Every finding on record at The Bluffs Rehabilitation and Healthcare Center

Based on observations, staff interviews, record reviews, facility's investigation review, and facility policy review, the facility failed to provide adequate supervision to prevent a cognitively impaired resident, from exiting the facility and entering an uncontrolled, hazardous environment without staff awareness for one (1) of three (3) residents reviewed for elopement. Resident #1. This failure resulted in the resident propelling in a wheelchair approximately one-half (0.5) mile down the facility driveway and across a busy roadway, where environmental hazards included a steep ditch and wooded area, creating a situation that was likely to cause serious injury, harm, impairment, or death. During the investigation, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 4/14/26 and existed at 42 CFR: 483.25 (d)(1)(2)- Free of Accidents Hazards/Supervision/Devices (F689) - Scope and Severity J. This situation placed Resident #1 and other cognitively impaired residents, at risk for serious injury, serious harm, serious impairment, or death. The SA notified the facility's Administrator of the IJ and SQC on 4/20/26 at 5:01 PM and provided the Administrator with the IJ template. Based on the facility's implementation of corrective actions on 4/16/26, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 4/17/26, prior to the SA's entrance on 4/20/26. Findings Include: A review of the facility's policy, titled Wanderer Management, Monitoring System and Resident Elopement Protocol reviewed 3/3/26, revealed Policy, it is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. A record review of the facility's investigation, revealed on Tuesday, 4/14/26, at approximately 3:32 PM, Certified Nursing Assistant #1 (CNA), was entering her personal vehicle when a pest control representative informed her that a resident in a wheelchair was heading toward the bottom of the facility driveway. Earlier, Resident #1 had been seen sitting on the facility's front porch. CNA #1 immediately went down the driveway to assist him and found Resident #1 seated in his wheelchair across the driveway in a grassy section. She then blocked the roadway with her car and called the nurse's station to request help. CNA #1 stayed with him until additional staff arrived. Staff proceeded to assist with escorting Resident #1 into the facility. At 3:34 PM, the Human Resources Director received a call from an officer of the County Emergency Management/ Police Department, who reported that he was present with the resident and employee securing the roadway. Resident #1 was assisted back into the facility at 3:45 PM. He was alert and oriented. He denied pain or discomfort. No apparent injuries. The resident was received in a pleasant and cooperative mood. He was placed on one-on-one observation. A body audit was completed with no adverse findings. The Physician/Medical Director, Nurse Practitioner, Responsible Party were notified. An observation of the route taken by Resident #1 on 4/20/26 at 3:35 PM revealed resident propelled one-half (0.5) mile down the facility driveway and across a heavily trafficked road. Environmental hazards across the road included a steep ditch and wooded area. Record review of past weather in the area on 4/14/26 revealed a temperature between 81 and 84 degrees, with no precipitation. Record review of Nex-Wander Data Collection-V2 form, dated 11/17/25, for Resident #1 revealed a score of seven (7), indicating that the resident was a moderate risk for wandering. Interview with CNA #2 on 4/20/26 at 12:05 PM, revealed that she was assigned to Resident #1 on 4/14/26. She stated that when she clocked out at 3:08 PM Resident #1 was sitting on the front porch. She stated he was wearing long pants, a short- sleeved shirt and non-slip shoes. She stated that he usually went outside with the smokers to drink coffee and staff were always present. She stated she was unsure of how he got outside and felt he possibly followed one of the other residents out. During an interview with the Interim Director of Nursing (IDON) on 4/20/26 at 1:00 PM she verified that the resident did not wander and had never attempted elopement in the past. Telephone interview with CNA #1 on 4/20/26 at 3:10 PM she stated she was leaving the facility, and the pest control person told her a resident was rolling down the driveway. She stated she got into her car and started driving down the driveway and saw the resident. She verified that she tried to get him to stop but he propelled his wheelchair across the street. She further stated that she blocked traffic on the street with her car and called staff to assist with getting the resident back to the facility. Record review of the admission Record revealed the facility admitted Resident #1 on 11/17/25 with diagnoses that included Cerebral Infarction and Hemiplegia and Hemiparesis affecting Right Dominant Side. Record review of the Brief Interview for Mental Status (BIMS) assessment, dated 4/14/26, revealed a score of nine (9), indicating that Resident #1 was moderately cognitively impaired. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 4/20/26: The facility failed to provide supervision to a cognitively impaired resident. On 04/14/2026 at 3:32pm, Resident #1 was seen propelling wheelchair moving down the facility driveway. Resident #1 was observed sitting on front porch prior to incident. CNA # 1 was alerted and responded. Before CNA #1 arrived at residents' location, Resident #1 had crossed the facility drive into a grassy area. State agency provided IJ template on 4/20/2026 at 5:01 PM. Corrective Actions On 4/14/2026 at 3:08 PM, CNA #2 saw Resident #1 on the front porch in a wheelchair drinking water. On 04/14/2026 at 3:32 PM, CNA #1 was getting into her personal vehicle and was notified by pest control representative that Resident #1 was headed towards the bottom of the facility driveway. On 04/14/2026 at 3:34 PM, CNA #1 was with Resident #1, blocking road with car to secure Resident #1 safety. On 04/14/2026 at 3:35 PM, CNA #1 contacted Nurses station to obtain assistance escorting Resident #1 back into the facility. On 04/14/2026 at 3:35 PM Licensed Practical Nurse (LPN) #1 received notification to assist with escorting Resident #1 back into the facility. On 04/14/2026 at 3:35 PM, Interim DON was notified of resident location. On 04/14/2026 at 3:36 PM Local County Police officer #1 notified Human Resources (HR) that he was also with resident and blocking off roadway on opposite side. On 04/14/2026 at 3:45 PM, Resident #1 was escorted back into the facility. On 04/14/2026 at 3:45 PM, the facility initiated a one-to-one monitoring for Resident #1. On 04/14/2026 at 3:48 PM, LPN #1 conducted a head-to-toe body audit on Resident #1 to review for any skin abnormalities with no negative findings. On 04/14/2026 at 3:55 PM, the Administrator was notified of Resident #1 location and return. On 04/14/2026 at 3:55 PM, Resident #1 had a wander guard bracelet placed on his left ankle and a new wandering evaluation conducted by LPN #1. On 04/14/2026 at 3:58 PM, the Maintenance Director changed the door codes of all exit doors. On 04/14/2026 at 4:15 PM, Resident #1 Responsible Party (RP) was notified of the incident. On 04/14/2026 at 4:24 PM, the Risk Manager (RM) audited the facility; all residents were accounted for, and none were missing. On 04/14/2026 at 4:27 PM, the Nurse Practitioner (NP) was notified of resident previous location and return. On 4/14/2026 at 4:29 PM the Social Services Director (SSD) administered a Brief Interview for Mental Status (BIMS) for Resident #1, yielding a score of nine (9). On 04/14/2026 at 5:04 PM, the Staff Development Coordinator (SDC) initiated in-servicing with all direct care staff to include all Licensed Nurses and CNAs on Elopement policy and procedures along with Abuse, Neglect, and Resident Rights. No one will be allowed to work until in-serviced. On 4/15/2026 at 9:30 AM, the Administrator, Corporate Clinical Specialist (CCS), and Regional [NAME] President (RVP) discussed facility wide procedure changes initiated with residents not exiting facility with BIMS below 12 unless they are supervised and signed out along with safety vest provided. On 4/15/2026 at 11:58 AM, Resident #1 was assessed by the Social Service Director (SSD) to follow up with no signs of distress resulting. On 4/15/2026 at 12:30 PM, the facility NP evaluated and assessed Resident #1 and ordered labs to be obtained. On 4/15/2026 at 12:40 PM, a meeting was held with NP, the Administrator, Corporate Clinical Specialist, Risk Manager along with the Interdisciplinary Team to discuss the plan of action for Resident #1 investigation and new process that all cognitively intact residents with a BIMS score of 12 or higher must sign out when exiting and sign back in upon return. A safety vest will be provided. All residents with a BIMS of less than 12 must be accompanied by a staff or family member. On 04/15/2026 at 12:44 PM, the Interim DON notified psychiatric Nurse Practitioner to conduct and evaluate Resident #1. Addition of antidepressant to medical record. On 04/15/2026 at 1:35 PM, the Minimum Data Set (MDS) #1 updated Resident #1 care plans to reflect wander behavior along with wander guard and monitoring in place. On 4/15/2026 at 2:15 PM the Risk Manager performed an elopement drill with the day shift staff to review and discuss the elopement policies and procedures. On 4/15/2026 at 2:35 PM, a Quality Assurance (QA) Committee Meeting was held with Medical Director, Administrator, Corporate Clinical Specialist and Interdisciplinary team to discuss Resident #1 exit of facility and return. Root cause analysis along with a plan of correction and new procedures put into place. On 4/15/2026 at 3:00 PM, an audit was conducted by Medical Records (MR) on current high-risk wander patients to review orders, wander binder, wander guards, and care plans for accuracy. There are currently nine (9) high risk wandering patients. No changes were needed. On 4/15/2026 at 3:00 PM, an audit was conducted by LPN # 2 on the current resident sign out book to ensure all resident's sign out sheet is correctly color coded according to BIMS. On 4/15/2026 at 3:30 PM, a resident council meeting was held to discuss effective new procedures immediately regarding signing out with supervisor requirements prior to exit for safety. On 4/15/2026 at 4:35 PM, the Mississippi State Department of Health was notified of Resident #1 exit and return to facility. On 4/15/2026 at 5:55 PM, the Social Service Director (SSD) held a care plan conference with Responsible Party regarding Resident #1 incident along with plan of action. On 4/15/2026 at 6:43 PM, the Risk Manager (RM) performed an elopement drill with the evening shift staff to review and discuss the elopement policies and procedures. On 4/15/2026 at 7:04 PM, the RM notified the Ombudsman of Resident #1 exit and return to facility along with action plans in place. On 4/16/2026 at 9:13 PM, an electronic automatic phone system notification was utilized to alert residents' Responsible Parties and Staff members of new changes put into place regarding residents increased supervision with signing out prior to exiting facility. On 4/16/2026 at 10:00 PM, the elopement quiz along with education on the new procedures regarding residents increased supervision was placed into the orientation packet. On 04/16/2026 at 11:05 PM the Maintenance Director performed an elopement drill with the night shift staff to review and discuss the elopement policies and procedures. In order to monitor current residents for potential risk, residents will be monitored by the DON through incident report review, observations, and communication with staff. Daily checks to ensure that no residents with a BIMS score of less than 12 are out unattended will be conducted by DON for two (2) weeks, then three (3) times weekly for six (6) weeks, and then monthly for three (3) months. The administrator/designee will conduct elopement drills/scenarios quarterly for up to a year and then bi-annually thereafter. The maintenance or designee will conduct staff training elopement drill monthly with rotating shifts until all shifts are completed for three (3) months and then quarterly thereafter. The facility alleged all corrective measures were fully implemented on 4/16/2026 and the Immediate Jeopardy was removed on 4/17/2026. Validation: The State Agency (SA) validation of the Corrective Action Plan was made on-site during the Complaint Investigation (CI) #2985572 through observations, record review and interviews on 4/20/26 through 04/21/26. The SA determined all corrective actions were completed on 4/16/26 and the IJ was removed on 4/17/26 prior to the SA entrance into the facility.

Based on observation, staff interview, record review and facility policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) when staff did not wear a gown during Percutaneous Endoscopic Gastrostomy (PEG) tube medication administration for one (1) of four (4) residents reviewed for infection control practices. Resident #1. Findings Included: Record review of facility policy, Enhanced Barrier Precautions, latest review date 6/30/25, revealed, Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities.EBP are indicated for residents with any of the following:.indwelling medical devices.Indwelling medical device examples include.feeding tubes. Record review of signage posted outside Resident #1's room revealed a notice indicating Enhanced Barrier Precautions (EBP) and instructed that providers and staff must wear gloves and a gown during high-contact resident care activities, including device care and use involving a feeding tube. Observation on 2/10/26, at 9:00 AM, of Licensed Practical Nurse (LPN) #1 administering medications via Resident #1's Percutaneous Endoscopic Gastrostomy (PEG) tube revealed that she did not don a gown prior to administering medications. Interview with LPN #1 on 2/10/26, at 9:25 AM, revealed that she stated EBP were used to prevent the spread of infection. She verified that she did not wear a gown while administering medications through Resident #1's PEG tube and agreed that she should have worn a gown. Interview with the Director of Nursing (DON) on 2/10/26, at 10:00 AM, revealed that she verified it was her expectation that LPN #1 would have worn a gown when administering medications through a PEG tube in accordance with Enhanced Barrier Precautions. Record review of the admission Record revealed the facility admitted Resident #1 on 11/17/25, with diagnoses including ENCOUNTER FOR ATTENTION TO GASTROSTOMY.

