failure to notify Resident #1's (RR) at the time of the discharge placed Resident #1 in a situation that would likely cause serious injury, harm, impairment, or death. The SA identified an Immediate Jeopardy (IJ) that began on 12/29/22 when the facility failed to ensure a safe discharge for Resident #1. Two (2) staff members transported Resident #1 to his RR ' s home per the facility van. The staff members did not see a person at the home. Both staff members stated that Resident #1 had medications in a bag. There was a Ring doorbell system and a female voice said to facility staff that no one was at home. The facility staff left Resident #1 sitting in a chair on the front porch of the RR's home. On 1/17/23 at 1:30 PM, the SA notified the Administrator, Director Of Nurses and Regional [NAME] President of the IJ and provided the facility with the IJ template. The IJ existed at: CFR 483.15 (c) (3) Discharge Rights (F623)-Scope and Severity J. The facility submitted an acceptable Removal Plan on 1/19/23, in which the facility alleged all corrective action to remove the IJ were completed on 1/19/23 and IJ removed on 1/19/23. The SA validated the Removal Plan on 1/21/23, and determined the IJ was removed on 1/19/23, prior to exit. Therefore, the scope and severity for CFR 483.15 (c) (3) Discharge Rights (F623), was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review on 1/12/23 of the facility's Discharge and transfer policies-Involuntary policy/procedure, last revised 7/18 revealed the Responsibility: All staff, monitored by the Director of Nursing and Executive Director. The Procedure: 4. The facility will provide sufficient orientation to residents to ensure safe and orderly transfer or discharge from the facility including an opportunity to participate in deciding where to go. Policy/procedure of the facility's Discharge Medications last revised 8/16 revealed the policy Discharge Medications Policy: Medications are sent with the resident upon discharge only under conditions that protect the resident and ensure compliance with the law. Record review of the Care Plan with a problem onset date of 06/17/2019 revealed, Problem/Need: I/Rp (Responsible party) desired length of stay is long term. I/Rp and care planning team have determined that d/c (discharge) to community is not feasible. Goal and Target Date: Resident/Rp goal/desire: Plan/desire is to remain in this facility through NRD (next review date) .10/22 CPOC (continue Plan of Care) thru 1/23 . Record review of the facility investigation revealed, .Facility will utilize appropriate action to discharge (formal name of resident) to another institution to meet his needs . Record review of the Face Sheet revealed Resident # 1 was readmitted to the facility on [DATE]. His admitting diagnosis included Schizophrenia, Bipolar Disorder, Other Seizures, Hypothyroidism. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) was 10/4/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was cognitively intact. Record review of the care plan revealed for behaviors of suicidal ideations, pacing, easily agitated, verbally/physically aggressive, hallucinations, paranoid thinking. Record review of the medical record for Resident #1 revealed he had returned to the facility on [DATE] from a Geri-psych unit admission on 12/26/22. He was discharged from the Geri-psych unit on 12/29/22 due to refusal to take medications and participate in his treatment. He arrived at the nursing home and refused to go to his room. He was requesting to discharge from the nursing home and go to his RR ' s home in [NAME], Ms. The facility attempted three (3) times to contact the RR with no success. Resident #1 was transported in the nursing homes van by 2 staff members to the RR's home and left outside the home, unattended. Review of the internet site www.wunderground.com for the weather in [NAME], MS on 12/29/22 revealed the temperature high-73 degrees Fahrenheit (F), low temperatures 58 degrees F, zero (0) rain and the maximum winds were 20 Miles Per Hour (MPH). Record review of Resident #1's Discharge Summary/Instructions dated 12/29/22, revealed there are no medications listed as being sent home with the resident and there is nothing listed under the Education regarding medications/treatments, exercises, or other services sections of the Discharge Summary. Interview with the Administrator on 1/11/23 at 11:44 AM, revealed that when Resident #1 was sent to the Geri-psych for evaluation and treatment on 12/26/22. The Administrator stated We sent him with his medications to senior care. He returned with his same medications. I saw the meds with him when he returned here. The facility did not send him home with any medications. That's why there were no meds on the discharge summary. Interview with the Facility Transporter on 1/11/23 at 10:40 AM, revealed that the Maintenance Assistant went with him to transfer Resident #1 to his RR ' s home in Bryam, MS on 12/29/22 in the facility van. He stated We didn ' t take any paperwork. Resident #1 had a bag of meds with him. He stated after arriving at the RR ' s home a female talked through the Ring camera. She said a name, but I never understood it. No, he didn ' t go inside. He sat on the porch in front of the camera. The nursing home Administrator gave me the address of where to take him. I did call the facility saying there was no one coming to the door. I told the facility staff that someone was talking to me through the door Ring camera. He was unable to recall who he spoke to at the nursing home when he called to inform the facility that no one was coming to the door. Interview with the Maintenance Assistant on 1/11/23 at 10:55 AM, revealed he was with the Facility Transporter transferring Resident #1 to his RR ' s home. He stated the Facility Transporter was talking to someone through the Ring doorbell. Yes, there was a zip-lock bag with medications. They were his meds from the nursing home. Yes, I saw pills. The person speaking on the Ring camera said his sister was not there. He stated that Resident #1 was wearing a shirt, pants, shoes, socks, jacket, and hat. He stated that Resident #1 was sitting in a chair on the front porch in front of the door when we left. His belongings were beside him. The SA conducted an interview with the RR of Resident #1 on 1/12/23 at 8:31 AM, revealed that she was not home when the nursing home van dropped Resident #1 off at her house. She stated she was out of state at the time. She stated, I had to call 911 and the police and ambulance had to come. There was no one home when they left him. The house was locked. I had not been contacted by the nursing home prior to him coming home. She did state that there had been a family conference 24 days earlier and discharge of Resident #1 was discussed. She stated, the Administrator said Well, he's got to go. She said Resident #1 does have behaviors if provoked. She revealed that the police contacted an ambulance service and Resident #1 was admitted to the hospital and remains there at this time. She stated it took the police 2 hours to get to her residence to make initial contact with Resident #1. Interview with the facility Business Office Manager (BOM) on 1/12/23 at 1:42 PM, revealed that when Resident #1 returned from the Geri-psych unit on 12/29/22, he came into her office. She stated (name of Administrator) came in and talked to him and he said he wanted to go home to Drew, MS. He then said take him to his sister ' s house and gave (name of administrator) the phone number. I was looking at his Face Sheet and he gave the right number for his sister/RR. I called her number 2 or three times. I didn ' t get an answer. The voicemail wouldn ' t let me leave a message. He kept saying he wanted to go to his sister's house. Interview with the facility Housekeeping Supervisor on 1/12/23 at 1:55 PM, revealed he was in the BOM ' s office on 12/29/22 when Resident #1 said he wanted to go home. He stated he was agitated, saying he wanted to go home. (Name of BOM) tried to call the (RR) with no answer a couple of times. They offered to take him to his room. The Administrator said for him to let her read a paper to him about leaving AMA. He signed it, said he understood it. He left in the facility van to go home. Interview with Licensed Practical Nurse (LPN) #2 on 1/12/23 at 3:18 PM, revealed that she contacted the Medical Director/Resident #1 ' s primary physician to let him know that Resident #1 wanted to