Based on staff interviews, record review, and facility policy review, the facility failed to complete a baseline care plan that included the minimum healthcare information necessary to provide effective, person-centered care. This failure resulted in the residents' transfer needs not being identified or communicated to staff. This deficient practice was identified for one (1) of five (5) residents reviewed for baseline care plans (Resident #1). Cross-reference F689. Findings include: Review of the facility policy titled, “Care Plans-Baseline,” last reviewed 6/2/25, revealed: “The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident.” Record review of the Baseline Care Plan for Resident #1 dated 9/3/25 (day of admission) revealed Self-Care: admission Performance – Chair/bed to chair transfer was marked not assessed/no information. Record review of the Visual/Bedside Kardex Report as of 9/23/25 for Resident #1 revealed Transfer Assistance: no information listed. Record review of the Section GG Mobility form for Resident #1 dated 9/4/25 revealed chair/bed transfer coded as dependent. Record review of Resident #1's progress note dated 9/18/25 documented: “Resident obtained a laceration during transfer from bed to chair. Classified as trauma injury. Area measured 4.5 cm (centimeter) x 5.5 cm x 0.2 cm.” On 9/22/25 at 3:00 PM, during an interview with the Risk Manager she confirmed Resident #1 was dependent and required a total lift for transfers. She acknowledged this information was not reflected on the Kardex and confirmed staff should have consulted the nurse supervisor for clarification. During an interview with the Minimum Data Set (MDS) Coordinator on 9/23/25 at 8:50 AM, she confirmed the baseline care plan was incomplete related to Resident #1's transfer status, and the Kardex was missing this information as well. She stated the resident was dependent and required a total lift for transfer, and staff should have clarified with the nurse supervisor when the information was not documented. Record review of the “admission Record” revealed Resident #1 was admitted on [DATE] with a diagnosis of alcoholic cirrhosis of liver with ascites. Record review of Resident #1's MDS with an Assessment Reference Date (ARD) of 9/12/25 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure Resident #1 was transferred safely in accordance with her assessed needs. Staff performed a manual transfer instead of using the required total lift, which resulted in a traumatic injury to the resident's right leg. This deficient practice was identified for one (1) of three (3) residents reviewed for accident hazards (Resident #1). Cross-reference F655 Findings include: Review of the facility policy titled, “Safe Patient Handling and Moving Protocol,” latest review 6/18/25, revealed: “The licensed nurse will, upon resident admission, determine the level of assistance required to safely transfer the resident, while minimizing risk to resident and staff.” An observation and interview on 9/22/25 at 2:00 PM revealed Resident #1 with a large bandage to her right lateral lower leg. She stated that on 9/18/25 two staff members attempted to transfer her from the bed to the wheelchair without using a mechanical lift. She stated she told the staff she required the lift because she was very weak, but they proceeded to remove the wheelchair armrest and slide her over. She reported her legs and torso slipped downward, striking the exposed metal of the wheelchair armrest slot, causing a laceration to her right leg. In an interview with Resident #1's Representative (RR) on 9/22/25 at 2:10 PM, she confirmed that she observed the staff transfer Resident #1 without a lift on 9/18/25 after both her and the resident informed them that a lift was required. She confirmed that the resident slipped, her right leg struck the wheelchair, and a laceration occurred. Record review of the Section GG Mobility form for Resident #1 date 9/4/25 revealed chair/bed transfer coded dependent. During an interview on 9/23/25 at 8:27 AM, Certified Nurse Assistant (CNA) #2 confirmed she assisted with the transfer along with the Van Transporter (VT) for Resident #1 on 9/18/25. She stated they slid the resident into the wheelchair, and the resident's leg struck the metal frame, resulting in a tear. She confirmed the sling pad was in the wheelchair seat but stated she did not think to question why. During an interview on 9/23/25 at 8:30 AM, the VT confirmed she assisted with the transfer of Resident #1 on 9/18/25 and acknowledged the resident slipped. She admitted that she noticed the sling pad in the resident's chair but did not question it. During an interview on 9/23/25 at 8:45 AM, the Treatment Nurse stated that she assessed Resident #1's wound after the transfer on 9/18/25 and confirmed it was a trauma laceration, not a skin tear. She measured the injury at 4.5 centimeter (cm) x 5.5 cm x 0.2 cm and confirmed it occurred when staff manually slid the resident instead of using the lift. Record review of Resident #1's progress note dated 9/18/25 documented: “Resident obtained a laceration during transfer from bed to chair. Classified as trauma injury. Area measured 4.5 cm x 5.5 cm x 0.2 cm.” During an interview with the Risk Manager on 9/22/25 at 3:00 PM, she confirmed Resident #1 was not transferred according to her assessed needs. She stated the resident was dependent and required a total lift for transfers. She further confirmed the transfer status was not reflected on the Kardex for staff to follow, and that staff should have consulted the nurse supervisor to clarify. She acknowledged that failing to transfer a resident properly can lead to accidents. Record review of the “admission Record” revealed Resident #1 was admitted on [DATE] with a diagnosis of alcoholic cirrhosis of liver with ascites. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/12/25 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

Based on staff interviews, record review and facility policy review, the facility failed to ensure that a resident was free from restraints for one (1) of three (3) residents reviewed: Resident #1. Based on the implementation of the facility's corrective actions on 2/18/25, the deficient practice was determined to be past noncompliance, and the facility was found in compliance as of 2/19/25. Findings Include: A review of the facility policy titled Facility Policy on Personal Safety Devices (PSDs) with a revision date of 02/2025 - Enablers - Side Rails and Restraints revealed the following: Restraint Policy Intent: Patients/Residents have the right to be free from any physical restraint imposed for purposes of discipline or convenience . Record review of the Admission Record revealed that the facility admitted Resident #1 on 12/5/24 with a medical diagnosis that included Unspecified Dementia. A record review of the facility investigation revealed that on 2/18/25, an allegation of restraint was reported to the Director of Nursing (DON). The DON was notified by Licensed Practical Nurse #1 (LPN #1) that Resident #1 was observed lying on her left side with a sheet tied across her chest to the bed frame and another sheet tied across her legs to the bed frame. It was further alleged that LPN #2 was the perpetrator. It was reported that LPN #1 and Certified Nursing Assistant #1 (CNA #1) immediately went to the room and removed the bed sheets. The DON notified the Administrator (ADM) of the allegation. LPN #2 was interviewed by the ADM and was notified of suspension pending investigation. A complete body audit of Resident #1 revealed no adverse findings. Resident #1 was placed under one-on-one observation until further notice. Upon completion of staff interviews assigned to the shift on 2/18/25, it was determined that LPN #2 had secured two flat sheets across Resident #1's torso and lower extremities, tying them to the bed frame. Additionally, it was established that the resident was restrained for approximately five (5) minutes before being released. LPN #2 denied the allegations but verbally admitted to securing the sheet at two corners, stating that this was intended to prevent the resident from getting up unassisted to avoid falls and to aid with turning. In conclusion, the allegations were substantiated, and LPN #2 was terminated. A review of a written statement dated 2/18/25 and signed by LPN #2 revealed: Resident was up and down throughout the night, in and out of bed, using a wheelchair, and walking in the dining room. Numerous attempts to redirect and educate failed by CNA staff and the nurse. The resident continued talking to persons not present. This nurse took a flat sheet and laid it across the top of the resident, sat there, and explained the importance of not getting out of bed. The nurse reminded the resident of her last two falls and discussed the use of the sheet across the top of her as an indicator/reminder that she should not get out of bed. This nurse tucked one side of the sheet loosely under the mattress, with the other side open and resting on the floor mat. The resident remained in bed for the rest of the night. The resident was not restrained in any way and was fully capable of movement in bed and of getting out of bed, as demonstrated earlier. The use of the flat sheet was a 'mind over matter' approach for the safety of the resident, as the resident had previously harmed herself by attempting to ambulate and transfer without assistance while refusing to call for help. A review of a written statement dated 2/18/25 and signed by CNA #3 revealed that during rounds, she witnessed Resident #1 tied in two (2) places to her bed with sheets-one across the legs and the other across the abdomen. A review of an undated witness statement signed by CNA #4 revealed that LPN #2 stated she had tied Resident #1 up. The assigned agency CNA checked the resident and reported that she was restrained. During a telephone interview with LPN #1 on 2/24/25 at 3:41 PM, she stated that when she returned from lunch between 2:00 AM and 2:30 AM, CNA #4 informed her that Resident #1 was tied to the bed. LPN #1 went to the room and observed a sheet over the resident's torso, tied under the bed, and another sheet over the resident's legs, also tied under the bed. She stated that the resident was asleep and in no distress. She immediately removed the sheets, evaluated the resident, and noted no injuries. She then notified the DON. In an interview with the ADM on 2/24/25 at 11:00 AM, the ADM confirmed that on 2/18/25, she received a report that Resident #1 had been restrained to her bed with sheets by LPN #2. She verified that the investigation revealed that Resident #1 was seen by staff lying on her left side with a sheet tied across her chest to the bed frame and another sheet tied across her legs to the bed frame. Staff immediately removed the sheets and evaluated the resident, who was found to have no injuries. She stated that on 2/18/25, LPN #2 was suspended pending investigation and subsequently terminated when the investigation substantiated that she had restrained Resident #1. The ADM further stated that on 2/18/25 at 7:30 AM, the Risk Manager initiated an update of the care plan for Resident #1. The Staff Development Coordinator provided education to all staff on abuse prohibition, resident rights, the Vulnerable Adults Act, the Restraint-Free Facility Initiative, and a physical abuse competency quiz. A head-to-toe body assessment was conducted by the Registered Nurse Supervisor, with no negative findings. The Medical Director was notified, and Resident #1 was placed on one-on-one monitoring. A telehealth visit with a Psychiatric Nurse Practitioner, along with the Assistant DON and Resident #1, resulted in no negative findings. The DON notified Resident #1's resident representative. Record review revealed that on 2/18/25 at 10:30 AM, life satisfaction rounds were conducted with residents scoring 12 or higher on the Brief Interview for Mental Status (BIMS) test to determine any knowledge of the perpetrator, witness accounts, or experience of abuse. Peer reviews were also initiated with staff to assess any knowledge of the perpetrator or abuse incidents. A physician assessed Resident #1, noting no negative findings. The Social Services Director conducted a trauma assessment on the resident. Record review revealed that at 2:30 PM on 2/18/25, an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held to assess the situation, establish a timeline of events, discuss immediate and systemic actions, and develop monitoring plans related to Resident #1's restraint incident. On 2/19/25 at 4:15 PM, a Resident Council Meeting was held to inform residents of the incident, discuss the suspension of the perpetrator, and provide education on different forms of abuse, including restraints and reporting procedures. The facility committed to conducting abuse drills for three (3) months, then quarterly. Random resident interviews and body audits will be conducted weekly for four (4) weeks, biweekly for eight (8) weeks, and then monthly for three (3) months. Findings will be reviewed by the QAPI Committee for further action. In a further interview on 2/25/25 at 8:45 AM, the ADM reiterated that the facility maintains a restraint-free policy and that it was her expectation that LPN #2 would not have restrained Resident #1. Validation: On 2/25/25, the State Agency (SA) validated through interviews and record reviews that all corrective actions had been implemented as of 2/18/25, and the facility was in compliance as of 2/19/25, prior to the SA's entrance on 2/24/25.

Based on staff interviews, record review and facility policy review, the facility failed to provide a Registered Nurse (RN) eight (8) hours a day for one (1) of 14 staffing days reviewed. Findings Include Record review of the facility policy titled, Staffing, Sufficient and Competent Nursing with a review date of 3-2023 revealed under Policy Interpretation and Implementation: Sufficient Staffing .A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week . Record review of the Staffing Grid for the dates of 12/24/24 through 1/6/25 revealed there was no RN coverage on 12/25/24. An interview on 1/6/25 at 11:15 AM with the Director of Nurses (DON) confirmed there was no RN coverage on 12/25/24. She stated that the RN that was scheduled did not call in or show up and no one notified her. She stated that she figured it out around noon on Christmas Day when she looked through the computer at the time clock ins. She admitted that she did not come to cover it, everyone else was on vacation and they are not allowed to use agency RN for coverage. She confirmed that the purpose of having an RN on duty is for supervision to handle emergencies or intravenous medications (IV). She admitted there were no incidents or IV therapy on 12/25/24. An interview on 1/6/25 at 2:45 PM with the Administrator confirmed there was no RN coverage on 12/25/24. She stated that the DON put an RN on the schedule that had already requested off for that day and is not sure if the DON just forgot or was not aware. She confirmed that they need an RN for at least 8 hours a day to handle emergencies and IV's. She verifies that the DON was the person that should have covered it. A follow up interview on 1/6/25 at 3:00 PM with the DON confirmed that she does the schedule, and she put an RN on the schedule that had requested off, but she was not aware of her request. She stated that after she put the schedule out that the RN called and told her that she had already requested off for that day. When asked if she expected her to come to work after that phone conversation she stated, she never said she wasn't. When asked if she should have come in and covered, she stated, Yes but I was not coming in to cover someone else's responsibility and miss my family.

Based on staff interviews, record review, and facility policy review, the facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one (1) of the four quarters reviewed. Fourth quarter 2024 Findings include: Record review of the facility policy titled, Reporting Direct-Care Staffing Information (Payroll-Based Journal) Dated October 2022, revealed, . 10 .Staffing data includes the number of hours worked each day by each staff member. Record review of PBJ Staffing Data Report CASPER (Certification and Survey Provider Enhanced Reporting) Report 1705D FY (Fiscal Year) Quarter 4 2024 (July 1-September 30) revealed Excessively Low Weekend Staffing-Triggered. Triggered=Submitted Weekend Staffing data is excessively low. During an interview on 1/09/25 at 8:27 AM with the Administrator and the Director of Nurses (DON), they confirmed that the data entered for the fourth quarter PBJ was entered incorrectly and did not capture the full direct care on the PBJ. The DON revealed they had an issue with employees failing to clock out and in for weekend mealtimes, affecting their overall weekend hours.