go home. I called (name of Medical Director/Primary Physician) and let him know Resident #1 wanted to go home to his sister ' s home and needed an order for Home Health and the discharge. He said Ok. Resident #1 had already left when I called (name of Medical Director/Primary Physician). Interview with the Medical Director and Primary Physician at 1:20 PM on 1/12/23, revealed that he was unaware the facility van left Resident #1 on his RR's front steps without anyone at home. Interview with the Administrator on 1/13/23 at 12:10 PM, revealed We never sent a 30 day discharge letter related to Resident #1. We discussed it after a meeting with his RR/sister but decided against it. We wanted to wait on that. Failure Statement: Facility failed to ensure residents were protected from physical abuse when Resident #1, who had a pattern and history of aggression, assaulted Resident #2 and #8 causing injury. The facility failed to ensure Resident #1 was transferred/discharged in a safe orderly manner with sufficient instruction related to medications. Facility failed to ensure Resident #1 Responsible Representative was notified of detailed discharge planning, and arrangements for post-discharge care including medication instruction. Summary: On 09/08/2022 Resident #1 began having episodes of aggression. Resident #1 was involved in a physical altercation with resident #8 who was the aggressor. Resident #8 sustained a laceration to the right eyebrow. Resident #1 was transferred to Geri-psych #1 and Resident #8 was transferred to Geri-psych #2. Resident #8 was assessed by Charge Nurse #3. First aide was provided by Charge Nurse #3 prior to transfer to Geri-psych #2. On 12/22/2022 Resident #1 was involved in an altercation with Resident #2 resulting in injury to nose and face. Residents #1 and #2 were assessed by Director of Nursing and Charge Nurse #1 prior to sending to Hospital for evaluation. Resident #1 was returned to facility on 12/23/22 and placed on one-on-one observation. Resident #2 was treated at the hospital for nasal fracture and facial swelling and returned to facility on 12/22/2022 at 9:09 p.m. Resident #1 remained on one-on-one observation at facility until discharged to Geri-psych #1 on 12/26/2022 for evaluation and treatment. He returned to facility on 12/29/2022 at which time he refused to be readmitted to facility and signed himself out Against Medical Advice. Facility transported resident to sisters ' home at his request on 12/29/2022 at 1:30 p.m. by facility transporters in the facility van with two attendants. Resident #1 was left unattended. Resident #1 had a zip lock bag with medication on his person when returned from Geri-Psych #1. Resident #1 medications were not reconciled by facility due to resident #1 refusal to readmit to facility. Medical Director was notified of Resident #1 leaving facility Against Medical Advice on 12/29/2022 at 2:36p.m. by Staff Development Coordinator. Ombudsman notified of Resident #1 leaving facility Against Medical Advice on 12/29/2022 at 5:52 p.m. by Administrator. Facility's action: 1.Abuse and neglect in-service for all staff completed by Staff Development Coordinator in-servicing starting on 12/22/22 through 12/25/22. The staff verbalized understanding the importance of protecting all residents from abuse to include resident to resident abuse and how to deal with combative residents. No staff will be allowed to work until completion of in-service. 2.Licensed nurses, and Social Services in-serviced on safe and orderly discharge with sufficient instruction related to medications will be completed by 01/17/23 by Staff Development, Director of Nursing and Administrator. Social Services or licensed nursing staff will not be allowed to work until in-serviced. On 01/12/2023 through 1/14/2023 an Staff Development Nurse in-serviced Minimum Data Set Nurse, Social Services, and Nursing Service on baseline care plan policy. 3. Resident #1 was placed on one-on-one observation starting 12/22/22 while in facility until transferred to Geri-psych hospital for evaluation 12/26/22. Then returned from Geri-psych #1 on 12/29/22 and Resident #1 left Against Medical Advice prior to readmission. 4. Head to toe assessment was completed on Resident #8 by Charge Nurse #3 on 09/08/2022. Head to toe assessments of Residents #1 and #2 was completed by Charge Nurse #1 and Director of Nursing on 12/22/22. On 09/08/22, Resident #8 received in-house treatment of injury to right eyebrow and was later transferred to Geri-psych #2 for psych evaluation on 09/08/22 at 7:11 a.m. Residents #1 and #2 were sent to hospital for evaluation and treatment 12/22/22. 5. All residents were assessed for post traumatic issues related to abuse or neglect by Social Services, this was completed on 12/23/2022. No other residents were identified. 6. On 1/17/23, Staff Development Coordinator, Director of Nursing, and Administrator in-serviced Licensed nurses to ensure sufficient instruction will be given to resident or their representative related to discharge medications. 7. Administrator and Director of Nursing in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident by Regional [NAME] President on 01/13/2023. 8. Social Services and facility van transporters in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident. Staff Development Coordinator completed an in-service 1/17/23 by 5 p.m. Social Service or van drivers will not be allowed to transport or transfer any resident until in-service is completed. 9. Disciplinary counseling completed on Administrator for failure to ensure Resident Representative was notified of discharge of Resident #1. Failure to ensure safe discharge of Resident #1 with medication reconciliation. Completed by Regional [NAME] President on 01/13/2023. 10. All resident ' s discharged home was audited from July 15, 2022, through 12/29/2022 to ensure safe discharge with medication and care instruction. Only 1 resident was discharged home during this time frame, there were no issues noted. This audit was completed by Director of Nursing on 01/13/2023. Quality Assurance: 1. An emergency Quality Assurance Performance Improvement Committee meeting was held on 12/22/2022 at 9:30 a.m. until 10:30 a.m. to review the resident-to-resident abuse between Resident #1 and #2. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, RN Unit Manager, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. 2. Facility held a second emergency Quality Assurance Performance Improvement Committee meeting on 01/17/2023 4:00p.m. to review immediate jeopardy F-tag .600, F623, F660. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed discharge look back from 07/15/2022 through 12/29/22 audit was performed Director of Nursing. One issue noted. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. 3. Facility held a third emergency Quality Assurance Performance Improvement Committee was held on 01/18/2023 at 3:30 p.m. to review immediate jeopardy F-tag 835. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed Safe Discharge policies and medications. No issues or concerned voiced. There were no new recommendations. The facility alleges compliance as reported to the Department of Health on 1/19/2023. VALIDATION: 1. Record review and staff interviews on 1/21/23 confirmed the facility had conducted Abuse and neglect in-service for all staff completed by Staff Development Coordinator in-servicing starting on 12/22/22 through 12/25/22. During staff interviews on 1/21/23, staff verbalized understanding the importance of protecting all residents from abuse to include resident to resident abuse and how to deal with combative residents. No staff will be allowed to work until completion of in-service. 2. Record review and staff interviews on 1/21/23 confirmed that Licensed nurses, and Social Services were in-serviced on safe and orderly discharge with sufficient instruction related to medications completed by 01/17/23 by Staff Development, Director of Nursing and Administrator. Social Services or licensed nursing staff will not be allowed to work until in-serviced. On 01/12/2023 through 1/14/2023 an Staff Development Nurse in-serviced Minimum Data Set Nurse, Social Services, and Nursing Service on baseline care plan policy. 3. Record review and interview on 1/21/23 confirmed that Resident #1 was placed on one-on-one observation starting 12/22/22 while in facility until transferred to Geri-psych hospital for evaluation 12/26/22. Then returned from Geri-psych #1 on 12/29/22 and Resident #1 left Against Medical Advice prior to readmission. 