Based on staff and resident interviews, record review, and facility policy review the facility failed to send a written transfer/discharge notice to a resident or resident representative for a hospital transfer for three (3) of 3 residents reviewed. Residents #8, # 27, and #45 Findings include: Record review of the facility policy, titled Transfer or Discharge Documentation and Notice with a review date of 5/17/24 revealed under Policy Interpretation and Implementation .5. The residents and representatives are notified in writing the following information: a. the specific reason for the transfer . Resident #8 Record review of the Discharge Minimum Data Set (MDS) for Resident #8 with an Assessment Reference Date (ARD) of 8/22/24 revealed, Section A-2000: discharge date : 8/22/24 . Section A-2105: Discharge Status: coded Short-Term General Hospital. During an interview on 1/7/25 at 12:45 PM, the Social Services Director revealed that she had not sent a written discharge/transfer notification form to any resident or resident representative and was unaware that she needed to provide the notifications when they went to the hospital. Record review of the Admission Record revealed that Resident #8 was admitted to the facility on [DATE], and her most recent hospital stay was from 08/22/2024 to 08/30/2024. Resident #8 was admitted with medical diagnoses that included End Stage Renal Disease, and Diastolic (Congestive) Heart Failure. 47158 Resident #27 Record review of Resident #27's electronic Census status revealed that the resident was transferred to the hospital on 5/9/24, 5/26/24, 7/3/24 and 7/13/24. Record review of Resident #27's electronic Contacts list revealed that Resident #27 was his own Responsible Party (RP). An interview with Resident #27 on 1/6/24 at 11:30 AM, he stated he had not received a written transfer notification for any of his hospitalization s. An interview with the Administrator on 1/7/24 at 2:45 PM stated that it was important to provide the resident or responsible party with a written transfer notification so that they could understand why they were transferred. The Administrator stated that it was her expectation that the Social Services Director would have provided the Resident/Resident Representative with a written transfer notification. Record review of the Admission Record revealed the facility admitted Resident # 27 on 3/15/21 with diagnoses that included Chronic Obstructive Pulmonary Disease. Record review of the Quarterly MDS with an ARD of 12/5/24 revealed Resident # 27 had a Brief Interview for Mental Status (BIMS) score of 15, which indicates he is cognitively intact. 47157 Resident #45 Record review of the Discharge MDS for Resident #45 with an ARD of 11/28/24 revealed, Section A-2000: discharge date : 11/28/24 . Section A-2105: Discharge Status : coded Short-Term General Hospital. Record review of the Discharge MDS for Resident #45 with an ARD of 12/06/24 revealed, Section A-2000: discharge date : 12/06/24 . Section A-2105: Discharge Status : coded Short-Term General Hospital. Record review Discharge MDS for Resident #45 with an ARD of 12/27/24 revealed, Section A-2000: discharge date : 12/27/24 . Section A-2105: Discharge Status : coded Short-Term General Hospital. Review of the Admission Record revealed Resident #45 was admitted by the facility on 11/12/24 with a diagnosis of Malignant Neoplasm of Glottis.

Based on staff and resident interview, record review, and facility policy review the facility failed to send a bed hold notice to a resident or resident representative following a transfer for three (3) of 3 resident hospitalization s reviewed. Residents #8, # 27, and #45 Findings Include Record review of the facility policy, titled Transfer or Discharge Documentation and Notice with a review date of 5/17/24 revealed under Policy Interpretation and Implementation .5. The resident and representative are notified in writing the following information .e. the facility bed hold policy . Resident #8 Record review Discharge Minimum Data Set (MDS) for Resident #8 with an Assessment Reference Date of 8/22/24 revealed, Section A-2000: discharge date : 8/22/24 . Section A-2105: Discharge Status: coded Short-Term General Hospital. Record review of the Admission Record revealed that Resident #8 was admitted to the facility on [DATE], and her most recent hospital stay was from 08/22/2024 to 08/30/2024. Resident #8 was admitted with medical diagnoses that included End Stage Renal Disease, and Diastolic (Congestive) heart failure. 47158 Resident #27 Record review of Resident #27's electronic Census status revealed that the resident was transferred to the hospital on 5/9/24, 5/26/24, 7/3/24 and 7/13/24. Record review of Resident #27's electronic Contacts list revealed that Resident #27 was his own Responsible Party (RP). An interview with Resident #27 on 1/6/24 at 11:30 AM, he stated that he had not received a written notification of the facility bed-hold policy for any of his hospitalization s. Record review of the Admission Record revealed the facility admitted Resident # 27 on 3/15/21 with diagnosis that included Chronic Obstructive Pulmonary Disease. Record review of the Quarterly MDS with an ARD of 12/5/24 revealed Resident # 27 had a Brief Interview for Mental Status (BIMS) score of 15, which indicates he is cognitively intact. 47157 Resident #45 Record review Discharge MDS for Resident #45 with an ARD of 11/28/24 revealed, Section A-2000: discharge date : 11/28/24 . Section A-2105: Discharge Status : coded Short-Term General Hospital. Record review Discharge MDS for Resident #45 with an ARD of 12/06/24 revealed, Section A-2000: discharge date : 12/06/24 . Section A-2105: Discharge Status : coded Short-Term General Hospital. Record review Discharge MDS for Resident #45 with an ARD of 12/27/24 revealed, Section A-2000: discharge date : 12/27/24 . Section A-2105: Discharge Status : coded Short-Term General Hospital. Review of the Admission Record revealed Resident #45 was admitted by the facility on 11/12/24 with a diagnosis of Malignant Neoplasm of Glottis. An interview with Social Services on 1/7/25 at 12:50 PM, she stated that she did not provide a written notification of the bed-hold policy to Resident #8, #27,or #45 for any of their hospital transfers. She stated that she did not realize that she needed to provide the residents or resident representative this notification. An interview with the Administrator on 1/7/24 at 2: 45 PM she stated that the importance of providing the resident or resident representative with a bed-hold notification was to give them an opportunity to decide if they want to hold their bed at the facility. The Administrator stated that her expectations were that Social Services would have provided the Resident/Resident Representative with a written bed-hold policy notification.

Based on observation, resident and staff interviews, record reviews, and facility policy reviews, the facility failed to implement a comprehensive care plan for personal hygiene for three (3) of 23 resident care plans reviewed. Residents #17, #49, and #57 Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered dated 10-2022 revealed under Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #17 Record review of Resident #17's Care Plans, undated revealed Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) decreased mobility and generalize weakness .Interventions .Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. The resident is totally dependent on one (1) staff with personal hygiene. On 1/06/25 at 9:30 AM, an observation and interview with Resident #17 revealed long and jagged fingernails with a brown substance under the nails on bilateral hands that measured approximately one (1) inch long. Facial hair measured approximately three-fourths (3/4) inch long to sporadic areas of her chin. Resident #17 stated, I don't like these whiskers. They are very long, and they need to be cut. She revealed it's been a while since I've had my fingernails cut, and I would like them cleaned and trimmed. On 1/07/25 at 1:00 PM, an observation and interview the Director of Nurses (DON) confirmed Resident #17's fingernails were long, jagged, and had a substance under them. The DON revealed that the nurses are responsible for trimming her fingernails since she is diabetic, and trimming her facial hair is part of her daily grooming when she gets a bed bath or shower. She revealed that with her fingernails, long and jagged, she could scratch herself and cause skin concerns. The DON confirmed that Resident #17 had long facial hair in her chin area and revealed that she had not been properly groomed. A review of the Admission Record revealed the facility admitted Resident #17 on 11/19/2019 with medical diagnoses that included Type 2 Diabetes Mellitus, Chronic Pulmonary Edema, and Heart Failure. Record review of Resident #17's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10-29-2024 revealed, under Section C, a Brief Interview for Mental Status (BIMS) summary score of 14, which indicates the resident is cognitively intact. Resident #49 Record review of Resident #49's Care Plans, date initiated: 08/19/2024, revealed Focus: The resident has an ADL self-care performance deficit r/t Activity Intolerance, Dementia, Limited Mobility . Interventions: The resident is totally dependent on 1 staff with personal hygiene and oral care. The resident requires extensive assistance by two (2) staff for toileting. An observation on 1/06/25 at 08:15 AM, revealed a strong urine smell when standing by Resident #49's bed and with approximately 3/4 inch of facial hair growth on his chin, above his lip, and on the sides of his cheeks. CNA #7 entered the room upon the State Agent's (SA) request and pulled back the blanket covering the resident. The resident was lying on a sheet that was saturated with urine extending from the right side of the resident's waist up to his torso and extending out approximately eight (8) inches towards the edge of the bed. The saturated urine area had a brown ring around the outer edges. CNA #7 confirmed that Resident #49 was lying in a large amount of urine and revealed that it looked like the night shift did not change him. On 1/6/25 at 8:55 AM, during an interview the DON confirmed that Resident #49 had long facial hair and revealed she wasn't sure when he was last properly groomed. She revealed the plan of care regarding his hygiene was not being followed, and it should have been. Record review of the Admission Record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, Type 2 Diabetes Mellitus, Hemiplegia, and Hemiparesis. Resident #57 Record review of Resident #57's Care Plans, date initiated: 10/20/2021, revealed Focus: The resident has an ADL self-care performance deficit r/t Confusion, Impaired balance . Interventions . Personal Hygiene: The resident is totally dependent on two (2) staff members for personal hygiene. On 1/06/25 at 8:00 AM, an observation revealed Resident #57 lying in bed with approximately 1-inch long facial hair growth on his chin, above his lip, and on the sides of his cheeks. Resident #57's fingernails on bilateral hands were approximately one-half (1/2) inch long and jagged with a brown substance under his fingernails. On 1/06/25 at 8:30 AM, during an observation and interview the DON confirmed that Resident #57 was unshaven, and his fingernails were long, jagged, and dirty. The DON revealed that it is the CNAs' responsibility to ensure the resident is shaven and adequately groomed, and the nurses are responsible for his nail care since he is a diabetic. During an interview on 1/07/25 at 2:40 PM, the Minimum Data Set (MDS) Nurse #1 revealed both MDS Coordinators are responsible for developing the resident's care plans. She revealed that it is patient-centered and addresses all areas of care that the resident is to receive. She revealed that the comprehensive care plans for Residents #17, #47, and #59 were not followed if the residents were not adequately groomed. She revealed that personal hygiene and bathing also covered nail care, perineal care, and shaving. MDS Coordinator #1 revealed there is no excuse for a resident not to have the care specified in their care plan. Record review of the Admission Record for Resident #57 revealed he was admitted to the facility on [DATE] with diagnoses that included Need for Assistance with Personal Care and Type 2 Diabetes Mellitus.

Based on observation, staff interviews, and facility policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by failing to utilize proper hand hygiene for one (1) of five (5) resident direct care observations. Resident #37 Findings include: Review of the facility policy titled, Handwashing-Hand Hygiene Policy and Procedures with a revised date of 10-2020 revealed, This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .g. Before handling clean or soiled dressings, gauze pads, etc .; k. After handling used dressings . An observation and interview on 1/8/25 at 9:50 AM with Registered Nurse (RN) #1 providing wound care for Resident #37 with the Director of Nurses (DON) present revealed RN #1 washed her hands, applied clean gloves after removing the residents wound bandage. RN#1 then cleaned Resident #37's sacral wound, patted the wound bed with a dry gauze and then applied Santyl ointment to the wound without changing her soiled gloves, washing her hands, and applying clean gloves. RN #1 confirmed she had not washed her hands and changed her gloves between the dirty and clean procedures and acknowledged that not practicing proper infection control measures could potentially cause an infection in the wound. An interview on 1/08/25 at 2:34 PM with the DON confirmed proper hand hygiene was not performed during the wound treatment for Resident #37 and confirmed their policy is to make sure to change gloves and wash hands between dirty and clean wound treatment. She revealed that not doing so is an infection control issue and could delay healing. A record review of Resident #37's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included a Pressure Ulcer of the Sacral Region, Stage 4.

Based on observations, resident and staff interviews, and facility policy reviews, the facility failed to provide a clean, comfortable, and homelike environment as evidenced by broken blinds or window coverings on three (3) of six (6) hallways observed during survey. Rooms 203, 505, 601, and 607. Findings included: A review of the facility policy titled Homelike Environment with a revision date of 02/2023 revealed under the Policy Statement .Residents are provided with a safe, clean, comfortable environment . During an initial facility tour on 1/6/25, beginning at 7:45 AM, observations revealed broken or missing slats on window blinds in Rooms 203, 505, 601, and 607. This observation revealed there were residents residing in these rooms and the broken blinds allowed the room to be visible from outside the building. An observation of room [ROOM NUMBER] on 1/6/25 at 8:00 AM, revealed four (4) broken slats on the left side of the blinds. An observation of room [ROOM NUMBER] on 1/6/25 at 9:05 AM, revealed four (4) missing slats at the bottom of the blinds. An observation of room [ROOM NUMBER] on 1/6/25 at 3:19 PM revealed ten (10) missing slats on the blinds. In an observation and interview with Certified Nursing Assistant (CNA) #4 on 1/7/25 at 1:00 PM, she confirmed that the window blinds were broken with multiple missing pieces. CNA #4 stated that maintenance needs are typically reported verbally to the Maintenance Director or Administrator, as there is no formal documentation process. She admitted she had noticed the broken blinds but forgot to report the issue due to other responsibilities. During an interview with the Administrator on 1/7/25 at 1:15 PM confirmed that she was aware of the broken blinds because she conducts daily rounds. She stated that she reports maintenance needs to the maintenance director and that replacement blinds had been received but admits they had not been put up yet. She admitted there was no documentation of her rounds or maintenance notifications regarding the blinds. In an interview with the Maintenance Director on 1/7/25 at 1:24 PM, he confirmed that he was aware of the broken blinds in multiple rooms and stated that some replacement blinds had arrived the previous week, but none had been installed yet. He then verified that there was no documentation available to show when the blinds were ordered.

Based on resident and staff interviews, record reviews, and facility policy reviews, the facility failed to protect a resident from verbal abuse for one (1) of 23 sampled residents. Resident #60. Findings Included: A review of the facility's policy titled Policy for Prohibition of Abuse, Neglect, and Misappropriation of Property with no revision date revealed under Intent .Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. Record review of the facility's investigation revealed that on 9/9/24 at 9:30 AM, Resident #60 reported that Certified Nursing Assistant (CNA) #5 made a verbal threat toward him on 9/8/24. Resident #60 stated that CNA #5 asked him to throw something in the trash, and when he refused, she responded by telling him she would run him over with her truck. This incident occurred as CNA #5 was leaving the facility. Witnesses stated that CNA #5 backed up, screeched her tires, and left the parking lot. Resident #60 was behind her vehicle in his motorized wheelchair at the time. No physical contact occurred. CNA #5 was suspended pending an investigation. The facility substantiated that verbal abuse occurred. A review of a written statement dated 9/9/24 and signed by CNA #5 revealed that she asked Resident #60 to throw something away while he was outside the facility. She stated that the resident insulted her, calling her an expletive. She responded by saying, Stop please and move and chill out, to which the resident replied that he did not have to do anything for her. CNA #5 stated that she got into her truck, put it in reverse, and assumed the resident would move. In an interview with Resident #60 on 1/6/25 at 9:00 AM, he recalled that on the morning of 9/8/24, at approximately 9:30 AM, CNA #5 asked him to throw something away but did so with an attitude. He told her he did not have to do anything for her. Resident #60 stated that CNA #5 then threatened to run him over, entered her truck, and began backing up while he was positioned behind and slightly to the left of her vehicle. She stopped, screeched her tires, and left the parking lot. Resident #60 reported feeling that CNA #5 intended to hit him but confirmed that no contact occurred. During an interview with CNA #3 on 1/6/25 at 2:40 PM, she stated that on 9/8/24 at around 9:30 AM, she witnessed CNA #5 asking Resident #60 to throw something away. Resident #60 threw the item on the ground and told CNA #5 to throw it away herself. CNA #3 reported hearing CNA #5 state, I ought to run down your [expletive]. She then observed CNA #5 back up toward Resident #60, screech her tires, and leave the facility. In an interview with the Administrator (ADM) on 1/6/25 at 3:00 PM, she confirmed that on 9/9/24, she received a report from Resident #60 about the incident on 9/8/24. The report indicated that CNA #5 was rude and verbally threatened to run over Resident #60 with her vehicle. The ADM stated that CNA #5 was immediately suspended pending investigation. She confirmed that the investigation substantiated verbal abuse by CNA #5. A review of Resident #60's Admission Record revealed that he was admitted to the facility on [DATE] with a diagnosis of an Unspecified Injury at the T2-T6 Level of the Thoracic Spinal Cord. A review of the Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/12/24 revealed that Resident #60 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that he is cognitively intact.

Based on observation, resident and staff interview, record review and facility policy review, the facility failed to implement a baseline care plan related to preferences and personal hygiene care for (1) one of 29 resident care plans reviewed. (Resident #195) Findings include: Review of the facility policy titled, Care Plans-Baseline, with a revision date of March 2022 revealed under Policy Interpretation and Implementation .the baseline care plan includes instructions needed to provide effective, person-centered care of the residents that meet professional standards of quality and must include the minimum healthcare information necessary to properly care for the resident . Review of the Baseline care plan for Resident #195 dated 12/21/24, revealed, Daily preferences that a resident prefers: receiving showers checked. Functional Abilities and Goals-Self Care: Shower/bathe care: coded requires partial/moderate assistance. I.) Personal Hygiene: coded requires setup or clean-up assistance. An observation and interview with Resident #195 on 1/6/25 at 9:00 AM revealed his hair appeared mated and his fingernails were approximately one-half (1/2) inch past the tips of the fingers with a brown substance underneath. He stated that he had been in the facility a couple of weeks and had not had a shower, shave or brushed his hair. He stated that he told the staff during admission that he preferred showers and had asked for one several times. In an interview with the Minimum Data Set (MDS) Coordinator #2 on 1/07/25 at 10:50 AM, she revealed after reviewing the baseline care plan for Resident #195, that the care plan reflected that it was the resident's preference to receive showers and required assistance with bathing and personal hygiene. She then confirmed if staff did not shower the resident, they did not implement his care plan for his preferences. She also confirmed if staff did not assist the resident with bathing and personal hygiene needs, staff did not implement his care plan related to self-care performance. The MDS Coordinator also revealed the purpose of any type of care plan is to direct resident specific care required to meet their needs. Review of the Admission Record revealed Resident #195 was admitted by the facility on 12/21/24 with a diagnosis of Acute Kidney Failure. Record review of Resident #195's Admission MDS with an Assessment Reference Date (ARD) of 12/27/24, revealed the Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact. Section GG0130: Self Care, revealed, E.) Shower/bathe: coded requires substantial/maximal assistance and I.) Personal Hygiene: coded requires supervision or touching assistance.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide personal hygiene for four (4) of 29 sampled residents. Residents #17, #49, #57, and #195 Findings include: Review of the facility policy titled Activities of Daily Living (ADL), Supporting with a revision date of March 2018 revealed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Resident #17 An observation and interview with Resident #17 on 1/06/25 at 9:30 AM revealed long and jagged fingernails measuring approximately one (1) inch long past the tip of the fingers with a brown substance under the nails on bilateral hands, facial hair approximately three-fourths (3/4) inch long to sporadic areas of her chin. Resident #17 stated, I don't like these whiskers. They are very long, and they need to be cut. She revealed it's been a while since she had her fingernails cut and wanted them cleaned and trimmed. An observation on 1/06/25 at 2:45 PM revealed Resident #17 sitting in the hallway with no change in appearance. An observation on 1/07/25 at 8:25 AM revealed Resident #17 with no change in appearance regarding long, jagged nails and long facial hair to the chin area. An observation and interview on 1/07/25 at 12:50 PM Certified Nurse Aide (CNA) #6 revealed she was assigned to Resident #17 today and confirmed the resident had a lot of facial hair to her chin area and the resident's fingernails were long and jagged with a brown substance under them. She revealed she couldn't cut the resident's fingernails but could have ensured they were cleaned up. Resident #13 told CNA #6 she wanted her nails trimmed and her facial hair removed. An observation and interview on 1/07/25 at 1:00 PM, the Director of Nurses (DON) confirmed Resident #17's fingernails were long, jagged, and had a substance under them. The DON revealed that the nurses are responsible for trimming her fingernails since she is diabetic, and trimming her facial hair is part of her daily grooming when she gets a bed bath or shower. She revealed that with her fingernails, long and jagged, she could scratch herself and cause skin concerns. The DON confirmed that Resident #17 had long facial hair in her chin area and revealed that she had not been properly groomed. During an interview on 1/07/25 at 1:47 PM, Licensed Practical Nurse (LPN) #1 revealed she cleaned and trimmed Resident #17's fingernails about a month ago. She revealed there is no set day to do nail care and there is not a reminder in the documenting system; she stated, We just do nail care when we notice that it needs to be done. I take full responsibility for not doing her nail care. Record review of the Admission Record revealed the facility admitted Resident #17 on 11/19/2019 with medical diagnoses that included Type 2 Diabetes Mellitus, Chronic Pulmonary Edema, and Heart Failure. Record review of Resident #17's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10-29-2024 revealed, under Section C, a Brief Interview for Mental Status (BIMS) summary score of 14, which indicates the resident is cognitively intact. Resident #49 On 1/06/25 at 08:15 AM, an observation revealed a strong urine smell when standing by Resident #49's bed. CNA #7 entered the room upon the State Agent's (SA) request and pulled back the blanket covering the resident. The resident was lying on a sheet that was saturated with urine extending from the right side of the resident's waist up to his torso and extending out approximately eight (8) inches towards the edge of the bed. The saturated urine area had a brown ring around the outer edges. CNA #7 confirmed that Resident #49 was lying in a large amount of urine and stated, You can tell he has not been changed in a while because of that brown ring around the outer edge. This observation also revealed Resident #49 with approx. 3/4 inch of facial hair growth on his chin, above his lip, and on the sides of his cheeks. During an observation and interview on 1/06/25 at 8:20 AM, LPN #1 confirmed she could smell a strong urine smell and that the urine-saturated sheet had a dried brown ring. She revealed that the urine looked like it had been there for a while and confirmed the resident was unshaven and unkempt. During an observation and interview on 1/06/25 at 8:30 AM, the Administrator (ADM) confirmed that Resident #49 was lying on a urine-saturated sheet with a brown ring around the outer edges of the stain. She revealed that this is not acceptable and confirmed that he doesn't look like he has been groomed in quite some time and has been left wet for a while. An observation and interview on 1/6/25 at 8:35 AM CNA #7 revealed she is assigned to the resident today and made quick rounds when she came on her shift at 7 AM, just glancing in at her residents, and Resident #49 was asleep; she revealed she hadn't changed his brief this morning because she got busy assisting with breakfast. She stated the resident had not been shaved in quite some time, and with his sheets being wet, I can tell you that the night shift did not change him like they were supposed to. During an interview on 1/6/25 at 8:55 AM, the DON confirmed that Resident #49 had long facial hair and revealed she wasn't sure when he was last properly groomed. She revealed there was no excuse for the resident to be found lying in urine and stated, We obviously have an issue with care not being done. Record review of the Admission Record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, Type 2 Diabetes Mellitus, Hemiplegia, and Hemiparesis. Resident #57 An observation on 1/06/25 at 8:00 AM revealed Resident #57 lying in bed with facial hair growth on his chin, above his lip, and on the sides of his cheeks that was approximately 1 inch long. Resident #57's fingernails were approximately one-half (1/2) inch long, jagged and had a brown substance underneath them on both hands. During an observation and interview on 1/06/25 at 8:10 AM, LPN #1 confirmed Resident #57 was unshaven with fingernails that were long and jagged, with a brown substance under them. She revealed she wasn't sure when the resident was shaven, but it looks like it has been a while. She revealed it is the nurses' responsibility to do his nail care since he is diabetic and revealed we do it whenever we notice they are getting long. She confirmed it had been about a month since the resident's nails were trimmed. During an observation and interview on 1/06/25 at 8:20 AM, CNA #8 revealed she was assigned to the resident today and wasn't sure what day the resident was supposed to get his showers. She revealed we take them when they need to be cleaned up or give them a bed bath. She revealed that it looked like the resident hadn't been shaven in a long time, and his nails were very long and dirty. During an observation and interview on 1/06/25 at 8:30 AM, the DON confirmed that Resident #57 was unshaven, and his fingernails were long, jagged, and dirty. She revealed that the resident could scratch himself and possibly cause an infection. The DON stated, The CNA's are responsible for making sure residents are properly groomed, and it honestly looks like it's been a while since that has happened. Record review of the Admission Record for Resident #57 revealed he was admitted to the facility on [DATE] with diagnoses that included Need for Assistance with Personal Care and Type 2 Diabetes Mellitus. 47157 Resident #195 An observation and interview on 1/06/25 at 9:00 AM revealed Resident #195's hair and beard to be unkept and matted in appearance, his fingernails were observed to be approximately 1/2 inch long with a thick dark brown substance under the nail beds. Resident #195 stated he had been in the facility for a little over two weeks and had not received a shower, a shave, or even had his hair brushed. He then stated that his nails had also not been trimmed or cleaned since he was admitted . Resident #195 stated he had asked for a shower several times and the staff would say ok but would never come back to give him a shower, and stated, I am unable to get up by myself, or I would try to do it myself. In an observation of Resident #195 on 1/6/24 at 12:10 PM with CNA #1 assigned to the resident, she confirmed that the resident's hair and beard were unkept and did not appear clean. She then stated he did not appear that he had received a shower lately and confirmed the resident's nails were dirty, long, and jagged with some type of brown substance under his nail beds. She then confirmed she had not attempted to do nail care on the resident or give him a shower. CNA #1 then revealed the facility did not have a shower schedule in place letting the staff know when the residents are to be bathed and stated that nail care should be provided as needed. In an interview with the shower CNA #2 and record review on 1/06/24 at 1:00 PM, she confirmed the facility did not have a set shower schedule for the residents. CNA #2 then revealed that when a resident receives a shower by the shower team that it would be documented on the shower schedule. She then confirmed she was unable to find any documentation of showers for Resident #195. During an interview with the DON on 1/07/25 at 10:39 AM, she confirmed that the facility did not have a shower schedule at this time. She stated The facility had one in place for a while, but no one was following up on it, so it was stopped. She confirmed she was aware there was a problem with residents not receiving showers and confirmed she should have put something in place before now. She then stated concerns from failing to provide a resident with their showers and personal hygiene, is it could cause skin irritation, infection control issues, and dignity concerns. Review of the Admission Record revealed Resident #195 was admitted by the facility on 12/21/24 with a diagnosis of Acute Kidney Failure. Record review of Resident #195's Admission MDS with an ARD of 12/27/24, revealed the BIMS score was 13, indicating the resident was cognitively intact. Section GG0130: Self Care, revealed, E.) Shower/bathe: coded requires substantial/maximal assistance . I.) Personal Hygiene: coded requires supervision or touching assistance.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to honor a resident 's preferences for (1) one of 23 sampled residents. Resident #195 Findings include: A review of the facility policy titled, Resident Rights, revised 04/2017, revealed, Residents shall: C.) Be assured of choice and share responsibility for decisions . E.) Receive care and services that are adequate and appropriate . An observation on 1/06/25 at 9:00 AM revealed Resident #195's hair and beard to be unkept and matted in appearance, his fingernails were observed to be approximately 1/2 inch long with a thick dark brown substance under the nail beds. In a continued interview with Resident #195, he stated he had been in the facility a little over two weeks, and he had not received a shower, a shave, or had his hair brushed at all. He went on to state he had told someone when he was admitted that he preferred a shower and had asked the staff for one several times, they would say ok but never come back. He then stated, I am unable to get up by myself, or I would try to shower myself. In an interview and observation of Resident #195 on 1/6/24 at 12:10 PM with Certified Nurse Assistant (CNA) #1, she confirmed she had not attempted to give the resident a shower, and stated the facility does not have a set shower schedule for the residents. She then admitted that the resident's hair, beard and nails did not appear clean or that he had had a bath lately. In an interview and record review with the shower CNA #2 on 1/06/24 at 1:00 PM, she confirmed that the facility does not have a set shower schedule for the residents letting us know when they need one. She then revealed that if a resident receives a shower by the shower staff, then it would be documented on the shower schedule forms. After record review she confirmed that Resident #195 had no documented shower since admission. In an interview with the Director of Nursing (DON) on 1/07/25 at 10:39 AM, she confirmed that the facility did not have a shower schedule in place at this time. She stated, we had one in place for a while, but no one was following up on it and so it was stopped. She confirmed she was aware there was a problem and should have put something in place to ensure residents received their showers. She stated that failing to provide Resident #195 showers per his preference is a failure to honor the residents' right of choice. Record review of the January Shower Record revealed there was no documented shower for Resident #195. Review of the Admission Record revealed Resident #195 was admitted by the facility on 12/21/24 with a diagnosis of Acute Kidney Failure. Record review of Resident #195's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/24, revealed the Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact. Section F0400 : Interview for Daily Preferences revealed, C. How important is it to you to choose a bath, shower, bed bath, or sponge bath? Coded: Very Important.