4. Record review and staff interview on 1/21/23 confirmed that a Head-to-toe assessment was completed on Resident #8 by Charge Nurse #3 on 09/08/2022. Head to toe assessments of Residents #1 and #2 was completed by Charge Nurse #1 and Director of Nursing on 12/22/22. On 09/08/22, Resident #8 received in-house treatment of injury to right eyebrow and was later transferred to Geri-psych #2 for psych evaluation on 09/08/22 at 7:11 a.m. Residents #1 and #2 were sent to hospital for evaluation and treatment 12/22/22. 5. Record review and staff interviews on 1/21/23 confirmed that all residents were assessed for post traumatic issues related to abuse or neglect by Social Services, this was completed on 12/23/2022. No other residents were identified. 6. Staff interviews and record review on 1/21/23 confirmed that on 1/17/23, Staff Development Coordinator, Director of Nursing, and Administrator in-serviced Licensed nurses to ensure sufficient instruction will be given to resident or their representative related to discharge medications. 7. Record review and staff interviews on 1/21/23 confirmed that the Administrator and Director of Nursing in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident by Regional [NAME] President on 01/13/2023. 8. Staff interview and record review on 1/21/23 confirmed that Social Services and facility van transporters were in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident. Staff Development Coordinator completed an in-service 1/17/23 by 5 p.m. Social Service or van drivers will not be allowed to transport or transfer any resident until in-service is completed. 9. Staff interview and record review on 1/21/23 confirmed that Disciplinary counseling completed on Administrator for failure to ensure Resident Representative was notified of discharge of Resident #1. Failure to ensure safe discharge of Resident #1 with medication reconciliation. Completed by Regional [NAME] President on 01/13/2023. 10. Record review and staff interviews on 1/21/23 confirmed that all residents discharged home was audited from July 15, 2022 through 12/29/2022 to ensure safe discharge with medication and care instruction. Only 1 resident was discharged home during this time frame, there were no issues noted. This audit was completed by Director of Nursing on 01/13/2023. Record review and staff interviews on 1/21/23 confirmed that an emergency Quality Assurance Performance Improvement Committee meeting was held on 12/22/2022 at 9:30 a.m. until 10:30 a.m. to review the resident-to-resident abuse between Resident #1 and #2. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, RN Unit Manager, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. Staff interviews and record review on 1/21/23 confirmed that the facility held a second emergency Quality Assurance Performance Improvement Committee meeting on 01/17/2023 4:00p.m. to review immediate jeopardy F-tag .600, F623, F660. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed discharge look back from 07/15/2022 through 12/29/22 audit was performed Director of Nursing. One issue noted. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. Record review and staff interviews on 1/21/23 confirmed that the facility held a third emergency Quality Assurance Performance Improvement Committee was held on 01/18/2023 at 3:30 p.m. to review immediate jeopardy F-tag 835. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed Safe Discharge policies and medications. No issues or concerned voiced. There were no new recommendations. Staff interviewed on 1/21/23 were seven (7) Certified Nurse Aides (CNA), two (2) Registered Nurses (RN), three (3) Licensed Practical Nurses (LPN), one (1) Business Office Manager (BOM), 1 Social Worker (SW), 1 Minimum Data Set LPN, 1 Administrator, 1 Director of Nurses, 2 Covid Screeners.

Based on record review, interviews, facility policy/procedure review, and job description review the facility failed to be administered in a manner that enables it to use it resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as evidenced by Resident #1 was discharged [DATE] without the Resident Representative (RR) being notified and Resident #1 was left alone outside the RR ' s locked home with a bag of medications with no discharge instructions for the medication for one (1) of five (5) discharged residents sampled. The facility's failure to notify Resident #1's (RR) at the time of the discharge and leaving Resident #1 outside the home alone placed Resident #1 in a situation that would likely cause serious injury, harm, impairment, or death. The SA identified an Immediate Jeopardy (IJ) that began on 12/29/22 when the facility failed to ensure a safe discharge for Resident #1. Two (2) staff members transported Resident #1 to his RR's home per the facility van. The staff members did not see a person at the home. Both staff members stated that Resident #1 had medications in a bag. There was a Ring doorbell system and a female voice said to facility staff that no one was at home. The facility staff left Resident #1 sitting in a chair on the front porch of the RR's home. On 1/18/23 at 1:00 PM, the SA notified the Administrator, Director of Nurses (DON) and Regional [NAME] President of the IJ and provided the facility with the IJ template. The IJ existed at: CFR 483.70 Administration (F835) -Scope and Severity J. The facility submitted an acceptable Removal Plan on 1/19/23, in which the facility alleged all corrective action to remove the IJ were completed on 1/19/23 and IJ removed on 1/19/23. The SA validated the Removal Plan on 1/21/23, and determined the IJ was removed on 1/19/23, prior to exit. Therefore, the scope and severity for CFR 483.70 Administration (F835), was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Cross reference F623. Record review of the facility's Executive Director/Administrator Job Description for Job Title: Executive Director. Department: Administration effective 8/01/2012 revealed The Executive Director leads and directs the overall operation of the facility in accordance with resident needs, government regulations and Facility policies so as to maintain quality care for the residents while achieving of the Facility's business objectives. The job description revealed Standard Requirements 2. Is knowledgeable of resident rights and supports an atmosphere which allows for the privacy, dignity and well-being of all residents in a safe, secure environment. Record review of the facility's Discharge and transfer policies-Involuntary policy/procedure, last revised 7/18 revealed the Responsibility: All staff, monitored by the Director of Nursing and Executive Director. The Procedure: 4. The facility will provide sufficient orientation to residents to ensure safe and orderly transfer or discharge from the facility . Record review of the Policy/procedure of the facility's Discharge Medications last revised 8/16 revealed the policy Discharge Medications Policy: Medications are sent with the resident upon discharge only under conditions that protect the resident and ensure compliance with the law. Record review of the Face Sheet revealed Resident # 1 was readmitted to the facility on [DATE]. His admitting diagnosis included Schizophrenia, Bipolar Disorder, Other Seizures, Hypothyroidism. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) was 10/4/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was cognitively intact. Record review of the medical record for Resident #1 had returned to the facility on [DATE] from a Geri-psych unit admission on 12/26/22. He was discharged from the Geri-psych unit on 12/29/22 due to refusal to take medications and participate in his treatment. He arrived at the nursing home and refused to go to his room. He was requesting to discharge from the nursing home and go to his RR's home in [NAME], Ms. The facility attempted three (3) times to contact the RR with no success. Resident #1 was transported in the nursing homes van by 2 staff members to the RR's home and left outside the home, unattended. Interview with the Administrator on 1/11/23 at 11:44 AM, revealed that Resident #1 was sent to the Geri-psych for evaluation and treatment on 12/26/22. The Administrator stated We sent him with his medications to senior care. He returned with his same medications. I saw the meds with him when he returned here. The facility did not send him home with any medications. That's why there were no meds on the discharge summary. Interview with the Facility Transporter on 1/11/23 at 10:40 AM, revealed that the Maintenance Assistant went with him to transfer Resident #1 to his RR's home in Bryam, MS, which is located approximately 2 to 2 1/2 hours from the nursing facility, on 12/29/22 in the facility van. He stated We didn ' t take any paperwork. Resident #1 had a bag of meds with him. He stated after arriving at the RR's home a female talked through the Ring camera. She said a name, but I never understood it. No, he didn ' t go inside. He sat on the porch in front of the camera. The nursing home Administrator gave me the address of where to take him. I did call the facility saying there was no one coming to the door. I told the facility staff that someone was talking to me through the door Ring camera. He was unable to recall who he spoke to at the nursing home when he called to inform the facility that no one was coming to the door. Interview with the Maintenance Assistant on 1/11/23 at 10:55 AM, revealed he was with the Facility Transporter transferring Resident #1 to his RR's home. He stated the Facility Transporter was talking to someone through the Ring doorbell. Yes, there was a zip-lock bag with medications. They were his meds from the nursing home. Yes, I saw pills. The person speaking on the Ring camera said his sister was not there. He stated that Resident #1 was wearing a shirt, pants, shoes, socks, jacket, and hat. He stated that Resident #1 was sitting in a chair on the front porch in front of the door when we left. His belongings were beside him. The SA conducted an interview with the RR of Resident #1 on 1/12/23 at 8:31 AM, revealed that she was not home when the nursing home van dropped Resident #1 off at her house. She stated she was out of state at the time. She stated, I had to call 911 and the police and ambulance had to come. There was no one home when they left him. The house was locked. I had not been contacted by the nursing home prior to him coming home. She did state that there had been a family conference 24 days earlier and discharge of Resident #1 was discussed. She stated, the Administrator said well, he's got to go. She said Resident #1 does have behaviors if provoked. She revealed that the police contacted an ambulance service and Resident #1 was admitted to the hospital and remains there at this time. She stated it took the police 2 hours to get to her residence to make initial contact with Resident #1. Interview with the Administrator on 1/13/23 at 12:10 PM, revealed We never sent a 30-day discharge letter, related to Resident #1. We discussed it after a meeting with his RR/sister but decided against it. We wanted to wait on that. Interview with the facility Housekeeping Supervisor on 1/12/23 at 1:55 PM, revealed he was in the BOM's office on 12/29/22 when Resident #1 said he wanted to go home. He stated he was agitated, saying he wanted to go home. (Name of BOM) tried to call the (RR) with no answer a couple of times. He left in the facility van to go home. Interview with Licensed Practical Nurse (LPN) #2 on 1/12/23 at 3:18 PM, revealed that she contacted the Medical Director/Resident #1 ' s primary physician to let him know that Resident #1 wanted to go home. I called (name of Medical Director/Primary Physician) and let him know Resident #1 wanted to go home to his sister's home and needed an order for Home Health and the discharge. He said OK. Resident #1 had already left when I called (Name of Medical Director/Primary Physician). Interview with the Medical Director and Primary Physician at 1:20 PM on 1/12/23, revealed that he was unaware the facility van left Resident #1 on his RR's front steps without anyone at home. Removal Plan: Failure Statement: Facility failed to ensure residents were protected from physical abuse when Resident #1, who had a pattern and history of aggression, assaulted Resident #2 and #8 causing injury. The facility failed to ensure Resident #1 was transferred/discharged in a safe orderly manner with sufficient instruction related to medications. Facility failed to ensure Resident #1 Responsible Representative was notified of detailed discharge planning, and arrangements for post-discharge care including medication instruction. Summary: On 09/08/2022 Resident #1 began having episodes of aggression. Resident #1 was involved in a physical altercation with resident #8 who was the aggressor. Resident #8 sustained a laceration to the right eyebrow. Resident #1 was transferred to Geri-psych #1 and Resident #8 was transferred to Geri-psych #2. Resident #8 was assessed by Charge Nurse #3. First aide was provided by Charge Nurse #3 prior to transfer to Geri-psych #2. On 12/22/2022 Resident #1 was involved in an altercation with Resident #2 resulting in injury to nose and face. Residents #1 and #2 were assessed by Director of Nursing and Charge Nurse #1 prior to sending to Hospital for evaluation. Resident #1 was returned to facility on 12/23/22 and placed on one-on-one observation. Resident #2 was treated at hospital for nasal fracture and facial swelling and returned to facility on 12/22/2022 at 9:09 p.m. Resident #1 remained on one-on-one observation at facility until discharged to Geri-psych #1 on 12/26/2022 for evaluation and treatment. He returned to facility on 12/29/2022 at which time he refused to be readmitted to facility and signed himself out Against Medical Advice. Facility transported resident to sisters ' home at his request on 12/29/2022 at 1:30 p.m. by facility transporters in the facility van with two attendants. Resident #1 was left unattended. Resident #1 had a zip lock bag with medication on his person when returned from Geri-Psych #1. Resident #1 medications were not reconciled by facility due to resident #1 refusal to readmit to facility. Medical Director was notified of Resident #1 leaving facility Against Medical Advice on 12/29/2022 at 2:36p.m. by Staff Development Coordinator. Ombudsman notified of Resident #1 leaving facility Against Medical Advice on 12/29/2022 at 5:52 p.m. by Administrator. Facility's action: 1. Abuse and neglect in-service for all staff completed by Staff Development Coordinator in-servicing starting on 12/22/22 through 12/25/22. The staff verbalized understanding the importance of protecting all residents from abuse to include resident to resident abuse and how to deal with combative residents. No staff will be allowed to work until completion of in-service. 2. Licensed nurses, and Social Services in-serviced on safe and orderly discharge with sufficient instruction related to medications will be completed by 01/17/23 by Staff Development, Director of Nursing and Administrator. Social Services or licensed nursing staff will not be allowed to work until in-serviced. On 01/12/2023 through 1/14/2023 an Staff Development Nurse in-serviced Minimum Data Set Nurse, Social Services, and Nursing Service on baseline care plan policy. 3. Resident #1 was placed on one on one observation starting 12/22/22 while in facility until transferred to Geri-psych hospital for evaluation 12/26/22. Then returned from Geri-psych #1 on 12/29/22 and Resident #1 left Against Medical Advice prior to readmission. 4. Head to toe assessment was completed on Resident #8 by Charge Nurse #3 on 09/08/2022. Head to toe assessments of Residents #1 and #2 was completed by Charge Nurse #1 and Director of Nursing on 12/22/22. On 09/08/22, Resident #8 received in-house treatment of injury to right eyebrow and was later transferred to Geri-psych #2 for psych evaluation on 09/08/22 at 7:11 a.m. Residents #1 and #2 were sent to hospital for evaluation and treatment 12/22/22. 5. All residents were assessed for post traumatic issues related to abuse or neglect by Social Services, this was completed on 12/23/2022. No other residents were identified. 6. On 1/17/23, Staff Development Coordinator, Director of Nursing, and Administrator in-serviced Licensed nurses to ensure sufficient instruction will be given to resident or their representative related to discharge medications. 7. Administrator and Director of Nursing in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident by Regional [NAME] President on 01/13/2023. 8. Social Services and facility van transporters in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident. Staff Development Coordinator completed an in-service 1/17/23 by 5 p.m. Social Service or van drivers will not be allowed to transport or transfer any resident until in-service is completed. 