Based on staff interviews, record review, and facility policy review the facility failed to accurately complete Section N of the Minimum Data Set (MDS) assessment for a Resident, as evidenced by incorrectly coding anticoagulant medication usage during the 7-day observation look-back period for 1 (one) of three (3) residents reviewed for anticoagulant use. Resident # 17 Findings include: Review of the facility policy titled, Certifying Accuracy of the Resident Assessment with a revision date of November 2019 revealed Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. 3 .The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Record review of the MDS with an Assessment Reference Date (ARD) of October 29, 2024, revealed under section N that Resident #17 received seven (7) days of anticoagulant medication for the observation look-back period of 10/23/24 through 10/29/24. Record review of the Electronic Medication Administration Record (eMAR) for the MDS 7-day observation look-back period for anticoagulant medication revealed Resident #17 did not receive anticoagulant medication between 10/23/24 and 10/29/24. An interview with the MDS Coordinator on 1/07/25 at 2:50 PM confirmed that Resident #17 was coded on the 7-day look-back period of 10/23/24 through 10/29/24 for receiving an anticoagulant medication. She revealed that the resident was not on an anticoagulant medication and that it was coded in error. Record review of the Admission Record for Resident #17 revealed the facility admitted the resident on 11/19/2019 with diagnoses that included Type 2 Diabetes Mellitus, Chronic Pulmonary Edema, and Heart Failure.

Based on observation, staff interview, facility policy review, and record review, the facility failed to develop a care plan for placement of splints to maintain or prevent worsening of contractures for two (2) of 22 resident reviewed with a contracture. Resident #26 and Resident #56 Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, with a reviewed date of January 2023, revealed, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being k. Reflect treatment goals, timetables, and objectives in measurable outcomes; l. Identify professional services that are responsible for each element of care; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and o. Reflect currently recognized standards of practice for problem areas and conditions . Resident #26 During an observation and interview with Resident #26 on 10/24/23 at 3:07 PM revealed a wrist and hand splint on the bed. He stated since he finished therapy they don't put it on much. There were no observations during the survey from 10/24/23 through 10/26/23 of the splint in place on Resident #26. In an interview on 10/25/23 at 9:00 AM, Certified Nursing Assistant (CNA) #2 revealed Resident #26 has a splint and he wears it. She stated the CNA is responsible for putting it on. An interview on 10/26/23 at 7:40 AM with CNA #1 revealed she thought therapy was putting Resident #26's splint on. She thought he was still in therapy. She stated when the resident comes off therapy, therapy will pull whoever is working with the resident and instruct them on the splint. She stated the splint is supposed to be on the resident's care plan for the CNAs to see. Record review of the Admission Record Resident Information Sheet revealed Resident #26 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Non traumatic Intracerebral Hemorrhage affecting left dominate side, Muscle wasting and atrophy, and Chronic Kidney Disease, Stage 5. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #56 During an observation on 10/24/23 at 11:35 AM, revealed Resident #56 had a left-hand contracture with fingers contracted but not pressed against his palm. During the survey from 10/24/23 through 10/26/23, observations revealed Resident #56 in his room and mobile in his wheelchair over the facility with no splint in place on his left hand. An interview on 10/26/23 at 7:40 AM, with CNA #1 revealed she has not seen a splint for Resident #56 and doesn't remember seeing it on the care plan. Review of the Admission Record Resident Information Sheet for Resident #56 revealed an admitted [DATE] with diagnoses that included Unspecified Focal Traumatic Brain Injury, Stiffness of the left hand, Muscle Wasting and Atrophy. Review of the quarterly MDS with and Assessment Reference Date (ARD) of 9/14/23 revealed a BIMS score of 10 which indicated Resident #56 had moderate cognitive impairment. An interview on 10/26/23 at 8:45 AM, with the DON confirmed that neither Resident #26 nor Resident #56 had a care plan for hand splints. The DON stated the care plan should be in place to ensure orders are followed and managed. An interview on 10/26/23 at 8:50 AM, with the Minimum Data Set (MDS) Nurse #2 revealed the purpose of the care plan is to provide person centered care and everyone knows collectively how to care for the resident. An interview on 10/26/23 at 8:53 AM, with MDS Nurse #1 revealed care plans are triggered from the MDS and from information received in their morning meeting about changes in residents. She stated she did not know Resident #26 did not have an order for a splint. MDS Nurse #1 stated that even if the splint was applied by therapy, there should be a care plan. When the resident is discharged from therapy and the splint is active, it should be put on the activities of daily living (ADL) care plan and the Kardex for the staff to see, and there should be an order. MDS Nurse #1 confirmed there was a splint order for Resident #56 but no care plan. She stated she remembered looking at it and thought she put it in the ADL care plan, but she did not. Record review of Resident #26 and Resident #56's record confirmed there was no care plan in place for their splints.

Based on observation, staff and resident interview, facility policy review, and record review, the facility failed to utilize splints for residents to maintain or prevent worsening of contractures for two (2) of 22 residents reviewed with contractures. Resident #26 and Resident #56 Findings include: Review of the facility policy titled, Contracture Management Program, with a revision date of 1/23/23, revealed, Intent: To have a program within the facility geared towards the prevention of new contractures and maintenance or improvement of range of motion . Resident #26 An observation and interview, on 10/24/23 at 3:07 PM, revealed a wrist and hand splint laying on Resident #26's bed. Resident #26 stated since he finished therapy, they don't put it on much. There were no observations during the survey of Resident #26's splint being in place. An interview, on 10/25/23 at 9:00 AM, with Certified Nursing Assistant (CNA) #2 revealed Resident #26 has a splint and he has worn it. She stated the CNA is responsible for putting it on. During an interview on 10/26/23 at 7:43 AM, Resident #26 stated that a man from therapy used to put his splint on and he took it off at night. He stated that he has not had it on any weekends. He stated that no nurse or CNA had put his splint on because they told him they didn't know how. In an interview on 10/26/23 at 7:40 AM, with CNA #1 revealed therapy was putting Resident #26's splint on, she thought he was still in therapy. She stated when the resident comes off therapy, therapy will pull whoever is working with the resident and instruct them on the splint. She stated the splint is supposed to be on the resident's care plan for the CNAs to see. An interview with the Physical Therapy Assistant (PTA) on 10/26/23 at 8:15 AM, revealed Resident #26 was not on therapy case load. He was discharged on [DATE]. The PTA confirmed staff should be trained when the resident is discharged from therapy. An interview on 10/26/23 at 8:17 AM, with the Certified Occupational Therapy Assistant (COTA) stated he works as needed (prn) and the therapist takes care of the orders. He stated he does train with the CNA's but cannot locate paperwork for Resident #26. He stated the facility does not have a restorative at present, so they catch the people working on the floor with the residents to teach them about the splints. Interview with the Director of Nursing (DON) on 10/26/23 at 8:35 AM, confirmed Resident #26 should have had an order in the computer for continued use of his splint after discharge from therapy. Record review of the Occupational Therapy discharge summary for Resident #26 dated 10/6/23 revealed patient will safely wear wrist cock-up splint on left hand and left wrist for up to eight hours with minimal signs/symptoms of redness, swelling, discomfort, or pain. Review of the Admission Record resident information sheet revealed Resident #26 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Non traumatic Intracerebral Hemorrhage affecting left dominate side, Muscle wasting and atrophy, and Chronic Kidney Disease, Stage 5. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #26 was cognitively intact. Resident # 56 An observation, on 10/24/23 at 11:35 AM, revealed Resident #56 had a left-hand contracture with fingers contracted but not pressed against his palm. Observations during the survey from 10/24/23 through 10/26/23 revealed Resident #56 in his room and mobile in his wheelchair over the facility with no splint in place on his left hand. During an interview, on 10/25/23 at 1:20 PM, with Licensed Practical Nurse (LPN) #2, she stated she had not put a splint on Resident #56. She confirmed there was an order for the splint but stated there was nowhere in the computer to document it being put on or to document the skin assessment. LPN #2 also confirmed the Medication Administration Record (MAR) for Resident #56 did not have the splint listed on it for documentation. An observation and interview, on 10/25/23 at 1:25 PM, with the Director of Nursing (DON) and Resident #56 confirmed the DON could not locate Resident #56's splint. The DON stated that she didn't expect to find it. Resident #56 stated that it had been about a week since he had the splint on. The DON stated that this was probably because the order was put in incorrectly and did not pull over for the staff to see. An interview on 10/25/23 at 1:55 PM, with the Director of Therapy revealed they do an evaluation on all residents who have a contracture quarterly. The Director of Therapy revealed therapy had Resident #56 for treatment on service from 3/13/23 to 5/2/23 and again from 6/8/23 to 7/17/23. The Occupational Therapist would have then given instructions to the staff on the application of the splint. Record review of the Occupational Therapy evaluation and plan of treatment form dated 10/25/23 revealed Resident #56 under clinical impression presents with left upper extremity (LUE) wrist, decreased range of motion (ROM) of elbow, wrist and digits that affects ability to wear palm splint with finger separators as part of contracture management. An interview on 10/26/23 at 7:40 AM, with CNA #1 revealed she has not seen a splint for Resident #56 and doesn't remember seeing it on the care plan. An interview on 10/26/23 at 8:35 AM, with the Director of Nursing (DON) and the Administrator (ADM) confirmed they have not had a Restorative Program since COVID-19 started. The process is for the order to be written on the computer for the splint, it goes to the Medication Administration Record (MAR) and the nurses are responsible for applying splints and assessing skin. The DON confirmed Resident #56's order was not on MAR and she was unable to find any documentation in the progress notes concerning the resident's splint. She stated this should be documented daily. The ADM stated she felt Resident #56's order was put in incorrectly by therapy which did not let it pull over to the MAR. The DON stated therapy can put the order in the que and nursing confirms it for accuracy and then it is pulled to the MAR for documentation. The DON stated that if the orders and treatments are not carried out for splints it could cause worsening of the contracture or skin breakdown. An interview on 10/26/23 at 11:53 AM, with the Occupational Therapist (OT) revealed Resident #56 had a decline in his wrist flexion from -70 in March 2023 to -88 on 10/26/23 and had a decline of the contracture to the index finger from -70 in March 2023 to -79 on 10/26/23. Record review of the OT Discharge Summary date of service 3/13/23 - 5/2/23 revealed Short Term Goals (STG) .#2 Patient will increase AROM (active range of motion) left wrist to -40 degrees .Baseline 3/13/23 -70 degrees. Discharge 5/2/23 -30 degrees. STG #3. Patient will increase AROM left index finger PIP (proximal interphalangeal joint) extension to -45 degrees .Baseline 3/13/23 -80 degrees .Discharge 5/2/23 -45 degrees . Record review of a Order Summary Report dated 3/27/23 revealed Resident #56 to wear left (L) resting hand splint daily in morning (am) up to four (4) hours or as tolerated. Nurse to check skin prior to applying splint and after removal of splint and report any skin changes immediately. Record review revealed a Splint and Range of Motion (ROM) Competency and Discharge Planning Form: Care Giver and /or Resident for Resident #56 dated 3/29/23. The form has instructions concerning the splint placement and is signed by the therapist, but no caregiver or resident signatures are noted upon discharge. Review of the Admission Record resident information sheet for Resident #56 revealed an admitted [DATE] with diagnoses that included Unspecified Focal Traumatic Brain Injury, Stiffness of the left hand, Muscle Wasting and Atrophy. Review of the quarterly MDS with and ARD of 9/14/23 revealed a BIMS score of 10 which indicated Resident #56 had moderate cognitive impairment.

Based on staff interview, record review, and facility policy review the facility failed to notify the Resident Representative (RR) of a change in condition and hospital transfer for a resident for one (1) of five (5) residents reviewed for transfer/discharge. Resident #152 Findings include: Review of the facility policy titled, Change of Condition and Family Notification, review date [DATE], revealed, PURPOSE To ensure that resident's family and /or legal representative and physician are notified of resident changes that fall under the following categories: .A significant change in the resident's physical, mental, or psychological status .Transfer of the resident from the facility. PROCEDURE When any of the above situations exists, the licensed nurse will contact the resident's family and their physician. Calls will be made to the family until they are reached. A message will be left on an answering machine which does not give specifics but leaves a request for the facility to be called . Record review of the Progress Note created on 12/16/22 at 18:57, revealed unable to reach RP (Responsible Party) will inform on-coming nurse to call RP of resident transferred to hospital. An interview, on 10/26/23 at 10:30 AM, with the Director of Nursing (DON) confirmed the nurse documented on 12/16/23 an attempt to notify the RR of the resident transfer to the hospital without success and documented she would report to the oncoming nurse to call RR again. The DON confirmed there was no documentation that a follow up call was made to notify the RR. During an interview concerning family notification, on 10/26/23 at 10:32 AM, the Administrator (ADM) stated that follow up calls should always be made, it is the policy. Review of the Admission Record resident information sheet revealed Resident #152 was admitted to the facility on [DATE] with diagnoses that included Acute Respiratory Failure with Hypoxia, Unspecified Dementia, Hemiplegia and Hemiparesis following Cerebral Infarction, Encounter for attention to Tracheostomy, and Acute Pulmonary Edema. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/22 revealed a Brief Interview for Mental Status (BIMS) should not be conducted. Resident # 152 is rarely/never understood.

Based on record review, staff interview, and facility policy review, the facility failed to perform Cardio-Pulmonary Resuscitation (CPR) for Resident #1, who had an Advance Directive, an order, and care plan for a full code. This was for one (1) of six (6) residents reviewed. Resident #1 expired in the facility. Resident #1 had an Advance Directive, an order and a care plan for CPR, and the facility failed to perform CPR when Resident #1 was found without a pulse and without respirations, on [DATE]. The facility's failure to honor the Advance Directive, physician's order, and care plan to perform CPR, on [DATE], when Resident #1 was found unresponsive, without pulse or respirations, placed this resident and other residents with Advance Directives, orders and care plans for a full code, in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on [DATE], when the facility failed to honor Resident #1's Advance Directive, physician's order, and care plan, to perform CPR, when Resident #1 was found without a pulse and without respirations. The facility's Administrator was notified on [DATE] at 12:20 PM, of the Immediate Jeopardy, and provided a removal plan, in which the facility alleged all corrective actions were completed on [DATE], and the IJ removed as of [DATE]. The SA validated the facility's removal plan and determined the IJ was removed on [DATE], prior to exit on [DATE]. Therefore, the scope and severity of CFR(s): 483.24 (a)(3); Cardio-pulmonary Resuscitation (CPR)-F678, was lowered to a D level, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Included: Review of the facility Policy entitled, CPR Policy, revised [DATE], revealed, 1. In the event of cardiopulmonary arrest of a resident/patient without DNR (Do Not Resuscitate) status, life support measures will be initiated. Also, C. Nurses Responding: Establish a patent airway, c. Begin CPR (Cardiopulmonary Resuscitation). Review of the Admission Record revealed the facility readmitted Resident #1 on [DATE], with Diagnoses, which included Dementia and [MEDICAL CONDITION]. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed he scored 11 of 15 on the Brief Interview for Mental Status which indicated Resident #1 had moderately impaired cognitive abilities. Review of the Resident/Family Consent for Cardiopulmonary Resuscitation, dated [DATE], revealed Resident #1 was a Full Code. The Order Summary, active orders as of (MONTH) 1, 2019, also confirmed Resident #1 should have received CPR. Review of a facility investigation, dated [DATE], revealed that Resident #1 was found without pulse and respiration on [DATE], at approximately 10:00 PM. The report documented that CPR was not performed on Resident #1. A written statement, documented by LPN #2, dated [DATE], revealed he thought Resident #1 was a DNR. Review of a written statement, dated [DATE], by LPN #3, revealed that she walked to the nurse's station on [DATE] at 10:30 PM, and was told by LPN #2 that Resident #1 was found deceased at 10:00 PM. LPN #3 documented that she checked the resident's chart and found that he was a full code. LPN #3 documented that she approached LPN #2 and asked if CPR was initiated, and the LPN responded that it wasn't, because he thought Resident #1 was a DNR, and did not check the chart. Review of the Progress Notes, dated [DATE] at 10:25 PM, by LPN #2, revealed Resident #1 was found not breathing around 10:00 PM. The note documented the resident was a DNR. There was no indication he had checked the Resident's Advance Directive, orders, or care plan, and CPR was not initiated. The progress note documented that Resident #1's stomach and neck were warm to touch. Review of the progress note dated [DATE] at 12:39 AM, by Respiratory Therapist (RT) #1, revealed LPN #1 stated the resident had passed and she was calling hospice. The RT documented that LPN #1 confirmed a DNR status. There was no documentation that CPR was initiated. Interview on [DATE] at 12:25 PM, with LPN #2 (primary nurse) confirmed he had not checked Resident #1's code status (CPR/full code or DNR/no code). He also stated the error had been noticed later, when LPN #3 was looking at Resident #1's chart after the staff from hospice had arrived at the facility (approximately ,[DATE] minutes later). LPN #2 stated that CPR would have been unsuccessful, due to the amount of time which had lapsed between the discovery of Resident #1 and the discovery of his full code status. Interview, on [DATE] at 12:50 PM, with LPN #1, confirmed she had attempted to locate the code status for Resident #1, but had been unable to locate the information in the electronic chart. She knew the Resident received hospice, and thought all residents who received hospice benefits had a DNR status. LPN #1 confirmed she did not start CPR on Resident #1. Interview, on [DATE] at 11:11 AM, with Respiratory Therapist (RT) #1 revealed that LPN #1 informed her Resident #1 had died , and said she was going to call hospice. RT #1 then found LPN #2, providing care in another resident's room, and informed him Resident #1 was deceased . RT #1 also stated she had never not performed CPR on anyone who was a full code, but she had been told the Resident was a no code by LPN #1. RT #1 stated that she did not check the chart to confirm what she had been told. RT #1 stated there had been nothing in the room to indicate the Resident had a full code order, and she had not been aware he had requested CPR (cardiopulmonary resuscitation). Interview, on [DATE] at 3:15 PM, with the facility's Medical Director, revealed he had been informed Resident #1 had not received CPR per his Advance Directive, the morning after the error had occurred. He also stated he expected all staff to follow the orders in the residents' clinical records. The facility submitted an acceptable Removal Plan on [DATE], for the Immediate Jeopardy. Review of the Removal Plan revealed the facility took the following corrective actions: Brief Summary 1. The facility failed to perform Cardiopulmonary Resuscitation (CPR) on a Resident with an Advance Directive for a full code. On [DATE], at approximately 10:00 PM, Resident #1 was found unresponsive by Certified Nursing Assistant (CNA) #1. CNA #1 yelled to Licensed Practical Nurse (LPN) #1 to come to the room. LPN #1 evaluated resident as non-responsive with cold wrists to touch and skin greyish in color. LPN #1 yelled for Respiratory Therapy. Respiratory Therapy (RT) #1 heard yelling and approached LPN #1, who informed RT #1 of Resident #1's health status, that Resident #1 was receiving hospice and had a Do Not Resuscitate (DNR) status. LPN #1 went to the nurses' station to call hospice because the resident was deceased and LPN #1 thought the Resident was a DNR. LPN #1 reviewed Resident #1's chart and did not verify code status. RT #1 assessed Resident #1 and found the resident to have cold arms, face and head with a warm torso and without respirations. RT #1 went to LPN #2, who was Resident #1's assigned nurse, and informed LPN #2 that the resident had expired, and LPN#1 had stated he was a DNR on hospice. On [DATE], at approximately 10:30 PM, LPN #3 informed LPN #1 and LPN #2 of resident being a full code. At this point the Resident's family and the hospice Chaplin were in the room, and LPN #2 stated at this point it was too late to initiate CPR. LPN #1 exited facility at approximately 10:30 PM. The Administrator was notified, on [DATE] at approximately 12:00 AM, by LPN #3, that Resident #1 had expired and did not receive CPR. Corrective Action 1. On [DATE], at approximately 8:00 AM, LPN #1, LPN #2 and RT #1 were suspended, pending further investigation for failing to initiate CPR on a resident with full code status. 2. The unusual occurrence investigation was initiated by the facility Administrator, on [DATE] at approximately 8:00 AM, for failure to verify the code status and initiate the Resident's Advanced Directive. 3. The following individuals were notified of the failure to follow the Advance Directive for a resident with a full code status on [DATE]: Responsible Party at approximately 5:00 PM, Attending Physician at approximately 4:00 PM, Medical Director at approximately 1:00 PM, Department of Health at approximately 6:30 PM, and the Mississippi State Attorney General (AG) Office was notified at approximately 6:30 PM, of failure to follow the Advance Directive for a resident with a full code status. 4. On [DATE], prior to providing care, LPN #2 and RT #1 received disciplinary action due to failure to verify the code status upon notification by LPN #1, and a one on one (1:1) in-service was conducted by the Administrator and the Respiratory Therapy Director to LPN #2 and RT #1, on verification of code status, following code status, and documentation of code status on [DATE], prior to providing care. On [DATE], LPN #2 and RT #2 were returned to work as scheduled. 5. LPN #1 was terminated at the conclusion of the investigation for failing to verify code status and initiate CPR on [DATE]. However, LPN #1 did not return to the facility to sign the disciplinary action until (MONTH) 10, 2019. LPN #1 was reported to the Board of Nursing, by the Director of Nursing (DON), on [DATE], at 3:50 PM, for failure verify the code status and initiate CPR. 6. On [DATE], beginning at approximately 8:00 AM, the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC) and Assistant Director of Nursing (ADON) initiated education with all direct care staff on Code Status verification and identification by instructing on how to find the code status in the record, on Electronic Medical Record (EMR), on the Kardex, and the resident's Medical Record, by having direct care staff complete a return demonstration on how to identify a resident's code status on the EMR, and following the Advance Directive Care Plan. No direct care staff are to return to work without completing required education. 7. On [DATE], beginning at approximately 8:00 AM, Medical Records began conducting a 100 percent (%) audit of Residents to ensure orders were in place for code status/Advance Directive and following the Care Plan, comparing the chart, Advance Directive and Kardex. The audit was completed on [DATE], at approximately 2:00 PM by Medical Records, with no negative findings. 8. On [DATE], at 8:00 AM, an audit was conducted by Medical Records on all residents who expired in the facility over the past three (3) months to ensure the code status was followed, Advanced Directives matched the code status orders, and that the Care Plan matched the code status and Advanced Directive, with no negative findings. The audit was completed by Medical Records on [DATE], by approximately 2:00 PM. 9. On [DATE], the Administrator met with the Hospice Company at approximately 2:30 PM, to change the wording on hospice charts from Don't call 911, call hospice to Notify Hospice with any change of condition, so there would be no misinterpretation of instructions. 10. On [DATE], at approximately 3:00 PM, an Ad H[NAME] Quality Assurance Performance Improvement (QAPI) meeting was held for failure to follow code status with an order for [REDACTED]. The facility CPR Policy and No Code Policy were reviewed with no changes. The facility implemented the following systems, as discussed in Ad H[NAME] QAPI, to ensure ongoing compliance on [DATE]: a. Audit of all new admissions Advance Directive and code status system review to include code status order, Advance Directive, Care Plan and Kardex, MD Progress Note and color coded door tags, b. Colored door tags of red (DNR) and green (Full Code) are utilized to help identify code status for all residents, new residents door tag are applied upon admission or with an Advance Directive change, after verification to signed Advance Directive and Physician's order by Medical Records. 11. On [DATE], at approximately 3:30 PM, the direct care staff was in-serviced by the Administrator, DON, ADON, Corporate Nurse Specialist, SDC, Medical Records, and RT on the color coded door tags, implemented on [DATE], to assist the direct care staff in identifying the resident code status, red (DNR) and green (Full Code). The facility is alleging that all activities to remove the Immediate Jeopardy were completed as of [DATE], and the Immediate Jeopardy was removed [DATE]. The SA validated the facility's Removal Plan on [DATE], by interview, observation, and record review, and determined the facility took the following actions to remove the IJ: Brief Summary 1. The SA validated that the facility failed to perform Cardiopulmonary Resuscitation (CPR) on Resident #1, who had an Advance Directive, care plan, and order for a full code, on [DATE], at approximately 10:00 PM, when the Resident was found unresponsive and without pulse and respirations. Corrective Action 1. The SA validated by interview and record review, that on [DATE], LPN #1, LPN #2, and RT #1 were suspended pending further investigation for failing to initiate CPR on a resident with full code status. 2. The SA validated through interview and record review, that an investigation was initiated by the facility Administrator, on [DATE], for failure to verify the code status and initiate the Resident's Advanced Directive. 3. The SA validated through interview and record review that the Responsible Party, Attending Physician, Medical Director, Department of Health, the Mississippi State Attorney General (AG) Office was notified of the failure to follow the Advance Directive for a resident with a full code status. 4. The SA validated through interview and record review that on [DATE], prior to providing care, LPN #2 and RT #1 received disciplinary action due to failure to verify the code status upon notification by LPN #1, and a 1:1 in-service was conducted by the Administrator and the Respiratory Therapy Director to LPN #2 and RT #1, on verification of code status, following code status and documentation of code status on [DATE], prior to providing care. 5. The SA validated through record review and interview that LPN #1 was terminated at the conclusion of the investigation for failing to verify code status and initiate CPR on [DATE], and that LPN #1 was reported to the Board of Nursing, by the Director of Nursing (DON), on [DATE], for failure verify the code status and initiate CPR. 6. The SA validated through interview and record review that on [DATE], the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC) and Assistant Director of Nursing (ADON) initiated education with all direct care staff on Code Status verification and identification by instructing on how to find the code status in the record, on Electronic Medical Record (EMR), on the Kardex, and the resident's Medical Record, by having direct care staff complete a return demonstration on how to identify a residents code status on the EMR, and following the Advance Directive Care Plan. Through interview and review of the facility staff roster, the SA verified that no direct care staff returned to work without completing required education. 7. The SA validated through interview and review of the documented audits, that on [DATE], Medical Records conducted a 100% audit of Residents to ensure orders were in place for code status/Advance Directive and following the Care Plan, comparing the chart, Advance Directive and Kardex, with no negative findings. 8. The SA validated through record review and interview that on [DATE], an audit was conducted by Medical Records on all residents who expired in the facility over the past three (3) months to ensure the code status was followed, Advanced Directives matched the code status orders, and that the Care Plan matched the code status and Advanced Directive, with no negative findings. 9. The SA validated through record review and interview, that on [DATE], the Administrator met with the Hospice Company and the hospice charts were observed to have Notify Hospice with any change of condition, so there would be no misinterpretation of instructions. 10. The SA validated through interview and sign-in sheets, that on [DATE], an Ad H[NAME] Quality Assurance Performance Improvement (QAPI) meeting was held for failure to follow code status with an order for [REDACTED]. The facility CPR Policy and No Code Policy were reviewed with no changes. The SA validated that the facility implemented the following systems, as discussed in Ad H[NAME] QAPI, to ensure ongoing compliance on [DATE], by observation , interview and record review: a. Audit of all new admissions Advance Directive and code status system review to include code status order, Advance Directive, Care Plan and Kardex, MD Progress Note and color coded door tags, b. Colored door tags of red (DNR) and green (Full Code) are utilized to help identify code status for all residents, new residents door tag are applied upon admission or with an Advance Directive change, after verification to signed Advance Directive and Physician's order by Medical Records. 11. The SA validated by in-service and sign-in sheets, that on [DATE], the direct care staff was in-serviced by the Administrator, DON, ADON, Corporate Nurse Specialist, SDC, Medical Records, and RT on the color coded door tags, implemented on [DATE], to assist the direct care staff in identifying the resident code status, red (DNR) and green (Full Code). The SA validated that all corrective actions to remove the IJ were completed on [DATE], and the Immediate Jeopardy removed on [DATE].