9. Disciplinary counseling completed on Administrator for failure to ensure Resident Representative was notified of discharge of Resident #1. Failure to ensure safe discharge of Resident #1 with medication reconciliation. Completed by Regional [NAME] President on 01/13/2023. 10. All residents discharged home was audited from July 15, 2022 through 12/29/2022 to ensure safe discharge with medication and care instruction. Only 1 resident was discharged home during this time frame, there were no issues noted. This audit was completed by Director of Nursing on 01/13/2023. Quality Assurance: 1. An emergency Quality Assurance Performance Improvement Committee meeting was held on 12/22/2022 at 9:30 a.m. until 10:30 a.m. to review the resident to resident abuse between Resident #1 and #2. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, RN Unit Manager, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. 2. Facility held a second emergency Quality Assurance Performance Improvement Committee meeting on 01/17/2023 4:00p.m. to review immediate jeopardy F-tag .600, F623, F660. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed discharge look back from 07/15/2022 through 12/29/22 audit was performed Director of Nursing. One issue noted. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. 3. Facility held a third emergency Quality Assurance Performance Improvement Committee was held on 01/18/2023 at 3:30 p.m. to review immediate jeopardy F-tag 835. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed Safe Discharge policies and medications. No issues or concerned voiced. There were no new recommendations. The facility alleges compliance as reported to the Department of Health on 1/19/2023. VALIDATION: 1. Record review and staff interviews on 1/21/23 confirmed the facility had conducted Abuse and neglect in-service for all staff completed by Staff Development Coordinator in-servicing starting on 12/22/22 through 12/25/22. During staff interviews on 1/21/23, staff verbalized understanding the importance of protecting all residents from abuse to include resident to resident abuse and how to deal with combative residents. No staff will be allowed to work until completion of in-service. 2. Record review and staff interviews on 1/21/23 confirmed that Licensed nurses, and Social Services were in-serviced on safe and orderly discharge with sufficient instruction related to medications completed by 01/17/23 by Staff Development, Director of Nursing and Administrator. Social Services or licensed nursing staff will not be allowed to work until in-serviced. On 01/12/2023 through 1/14/2023 an Staff Development Nurse in-serviced Minimum Data Set Nurse, Social Services, and Nursing Service on baseline care plan policy. 3. Record review and interview on 1/21/23 confirmed that Resident #1 was placed on one-on-one observation starting 12/22/22 while in facility until transferred to Geri-psych hospital for evaluation 12/26/22. Then returned from Geri-psych #1 on 12/29/22 and Resident #1 left Against Medical Advice prior to readmission. 4. Record review and staff interview on 1/21/23 confirmed that a Head-to-toe assessment was completed on Resident #8 by Charge Nurse #3 on 09/08/2022. Head to toe assessments of Residents #1 and #2 was completed by Charge Nurse #1 and Director of Nursing on 12/22/22. On 09/08/22, Resident #8 received in-house treatment of injury to right eyebrow and was later transferred to Geri-psych #2 for psych evaluation on 09/08/22 at 7:11 a.m. Residents #1 and #2 were sent to hospital for evaluation and treatment 12/22/22. 5. Record review and staff interviews on 1/21/23 confirmed that all residents were assessed for post traumatic issues related to abuse or neglect by Social Services, this was completed on 12/23/2022. No other residents were identified. 6. Staff interviews and record review on 1/21/23 confirmed that on 1/17/23, Staff Development Coordinator, Director of Nursing, and Administrator in-serviced Licensed nurses to ensure sufficient instruction will be given to resident or their representative related to discharge medications. 7. Record review and staff interviews on 1/21/23 confirmed that the Administrator and Director of Nursing in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident by Regional [NAME] President on 01/13/2023. 8. Staff interview and record review on 1/21/23 confirmed that Social Services and facility van transporters were in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident. Staff Development Coordinator completed an in-service 1/17/23 by 5 p.m. Social Service or van drivers will not be allowed to transport or transfer any resident until in-service is completed. 9. Staff interview and record review on 1/21/23 confirmed that Disciplinary counseling completed on Administrator for failure to ensure Resident Representative was notified of discharge of Resident #1. Failure to ensure safe discharge of Resident #1 with medication reconciliation. Completed by Regional [NAME] President on 01/13/2023. 10. Record review and staff interviews on 1/21/23 confirmed that all residents discharged home was audited from July 15, 2022 through 12/29/2022 to ensure safe discharge with Interview with Licensed Practical Nurse (LPN) #2 on 1/12/23 at 3:18 PM, revealed that she contacted the Medical Director/Resident #1 ' s primary physician to let him know that Resident #1 wanted to go home. I called (name of Medical Director/Primary Physician) and let him know Resident #1 wanted to go home to his sister ' s home and needed an order for Home Health and the discharge. He said Ok. Resident #1 had already left when I called (name of Medical Director/Primary Physician). medication and care instruction. Only 1 resident was discharged home during this time frame, there were no issues noted. This audit was completed by Director of Nursing on 01/13/2023. Record review and staff interviews on 1/21/23 confirmed that an emergency Quality Assurance Performance Improvement Committee meeting was held on 12/22/2022 at 9:30 a.m. until 10:30 a.m. to review the resident-to-resident abuse between Resident #1 and #2. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, RN Unit Manager, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. Staff interviews and record review on 1/21/23 confirmed that the facility held a second emergency Quality Assurance Performance Improvement Committee meeting on 01/17/2023 4:00p.m. to review immediate jeopardy F-tag .600, F623, F660. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed discharge look back from 07/15/2022 through 12/29/22 audit was performed Director of Nursing. One issue noted. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. Record review and staff interviews on 1/21/23 confirmed that the facility held a third emergency Quality Assurance Performance Improvement Committee was held on 01/18/2023 at 3:30 p.m. to review immediate jeopardy F-tag 835. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed Safe Discharge policies and medications. No issues or concerned voiced. There were no new recommendations. Staff interviewed on 1/21/23 were seven (7) Certified Nurse Aides (CNA), two (2) Registered Nurses (RN), three (3) Licensed Practical Nurses (LPN), one (1) Business Office Manager (BOM), 1 Social Worker (SW), 1 Minimum Data Set LPN, 1 Administrator, 1 Director of Nurses, 2 Covid Screeners.

Based on observation, record review, interviews, and facility policy/procedure review the facility failed to protect three (3) of 11 residents from abuse as evidenced by the failure to protect Resident #2 and Resident #8 of physical abuse from Resident #1 after Resident #1 physically attacked Resident #8 on 9/8/22 and Resident #2 on 12/22/22. On 12/26/22, Resident #1 was sent to Geri-psych for treatment and returned on 12/29/22 due to refusal to take his medications and treatment. He requested to go home to his Resident Representative's (RR) home and was discharged . The facility transported him to his RR's home without notifying the RR of the discharge. The RR was out of state and Resident #1 was left at the locked home in a chair on the front porch. The facility's failure to protect residents from resident-to-resident abuse and leaving Resident #1 outside of the RR's locked home placed Resident #1, Resident #2 and Resident #8 in a situation that caused serious injury, serious harm and serious impairment and placed other residents at risk in a situation that would likely cause serious injury, harm, impairment, or death. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/8/22 when Resident #1 physically attached Resident #8. On 1/17/23 at 1:30 PM, the SA notified the Administrator, Director Of Nurses and Regional [NAME] President of the IJ and SQC and provided the facility with the IJ template for F600. The facility submitted an acceptable Removal Plan on 1/19/23, in which the facility alleged all corrective action to remove the IJ were completed on 1/19/23 and IJ removed on 1/19/23. The SA validated the Removal Plan on 1/21/23, and determined the IJ was removed on 1/19/23, prior to exit. Therefore, the scope and severity for CFR 483.12 (a)(1) Abuse (F600) was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Abuse Prevention policy last revised 7/18 revealed, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. The facility Abuse Prevention policy defines Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident. Record review of the Incident Log dates 7/15/22-1/9/23 revealed that Resident #1 was involved with six (6) resident-to-resident altercations in that time frame. Record review of the Incident Log revealed the first incident involving a physical altercation was on 9/8/22 between Resident #1 and Resident #8. The SA investigation revealed that Resident #8 accidentally ran over the foot of Resident #1 with his wheelchair. The altercation ended when Resident #1 hit Resident #8 in the face causing a 2 cm laceration above his left eyebrow. Resident #8 received in-house treatment and sent for an evaluation at a Geri-Psych unit. Resident #1 was sent for an evaluation at a Geri-Psych unit. Record review of the Facility Investigation revealed the physical altercation between Resident #1 and Resident #2 was on 12/22/22. Resident #1 and Resident #2 were roommates at that time. Resident #2 was observed by staff ambulating down the hall from his room towards the nurses station bleeding from his head. He stated that his roommate had hit him. Resident #1 was noted in his wheelchair, sitting near the dayroom. Resident #2 was immediately taken into an empty resident room for a physical evaluation, treatment and to begin questioning regarding the incident. Resident #1 was taken into his room and put one on one with a staff member. The staff member sitting with Resident #1 noted blood on his hand. She began to question him about what happened, and Resident #1 wasn't speaking clear enough to be understood but she did understand that Resident #1 believed that Resident #2 had his television remote. Both residents were sent to the emergency room (ER) for evaluation and treatment. Resident #2 was treated for a broken nose, lacerations to his face and a black eye. He returned to the facility on [DATE]. Resident #1 refused to leave the nursing home to go to the ER for an evaluation on 12/22/22. The Medical Director and his primary physician were notified. He did a now order for Ativan and Haldol injection to calm his agitation. He was then transported by Emergency Medical Technician (EMT)'s to the local hospital for evaluation and treatment. He stayed in the ER until 12/23/22 and was then transferred back to the nursing home. The nursing home put Resident #1 one on one with staff. The Social Worker (SW) was attempting to find a Geri-psych unit to accept him for evaluation and treatment if necessary. He stayed one on one through to transport to a Geri-psych unit on 12/26/22. The Stage Agency (SA) investigation revealed that Resident #1 was returned to the nursing home on 12/29/22 due to Resident #1 refused medications and treatment while in the Geri-psych until and was discharged from the unit on 12/29/22. He returned to the nursing home and refused to be readmitted stating he wanted to go to his Resident Representative's home. The Administrator instructed Resident #1 on discharge Against Medical Advice (AMA). He was not his own RR. The Business Office Manager (BOM) attempted three times to contact the RR by phone with no success. She stated she was unable to leave a voice mail. Two staff members transported Resident #1 to his RR's home per the facility van. The staff members did not see a person at the home. Both staff members stated that Resident #1 had medications in a bag. There was a Ring doorbell system and a female voice said to facility staff that no one was at home. Facility staff left Resident #1 sitting in a chair on the front porch of the RR's home. Interview with the Administrator on 1/9/23 at 4:20 PM, revealed that Resident #1 had a physical altercation with Resident #2. Resident #2 had a broken nose and a black Left (L) eye. Resident #1 was sent to the local hospital due to his behaviors. He returned to the facility on [DATE] and was one on one with staff until 12/26/22. He was transferred to Geri psych on 12/26/22 and returned to the facility on [DATE] due to refusing medications and treatment. Record review of the hospital Patient Discharge Instructions Page 2 of 3 for Resident #2 dated 12/22/22 revealed that his Discharge Diagnosis were Abrasion (Rt (right) brow), Contusion (Rt orbit, Lt (left) orbit, Lt facia, Nasal septum), Fracture (Rt nasal bone). Record review of the CT (Computerized Tomography) CERVICAL SPINE W/O CONTRAST dated 12/22/22 of Resident #2 revealed Impression 2. Focal mild soft tissue swelling/contusion along the superolateral aspect of the right orbit. 3. Mild soft tissue swelling at the anterior nose with a subtle nondisplaced right nasal bone fracture. 4. Diffuse mild to moderate soft tissue swelling at the left upper face/inferior margin of the left orbit likely also representing contusion. During an interview with the Administrator on 1/11/23 at 11:44 AM, she revealed that when Resident #1 was sent to the Geri-psych for evaluation and treatment on 12/26/22. The Administrator stated We sent him with his medications to senior care. He returned with his same medications. I saw the meds with him when he returned here. The facility did not send him home with any medications. That's why there were no meds on the discharge summary. On 1/11/23 at 10:40 AM, in an interview with the Facility Transporter revealed that the Maintenance Assistant went with him to transfer Resident #1 to his RR's home in [NAME], MS which is located approximately 2 to 2 1/2 hours from the nursing facility on 12/29/22 in the facility van. He stated We didn't take any paperwork. Resident #1 had a bag of meds with him. He stated after arriving at the RR's home a female talked through the Ring camera. She said a name, but I never understood it. No, he didn't go inside. He sat on the porch in front of the camera. The nursing home Administrator gave me the address of where to take him. I did call the facility saying there was no one coming to the door. I told the facility staff that someone was talking to me through the door Ring camera. He was unable to recall who he spoke to at the nursing home when he called to inform the facility that no one was coming to the door. On 1/11/23 at 10:55 AM, during an interview with the Maintenance Assistant on revealed he was with the Facility Transporter transferring Resident #1 to his RR's home. He stated the Facility Transporter was talking to someone through the Ring doorbell. Yes, there was a zip-lock bag with medications. They were his meds from the nursing home. Yes, I saw pills. The person speaking on the Ring camera said his sister was not there. He stated that Resident #1 was wearing a shirt, pants, shoes, socks, jacket, and hat. He stated that Resident #1 was sitting in a chair on the front porch in front of the door when we left. His belongings were beside him. Observation and interview on 1/11/23 at 3:15 PM with Resident #8 revealed speech very difficult to understand. When the SA asked Resident #8 if he feared anyone in the facility, Resident #8 pointed to his left eye area and said he was scared of the man that scratched his face. Observation and interview on 1/11/23 at 3:30 PM with Resident #2 revealed he is leery of some residents. When the SA questioned Resident #2 further, he stated he is only scared of Resident #1. During an interview with the Resident #1's RR on 1/12/23 at 8:31 AM, revealed that she was not home when the nursing home van dropped Resident #1 off at her house. She stated she was out of state at the time. She stated, I had to call 911 and the police and ambulance