Based on record review, staff interview, and policy review, the facility failed to honor an Advance Directive for a full code status, for one (1) of six (6) residents reviewed. Resident #1. Resident #1 had an Advance Directive for Cardio-pulmonary Resuscitation (CPR), and the facility failed to perform CPR, when Resident #1 was found without a pulse and without respirations, on [DATE]. Resident #1 expired in the facility. The facility's failure to honor the Advance Directive of a full code status and the failure to perform CPR, on [DATE], when Resident #1 was found unresponsive, without pulse or respirations, placed this resident and other resident's with the Advance Directive of full code status in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ), which began on [DATE], when the facility failed to honor Resident #1's Advance Directive to perform CPR when the resident was found without a pulse and without respirations. The facility's Administrator was notified on [DATE] at 12:20 PM, of the Immediate Jeopardy. The facility provided a removal plan, 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 facility's removal plan and determined the IJ was removed on [DATE], prior to exit on [DATE]. Therefore the scope and severity of CFR(s): 483.10 (c)(6)(8)(g)(12)(i)-(v); Formulate Advance Directive-F578, was lowered to a D level, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy entitled, Advance Directives, revised ,[DATE], revealed, Policy Statement, Advance directives will be respected in accordance with state law and facility policy. Review of the Admission Record revealed the facility readmitted Resident #1 on [DATE], with diagnoses, which included Dementia and [MEDICAL CONDITION]. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed he scored 11 of 15 on the Brief Interview for Mental Status (BIMS), which indicated Resident #1 had moderately impaired cognitive abilities. Review of the Resident/Family Consent for Cardiopulmonary Resuscitation, dated [DATE], revealed the following: 1. This facility requests that a written signature of the resident be obtained in advance regarding his/her wishes in regard to the desire for cardiopulmonary resuscitation (CPR) in the event of extreme emergency. 2.This statement will remain in effect as long as the resident remains a resident of this facility or until we receive a written and signed notice of revocation from you. 3. The form also included a check mark by the statement, I understand that CPR constitutes an extraordinary measure and SHOULD be done on (Resident #1). Review of the Order Summary Report, as of (MONTH) 2019, confirmed Resident #1 had an order for [REDACTED]. Review of the Progress Notes for Resident #1 revealed the following: 1. A note for [DATE] at 10:25 PM for, (Resident #1) is DNR (Do Not Resuscitate). This entry was signed by Licensed Practical Nurse #2, and did not indicate any lifesaving efforts had been attempted. 2. A note, for [DATE] at 12:39 AM, by Respiratory Therapist (RT) #1 revealed (LPN #1) stated that (Resident #1) had passed (was deceased ) and she (LPN #1) was calling hospice. (LPN #1) confirmed DNR (Do Not Resuscitate). Review of a written statement, dated [DATE], by LPN #3, revealed that she walked to the nurse's station on [DATE] at 10:30 PM, and saw hospice staff. LPN #3 documented she was told by LPN #2 that Resident #1 was found deceased at 10:00 PM. LPN #3 documented that when she checked the resident's chart, she found that he was a full code. LPN #3 documented that she approached LPN #2 and asked if CPR was initiated, and the LPN responded he did not, because he thought Resident #1 was a DNR and did not check the chart. Interview, on [DATE] at 12:25 PM, with LPN #2 revealed he had been assigned to Resident #1 on the night shift, which began on [DATE]. He stated that he had been providing care to another resident when he was informed Resident #1 was deceased , and LPN #1 was notifying hospice of the resident's death. LPN #2 stated he would have done CPR if he had known the Resident had an Advance Directive for a full code, but he thought the Resident must have a DNR order, since hospice was being notified. Interview on [DATE] at 12:50 PM, with LPN #1, revealed she had looked in Resident #1's clinical record for the code status after she determined the resident did not have a pulse or respirations, but stated she had been unable to locate the code status. LPN #1 stated she thought the resident had a DNR status since he was on hospice. LPN #1 stated that she did find a notice in the chart to call hospice first, instead of 911. LPN #1 also stated she had informed LPN #2 she thought Resident #1 had a DNR status. LPN #1 confirmed she had not provided CPR to Resident #1. The facility submitted an acceptable Removal Plan on [DATE], for the Immediate Jeopardy. Review of the Removal Plan revealed the facility took the following corrective measures: Brief Summary 1. The facility failed to perform Cardiopulmonary Resuscitation (CPR) on a Resident with an Advance Directive for a full code. On [DATE], at approximately 10:00 PM, Resident #1 was found unresponsive by Certified Nursing Assistant (CNA) #1. CNA #1 yelled to Licensed Practical Nurse (LPN) #1 to come to the room. LPN #1 evaluated resident as non-responsive with cold wrists to touch and skin greyish in color. LPN #1 yelled for Respiratory Therapy. Respiratory Therapy (RT) #1 heard yelling and approached LPN #1, who informed RT #1 of Resident #1's health status, that Resident #1 was receiving hospice and had a Do Not Resuscitate (DNR) status. LPN #1 went to the nurses' station to call hospice because the resident was deceased and LPN #1 thought the Resident was a DNR. LPN #1 reviewed Resident #1's chart and did not verify code status. RT #1 assessed Resident #1 and found the resident to have cold arms, face and head with a warm torso and without respirations. RT #1 went to LPN #2, who was Resident #1's assigned nurse, and informed LPN #2 that the resident had expired, and LPN#1 had stated he was a DNR on hospice. On [DATE], at approximately 10:30 PM, LPN #3 informed LPN #1 and LPN #2 of resident being a full code. At this point the Resident's family and the hospice Chaplin were in the room, and LPN #2 stated at this point it was too late to initiate CPR. LPN #1 exited facility at approximately 10:30 PM. The Administrator was notified, on [DATE] at approximately 12:00 AM, by LPN #3, that Resident #1 had expired and did not receive CPR. Corrective Action 1. On [DATE], at approximately 8:00 AM, LPN #1, LPN #2 and RT #1 were suspended, pending further investigation for failing to initiate CPR on a resident with full code status. 2. The unusual occurrence investigation was initiated by the facility Administrator, on [DATE] at approximately 8:00 AM, for failure to verify the code status and initiate the Resident's Advanced Directive. 3. The following individuals were notified of the failure to follow the Advance Directive for a resident with a full code status on [DATE]: Responsible Party at approximately 5:00 PM, Attending Physician at approximately 4:00 PM, Medical Director at approximately 1:00 PM, Department of Health at approximately 6:30 PM, and the Mississippi State Attorney General (AG) Office was notified at approximately 6:30 PM, of failure to follow the Advance Directive for a resident with a full code status. 4. On [DATE], prior to providing care, LPN #2 and RT #1 received disciplinary action due to failure to verify the code status upon notification by LPN #1, and a one on one (1:1) in-service was conducted by the Administrator and the Respiratory Therapy Director to LPN #2 and RT #1, on verification of code status, following code status, and documentation of code status on [DATE], prior to providing care. On [DATE], LPN #2 and RT #2 were returned to work as scheduled. 5. LPN #1 was terminated at the conclusion of the investigation for failing to verify code status and initiate CPR on [DATE]. However, LPN #1 did not return to the facility to sign the disciplinary action until (MONTH) 10, 2019. LPN #1 was reported to the Board of Nursing, by the Director of Nursing (DON), on [DATE], at 3:50 PM, for failure verify the code status and initiate CPR. 6. On [DATE], beginning at approximately 8:00 AM, the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC) and Assistant Director of Nursing (ADON) initiated education with all direct care staff on Code Status verification and identification by instructing on how to find the code status in the record, on Electronic Medical Record (EMR), on the Kardex, and the resident's Medical Record, by having direct care staff complete a return demonstration on how to identify a resident's code status on the EMR, and following the Advance Directive Care Plan. No direct care staff are to return to work without completing required education. 7. On [DATE], beginning at approximately 8:00 AM, Medical Records began conducting a 100 percent (%) audit of Residents to ensure orders were in place for code status/Advance Directive and following the Care Plan, comparing the chart, Advance Directive and Kardex. The audit was completed on [DATE], at approximately 2:00 PM by Medical Records, with no negative findings. 8. On [DATE], at 8:00 AM, an audit was conducted by Medical Records on all residents who expired in the facility over the past three (3) months to ensure the code status was followed, Advanced Directives matched the code status orders, and that the Care Plan matched the code status and Advanced Directive, with no negative findings. The audit was completed by Medical Records on [DATE], by approximately 2:00 PM. 9. On [DATE], the Administrator met with the Hospice Company at approximately 2:30 PM, to change the wording on hospice charts from Don't call 911, call hospice to Notify Hospice with any change of condition, so there would be no misinterpretation of instructions. 10. On [DATE], at approximately 3:00 PM, an Ad H[NAME] Quality Assurance Performance Improvement (QAPI) meeting was held for failure to follow code status with an order for [REDACTED]. The facility CPR Policy and No Code Policy were reviewed with no changes. The facility implemented the following systems, as discussed in Ad H[NAME] QAPI, to ensure ongoing compliance on [DATE]: a. Audit of all new admissions Advance Directive and code status system review to include code status order, Advance Directive, Care Plan and Kardex, MD Progress Note and color coded door tags, b. Colored door tags of red (DNR) and green (Full Code) are utilized to help identify code status for all residents, new residents door tag are applied upon admission or with an Advance Directive change, after verification to signed Advance Directive and physician's orders [REDACTED]. 11. On [DATE], at approximately 3:30 PM, the direct care staff was in-serviced by the Administrator, DON, ADON, Corporate Nurse Specialist, SDC, Medical Records, and RT on the color coded door tags, implemented on [DATE], to assist the direct care staff in identifying the resident code status, red (DNR) and green (Full Code). The facility is alleging that all activities to remove the Immediate Jeopardy were completed as of [DATE], and the Immediate Jeopardy was removed [DATE]. The SA validated the facility's Removal Plan on [DATE], by interview, observation, and record review, and determined the facility took the following actions to remove the IJ: Brief Summary 1. The SA validated that the facility failed to perform Cardiopulmonary Resuscitation (CPR) on Resident #1, who had an Advance Directive, care plan, and order for a full code, on [DATE], at approximately 10:00 PM, when the Resident was found unresponsive and without pulse and respirations. Corrective Action 1. The SA validated by interview and record review, that on [DATE], LPN #1, LPN #2, and RT #1 were suspended pending further investigation for failing to initiate CPR on a resident with full code status. 2. The SA validated through interview and record review, that an investigation was initiated by the facility Administrator, on [DATE], for failure to verify the code status and initiate the Resident's Advanced Directive. 3. The SA validated through interview and record review that the Responsible Party, Attending Physician, Medical Director, Department of Health, the Mississippi State Attorney General (AG) Office was notified of the failure to follow the Advance Directive for a resident with a full code status. 4. The SA validated through interview and record review that on [DATE], prior to providing care, LPN #2 and RT #1 received disciplinary action due to failure to verify the code status upon notification by LPN #1, and a 1:1 in-service was conducted by the Administrator and the Respiratory Therapy Director to LPN #2 and RT #1, on verification of code status, following code status and documentation of code status on [DATE], prior to providing care. 5. The SA validated through record review and interview that LPN #1 was terminated at the conclusion of the investigation for failing to verify code status and initiate CPR on [DATE], and that LPN #1 was reported to the Board of Nursing, by the Director of Nursing (DON), on [DATE], for failure verify the code status and initiate CPR. 6. The SA validated through interview and record review that on [DATE], the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC) and Assistant Director of Nursing (ADON) initiated education with all direct care staff on Code Status verification and identification by instructing on how to find the code status in the record, on Electronic Medical Record (EMR), on the Kardex, and the resident's Medical Record, by having direct care staff complete a return demonstration on how to identify a residents code status on the EMR, and following the Advance Directive Care Plan. Through interview and review of the facility staff roster, the SA verified that no direct care staff returned to work without completing required education. 7. The SA validated through interview and review of the documented audits, that on [DATE], Medical Records conducted a 100% audit of Residents to ensure orders were in place for code status/Advance Directive and following the Care Plan, comparing the chart, Advance Directive and Kardex, with no negative findings. 8. The SA validated through record review and interview that on [DATE], an audit was conducted by Medical Records on all residents who expired in the facility over the past three (3) months to ensure the code status was followed, Advanced Directives matched the code status orders, and that the Care Plan matched the code status and Advanced Directive, with no negative findings. 9. The SA validated through record review and interview, that on [DATE], the Administrator met with the Hospice Company and the hospice charts were observed to have Notify Hospice with any change of condition, so there would be no misinterpretation of instructions. 10. The SA validated through interview and sign-in sheets, that on [DATE], an Ad H[NAME] Quality Assurance Performance Improvement (QAPI) meeting was held for failure to follow code status with an order for [REDACTED]. The facility CPR Policy and No Code Policy were reviewed with no changes. The SA validated that the facility implemented the following systems, as discussed in Ad H[NAME] QAPI, to ensure ongoing compliance on [DATE], by observation , interview and record review: a. Audit of all new admissions Advance Directive and code status system review to include code status order, Advance Directive, Care Plan and Kardex, MD Progress Note and color coded door tags, b. Colored door tags of red (DNR) and green (Full Code) are utilized to help identify code status for all residents, new residents door tag are applied upon admission or with an Advance Directive change, after verification to signed Advance Directive and physician's orders [REDACTED]. 11. The SA validated by in-service and sign-in sheets, that on [DATE], the direct care staff was in-serviced by the Administrator, DON, ADON, Corporate Nurse Specialist, SDC, Medical Records, and RT on the color coded door tags, implemented on [DATE], to assist the direct care staff in identifying the resident code status, red (DNR) and green (Full Code). The SA validated that all corrective actions to remove the IJ were completed on [DATE], and the Immediate Jeopardy removed on [DATE].