had to come. There was no one home when they left him. The house was locked. I had not been contacted by the nursing home prior to him coming home. She did state that there had been a family conference 24 days earlier and discharge of Resident #1 was discussed. She stated, the administrator said 'well, he's got to go. She said Resident #1 does have behaviors if provoked. She revealed that the police contacted an ambulance service and Resident #1 was admitted to the hospital and remains there at this time. She stated it took the police 2 hours to get to her residence to make initial contact with Resident #1. Interview with the Director of Nurses (DON) on 1/12/23 at 2:35 PM revealed that she was in the facility during the resident-to-resident altercation between Resident #1 and Resident #2. She stated that LPN #1 came and got her around 4:30 PM and that as she went down west hall, she saw Resident #2 with blood on his face and clothes with the right side of his face swollen, nose bleeding and blood all over his face. She said that she and LPN #2 took Resident #1 into the closest room for an evaluation and treatment. She stated Resident #2 said My roommate jumped on me. She stated that as she was taking Resident #2 into that room, she saw CNA #1 with Resident #1. CNA #1 took Resident #1 back to his room. I called (name of medical director) and got an order to send Resident #2 to the ER. He had a puncture under his right eye, open areas on scalp, bleeding and fractured nose. CNA#1 stayed in the room with Resident #1 and told me she found blood on the floor in their room blood on knuckles on both of Resident #1's hands. I asked Resident #1 if he hit someone and he said 'yeah, I hit him, he had my remote control and wouldn't give it back. The DON stated the Administrator had called the police. The Medical Director gave an order to send Resident #1 to the ER for evaluation due to behaviors. Resident #1 refused to leave with the Emergency Medical Technicians (EMT) when they arrived to take him. The medical director was notified and ordered a Now order for Ativan and Haldol injection. She stated that Resident #1 was calmer and went to the ER with the EMT's. The DON confirmed that she and the Administrator both called the RR of Resident #1. The DON stated that Resident #1 returned to the facility on [DATE] and was one on one until he was sent to Geri-psych on 12/26/22. She stated that Resident #1 was put in a private room until Geri-psych placement on 12/26/22. Interview with LPN #2 on 1/12/23 at 3:18 PM, revealed that she was working on 12/22/22 and saw Resident #2 standing by the DON and was bloody. LPN #2 went into the room with the DON and Resident #2 for an assessment. She stated that she saw Resident #1 after Resident #2 had left to go to the hospital. Resident #1 stated he wouldn't give me my remote, when LPN #2 asked what happened. She stated police returned to help in case Resident #1 refused the Ativan and Haldol injection. Resident #1 took the injection without problem after talking with the police. She stated that staff was with Resident #1 one on one until he went to Geri-psych on 12/26/22. Record review of Resident #1's Face Sheet revealed he was readmitted to the facility on [DATE]. His admitting diagnosis included Schizophrenia, Bipolar Disorder, Other Seizures, Hypothyroidism. Record review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/4/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Record review of Resident #1's care plans revealed he is care planned for behaviors of suicidal ideations, pacing, easily agitated, verbally/physically aggressive, hallucinations, paranoid thinking. Record review of Resident #8's Face Sheet revealed he was admitted to the facility on [DATE]. His diagnoses include Schizophrenia, Major depressive disorder, Alzheimer's disease, Extrapyramidal and movement disorder, Unspecified Dementia with other behavioral disturbances, Anxiety disorder. Record review of Resident #8's quarterly MDS assessment with an Assessment Reference Date of 12/21/22 and revealed a Brief Interview for Mental Status (BIMS) was 3, indicating severe cognitive impairment. Record review of Resident #2's Face Sheet revealed he was admitted to the facility on [DATE]. His diagnoses include Schizophrenia, Parkinson's disease, Anxiety disorder, Major depressive disorder, Unspecified Dementia without behaviors. Record review of Resident #2's quarterly MDS with an Assessment Reference Date of 10/28/22 and revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitive skills. The facility provided an acceptable Removal Plan on 1/19/23. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan: Failure Statement: Facility failed to ensure residents were protected from physical abuse when Resident #1, who had a pattern and history of aggression, assaulted Resident #2 and #8 causing injury. The facility failed to ensure Resident #1 was transferred/discharged in a safe orderly manner with sufficient instruction related to medications. Facility failed to ensure Resident #1 Responsible Representative was notified of detailed discharge planning, and arrangements for post-discharge care including medication instruction. Summary: On 09/08/2022 Resident #1 began having episodes of aggression. Resident #1 was involved in a physical altercation with resident #8 who was the aggressor. Resident #8 sustained a laceration to the right eyebrow. Resident #1 was transferred to Geri-psych #1 and Resident #8 was transferred to Geri-psych #2. Resident #8 was assessed by Charge Nurse #3. First aide was provided by Charge Nurse #3 prior to transfer to Geri-psych #2. On 12/22/2022 Resident #1 was involved in an altercation with Resident #2 resulting in injury to nose and face. Residents #1 and #2 were assessed by Director of Nursing and Charge Nurse #1 prior to sending to Hospital for evaluation. Resident #1 was returned to facility on 12/23/22 and placed on one-on-one observation. Resident #2 was treated at hospital for nasal fracture and facial swelling and returned to facility on 12/22/2022 at 9:09 p.m. Resident #1 remained on one-on-one observation at facility until discharged to Geri-psych #1 on 12/26/2022 for evaluation and treatment. He returned to facility on 12/29/2022 at which time he refused to be readmitted to facility and signed himself out Against Medical Advice. Facility transported resident to sisters' home at his request on 12/29/2022 at 1:30 p.m. by facility transporters in the facility van with two attendants. Resident #1 was left unattended. Resident #1 had a zip lock bag with medication on his person when returned from Geri-Psych #1. Resident #1 medications were not reconciled by facility due to resident #1 refusal to readmit to facility. Medical Director was notified of Resident #1 leaving facility Against Medical Advice on 12/29/2022 at 2:36p.m. by Staff Development Coordinator. Ombudsman notified of Resident #1 leaving facility Against Medical Advice on 12/29/2022 at 5:52 p.m. by Administrator. Facility's action: 1. Abuse and neglect in-service for all staff completed by Staff Development Coordinator in-servicing starting on 12/22/22 through 12/25/22. The staff verbalized understanding the importance of protecting all residents from abuse to include resident to resident abuse and how to deal with combative residents. No staff will be allowed to work until completion of in-service. 2. Licensed nurses, and Social Services in-serviced on safe and orderly discharge with sufficient instruction related to medications will be completed by 01/17/23 by Staff Development, Director of Nursing and Administrator. Social Services or licensed nursing staff will not be allowed to work until in-serviced. On 01/12/2023 through 1/14/2023 an Staff Development Nurse in-serviced Minimum Data Set Nurse, Social Services, and Nursing Service on baseline care plan policy. 3. Resident #1 was placed on one on one observation starting 12/22/22 while in facility until transferred to Geri-psych hospital for evaluation 12/26/22. Then returned from Geri-psych #1 on 12/29/22 and Resident #1 left Against Medical Advice prior to readmission. 4. Head to toe assessment was completed on Resident #8 by Charge Nurse #3 on 09/08/2022. Head to toe assessments of Residents #1 and #2 was completed by Charge Nurse #1 and Director of Nursing on 12/22/22. On 09/08/22, Resident #8 received in-house treatment of injury to right eyebrow and was later transferred to Geri-psych #2 for psych evaluation on 09/08/22 at 7:11 a.m. Residents #1 and #2 were sent to hospital for evaluation and treatment 12/22/22. 5. All residents were assessed for post traumatic issues related to abuse or neglect by Social Services, this was completed on 12/23/2022. No other residents were identified. 6. On 1/17/23, Staff Development Coordinator, Director of Nursing, and Administrator in-serviced Licensed nurses to ensure sufficient instruction will be given to resident or their representative related to discharge medications. 7. Administrator and Director of Nursing in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident by Regional [NAME] President on 01/13/2023. 8. Social Services and facility van transporters in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident. Staff Development Coordinator completed an in-service 1/17/23 by 5 p.m. Social Service or van drivers will not be allowed to transport or transfer any resident until in-service is completed. 9. Disciplinary counseling completed on Administrator for failure to ensure Resident Representative was notified of discharge of Resident #1. Failure to ensure safe discharge of Resident #1 with medication reconciliation. Completed by Regional [NAME] President on 01/13/2023. 10. All residents discharged home was audited from July 15, 2022 through 12/29/2022 to ensure safe discharge with medication and care instruction. Only 1 resident was discharged home during this time frame, there were no issues noted. This audit was completed by Director of Nursing on 01/13/2023. Quality Assurance: 1. An emergency Quality Assurance Performance Improvement Committee meeting was held on 12/22/2022 at 9:30 a.m. until 10:30 a.m. to review the resident-to-resident abuse between Resident #1 and #2. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, RN Unit Manager, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. 2. Facility held a second emergency Quality Assurance Performance Improvement Committee meeting on 01/17/2023 4:00p.m. to review immediate jeopardy F-tag .600, F623, F660. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed discharge look back from 07/15/2022 through 12/29/22 audit was performed Director of Nursing. One issues noted. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. 3. Facility held a third emergency Quality Assurance Performance Improvement Committee was held on 01/18/2023 at 3:30 p.m. to review immediate jeopardy F-tag 835. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed Safe Discharge policies and medications. No issues or concerned voiced. There were no new recommendations. The facility alleges compliance as reported to the Department of Health on 1/19/2023. VALIDATION: On 1/21/23, the SA validated the facility had implemented the following measures to remove the Immediate Jeopardy. The Removal Plan was verified by staff interviews and record reviews of in-services. 1. Record review and staff interviews on 1/21/23 confirmed the facility had conducted Abuse and neglect in-service for all staff completed by Staff Development Coordinator in-servicing starting on 12/22/22 through 12/25/22. During staff interviews on 1/21/23, staff verbalized understanding the importance of protecting all residents from abuse to include resident to resident abuse and how to deal with combative residents. No staff will be allowed to work until completion of in-service. 2. Record review and staff interviews on 1/21/23 confirmed that Licensed nurses, and Social Services were in-serviced on safe and orderly discharge with sufficient instruction related to medications completed by 01/17/23 by Staff Development, Director of Nursing and Administrator. Social Services or licensed nursing staff will not be allowed to work until in-serviced. On 01/12/2023 through 1/14/2023 an Staff Development Nurse in-serviced Minimum Data Set Nurse, Social Services, and Nursing Service on baseline care plan policy. 3. Record review and interview on 1/21/23 confirmed that Resident #1 was placed on one on one observation starting 12/22/22 while in facility until transferred to Geri-psych hospital for evaluation 12/26/22. Then returned from Geri-psych #1 on 12/29/22 and Resident #1 left Against Medical Advice prior to readmission. 4. Record review and staff interview on 1/21/23 confirmed that a Head-to-toe assessment was completed on Resident #8 by Charge Nurse #3 on 09/08/2022. Head to toe assessments of Residents #1 and #2 was completed by Charge Nurse #1 and Director of Nursing on 12/22/22. On 09/08/22, Resident #8 received in-house treatment of injury to right eyebrow and was later transferred to Geri-psych #2 for psych evaluation on 09/08/22 at 7:11 a.m. Residents #1 and #2 were sent to hospital for evaluation and treatment 12/22/22. 5. Record review and staff interviews on 1/21/23 confirmed that all residents were assessed for post traumatic issues related to abuse or neglect by Social Services, this was completed on 12/23/2022. No other residents were identified. 6. Staff interviews and record review on 1/21/23 confirmed that on 1/17/23, Staff Development Coordinator, Director of Nursing, and Administrator in-serviced Licensed nurses to ensure sufficient instruction will be given to resident or their representative related to discharge medications. 7. Record review and staff interviews on 1/21/23 confirmed that the Administrator and Director of Nursing in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident by Regional [NAME] President on 01/13/2023. 8. Staff interview and record review on 1/21/23 confirmed that Social Services and facility van transporters were in-serviced on safe and orderly discharge with medications and not to leave any residents unattended or unsupervised when transferring a resident. Staff Development Coordinator completed an in-service 1/17/23 by 5 p.m. Social Service or van drivers will not be allowed to transport or transfer any resident until in-service is completed. 9. Staff interview and record review on 1/21/23 confirmed that Disciplinary counseling completed on Administrator for failure to ensure Resident Representative was notified of discharge of Resident #1. Failure to ensure safe discharge of Resident #1 with medication reconciliation. Completed by Regional [NAME] President on 01/13/2023. 10. Record review and staff interviews on 1/21/23 confirmed that all residents discharged home was audited from July 15, 2022 through 12/29/2022 to ensure safe discharge with medication and care instruction. Only 1 resident was discharged home during this time frame, there were no issues noted. This audit was completed by Director of Nursing on 01/13/2023. Record review and staff interviews on 1/21/23 confirmed that an emergency Quality Assurance Performance Improvement Committee meeting was held on 12/22/2022 at 9:30 a.m. until 10:30 a.m. to review the resident-to-resident abuse between Resident #1 and #2. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, RN Unit Manager, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. Staff interviews and record review on 1/21/23 confirmed that the facility held a second emergency Quality Assurance Performance Improvement Committee meeting on 01/17/2023 4:00p.m. to review immediate jeopardy F-tag .600, F623, F660. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed discharge look back from 07/15/2022 through 12/29/22 audit was performed Director of Nursing. One issues noted. There were no new recommendations or changes made to policies. Abuse in-service completed for all staff, and Resident to Resident Abuse Audit Tool initiated. Record review and staff interviews on 1/21/23 confirmed that the facility held a third emergency Quality Assurance Performance Improvement Committee was held on 01/18/2023 at 3:30 p.m. to review immediate jeopardy F-tag 835. In attendance was Administrator, Director of Nursing, Minimum Data Set Nurse, Medical Records, Infection Control Nurse, House Keeping Supervisor, Social Service Director, Maintenance Director, Business Office Manager, Staff Development Nurse, and Medical Director. Reviewed Safe Discharge policies and medications. No issues or concerned voiced. There were no new recommendations. Staff interviewed on 1/21/23 were seven (7) Certified Nurse Aides (CNA), two (2) Registered Nurses (RN), three (3) Licensed Practical Nurses (LPN), one (1) Business Office Manager (BOM), 1 Social Worker (SW), 1 Minimum Data Set LPN, 1 Administrator, 1 Director of Nurses, 2 Covid Screeners.