Based on record review, staff interview, and policy review, the facility failed to implement the care plan for the advanced directive for Full Code for one (1) of six (6) residents reviewed, Resident #1. The resident expired in the facility on [DATE]. Resident #1 had a care plan for an Advance Directive for full code status, and the facility failed to follow the care plan to perform Cardio-pulmonary Resuscitation (CPR) when Resident #1 was found without a pulse and without respirations, on [DATE]. The facility's failure to follow the care plan for the Advance Directive of a full code, and failure to perform CPR on [DATE], when Resident #1 was found unresponsive, without pulse or respirations, placed this resident and other residents with a care plan for full code status in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ), which began on [DATE], when the facility failed to follow the care plan for Resident #1's Advance Directive to perform CPR, when the resident was found without a pulse and without respirations. The facility's Administrator was notified on [DATE] at 12:20 PM, of the Immediate Jeopardy, and provided a removal plan, in which the facility alleged all corrective actions were completed on [DATE], and the IJ removed as of [DATE]. The SA validated the facility's removal plan and determined the IJ was removed on [DATE], prior to exit on [DATE]. Therefore the scope and severity of CFR(s): 483.21 (b)(1); Develop/Implement Comprehensive Care Plan-F656, was lowered to a D level, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Using the Care Plan policy, revised ,[DATE], revealed, Policy Statement, The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have the responsibility for providing care or services to the resident. Review of the care plan for Resident #1, provided by the facility as the resident's current care plan, revealed, My responsible party has been provided the information explaining the Advanced Directive process and following the education, my family has decided that I am a (FULL CODE). The Goal was for My (FULL CODE) status will be honored by my family and staff. Review of the Admission Record revealed the facility readmitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed he scored 11 of 15 on the Brief Interview for Mental Status which indicated Resident #1 had moderately impaired cognitive abilities. Review of the Resident/Family Consent for Cardiopulmonary Resuscitation, dated [DATE], revealed Resident #1 was a Full Code, this was signed by the Responsible Party. Review of a facility's investigation, dated [DATE], revealed that Resident #1 was found without pulse and respiration on [DATE] at approximately 10:00 PM. The report documented that CPR was not performed on Resident #1, per the care plan. Review of a written statement, dated [DATE], by LPN #3, revealed that she walked to the nurse's station on [DATE] at 10:30 PM, and saw hospice staff. LPN #3 documented she was told by LPN #2 that Resident #1 was found deceased at 10:00 PM. LPN #3 documented that when she checked the resident's chart, she found that he was a full code. LPN #3 documented that she approached LPN #2 and asked if CPR was initiated, and the LPN responded he did not, because he thought Resident #1 was a DNR and did not check the chart. Interview, on [DATE] at 12:50 PM, with Licensed Practical Nurse (LPN) #1 confirmed she had not referred to the Care Plan for Resident #1's code status. LPN #1 was the first nurse in the room. LPN #1 stated the resident wasn't breathing and she called for the Respiratory Therapist, who confirmed the resident was pulseless and not breathing. LPN #1 stated she did not do CPR, because she thought the resident was not a full code, due to hospice status. Interview, on [DATE] at 12:20 PM, with the Registered Nurse (RN) responsible for the MDS and Care Plans, confirmed the staff should have followed the instructions in the Care Plan for Advance Directives for Resident #1. The facility submitted an acceptable Removal Plan on [DATE], for the Immediate Jeopardy. Review of the Removal Plan revealed the facility took the following corrective measures: Brief Summary 1. The facility failed to perform Cardiopulmonary Resuscitation (CPR) on a Resident with an Advance Directive for a full code. On [DATE], at approximately 10:00 PM, Resident #1 was found unresponsive by Certified Nursing Assistant (CNA) #1. CNA #1 yelled to Licensed Practical Nurse (LPN) #1 to come to the room. LPN #1 evaluated resident as non-responsive with cold wrists to touch and skin greyish in color. LPN #1 yelled for Respiratory Therapy. Respiratory Therapy (RT) #1 heard yelling and approached LPN #1, who informed RT #1 of Resident #1's health status, that Resident #1 was receiving hospice and had a Do Not Resuscitate (DNR) status. LPN #1 went to the nurses' station to call hospice because the resident was deceased and LPN #1 thought the Resident was a DNR. LPN #1 reviewed Resident #1's chart and did not verify code status. RT #1 assessed Resident #1 and found the resident to have cold arms, face and head with a warm torso and without respirations. RT #1 went to LPN #2, who was Resident #1's assigned nurse, and informed LPN #2 that the resident had expired, and LPN#1 had stated he was a DNR on hospice. On [DATE], at approximately 10:30 PM, LPN #3 informed LPN #1 and LPN #2 of resident being a full code. At this point the Resident's family and the hospice Chaplin were in the room, and LPN #2 stated at this point it was too late to initiate CPR. LPN #1 exited facility at approximately 10:30 PM. The Administrator was notified, on [DATE] at approximately 12:00 AM, by LPN #3, that Resident #1 had expired and did not receive CPR. Corrective Action 1. On [DATE], at approximately 8:00 AM, LPN #1, LPN #2 and RT #1 were suspended, pending further investigation for failing to initiate CPR on a resident with full code status. 2. The unusual occurrence investigation was initiated by the facility Administrator, on [DATE] at approximately 8:00 AM, for failure to verify the code status and initiate the Resident's Advanced Directive. 3. The following individuals were notified of the failure to follow the Advance Directive for a resident with a full code status on [DATE]: Responsible Party at approximately 5:00 PM, Attending Physician at approximately 4:00 PM, Medical Director at approximately 1:00 PM, Department of Health at approximately 6:30 PM, and the Mississippi State Attorney General (AG) Office was notified at approximately 6:30 PM, of failure to follow the Advance Directive for a resident with a full code status. 4. On [DATE], prior to providing care, LPN #2 and RT #1 received disciplinary action due to failure to verify the code status upon notification by LPN #1, and a one on one (1:1) in-service was conducted by the Administrator and the Respiratory Therapy Director to LPN #2 and RT #1, on verification of code status, following code status, and documentation of code status on [DATE], prior to providing care. On [DATE], LPN #2 and RT #2 were returned to work as scheduled. 5. LPN #1 was terminated at the conclusion of the investigation for failing to verify code status and initiate CPR on [DATE]. However, LPN #1 did not return to the facility to sign the disciplinary action until (MONTH) 10, 2019. LPN #1 was reported to the Board of Nursing, by the Director of Nursing (DON), on [DATE], at 3:50 PM, for failure verify the code status and initiate CPR. 6. On [DATE], beginning at approximately 8:00 AM, the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC) and Assistant Director of Nursing (ADON) initiated education with all direct care staff on Code Status verification and identification by instructing on how to find the code status in the record, on Electronic Medical Record (EMR), on the Kardex, and the resident's Medical Record, by having direct care staff complete a return demonstration on how to identify a resident's code status on the EMR, and following the Advance Directive Care Plan. No direct care staff are to return to work without completing required education. 7. On [DATE], beginning at approximately 8:00 AM, Medical Records began conducting a 100 percent (%) audit of Residents to ensure orders were in place for code status/Advance Directive and following the Care Plan, comparing the chart, Advance Directive and Kardex. The audit was completed on [DATE], at approximately 2:00 PM by Medical Records, with no negative findings. 8. On [DATE], at 8:00 AM, an audit was conducted by Medical Records on all residents who expired in the facility over the past three (3) months to ensure the code status was followed, Advanced Directives matched the code status orders, and that the Care Plan matched the code status and Advanced Directive, with no negative findings. The audit was completed by Medical Records on [DATE], by approximately 2:00 PM. 9. On [DATE], the Administrator met with the Hospice Company at approximately 2:30 PM, to change the wording on hospice charts from Don't call 911, call hospice to Notify Hospice with any change of condition, so there would be no misinterpretation of instructions. 10. On [DATE], at approximately 3:00 PM, an Ad H[NAME] Quality Assurance Performance Improvement (QAPI) meeting was held for failure to follow code status with an order for [REDACTED]. The facility CPR Policy and No Code Policy were reviewed with no changes. The facility implemented the following systems, as discussed in Ad H[NAME] QAPI, to ensure ongoing compliance on [DATE]: a. Audit of all new admissions Advance Directive and code status system review to include code status order, Advance Directive, Care Plan and Kardex, MD Progress Note and color coded door tags, b. Colored door tags of red (DNR) and green (Full Code) are utilized to help identify code status for all residents, new residents door tag are applied upon admission or with an Advance Directive change, after verification to signed Advance Directive and physician's orders [REDACTED]. 11. On [DATE], at approximately 3:30 PM, the direct care staff was in-serviced by the Administrator, DON, ADON, Corporate Nurse Specialist, SDC, Medical Records, and RT on the color coded door tags, implemented on [DATE], to assist the direct care staff in identifying the resident code status, red (DNR) and green (Full Code). The facility is alleging that all activities to remove the Immediate Jeopardy were completed as of [DATE], and the Immediate Jeopardy was removed [DATE]. The SA validated the facility's Removal Plan on [DATE], by interview, observation, and record review, and determined the facility took the following actions to remove the IJ: Brief Summary 1. The SA validated that the facility failed to perform Cardiopulmonary Resuscitation (CPR) on Resident #1, who had an Advance Directive, care plan, and order for a full code, on [DATE], at approximately 10:00 PM, when the Resident was found unresponsive and without pulse and respirations. Corrective Action 1. The SA validated by interview and record review, that on [DATE], LPN #1, LPN #2, and RT #1 were suspended pending further investigation for failing to initiate CPR on a resident with full code status. 2. The SA validated through interview and record review, that an investigation was initiated by the facility Administrator, on [DATE], for failure to verify the code status and initiate the Resident's Advanced Directive. 3. The SA validated through interview and record review that the Responsible Party, Attending Physician, Medical Director, Department of Health, the Mississippi State Attorney General (AG) Office was notified of the failure to follow the Advance Directive for a resident with a full code status. 4. The SA validated through interview and record review that on [DATE], prior to providing care, LPN #2 and RT #1 received disciplinary action due to failure to verify the code status upon notification by LPN #1, and a 1:1 in-service was conducted by the Administrator and the Respiratory Therapy Director to LPN #2 and RT #1, on verification of code status, following code status and documentation of code status on [DATE], prior to providing care. 5. The SA validated through record review and interview that LPN #1 was terminated at the conclusion of the investigation for failing to verify code status and initiate CPR on [DATE], and that LPN #1 was reported to the Board of Nursing, by the Director of Nursing (DON), on [DATE], for failure verify the code status and initiate CPR. 6. The SA validated through interview and record review that on [DATE], the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC) and Assistant Director of Nursing (ADON) initiated education with all direct care staff on Code Status verification and identification by instructing on how to find the code status in the record, on Electronic Medical Record (EMR), on the Kardex, and the resident's Medical Record, by having direct care staff complete a return demonstration on how to identify a residents code status on the EMR, and following the Advance Directive Care Plan. Through interview and review of the facility staff roster, the SA verified that no direct care staff returned to work without completing required education. 7. The SA validated through interview and review of the documented audits, that on [DATE], Medical Records conducted a 100% audit of Residents to ensure orders were in place for code status/Advance Directive and following the Care Plan, comparing the chart, Advance Directive and Kardex, with no negative findings. 8. The SA validated through record review and interview that on [DATE], an audit was conducted by Medical Records on all residents who expired in the facility over the past three (3) months to ensure the code status was followed, Advanced Directives matched the code status orders, and that the Care Plan matched the code status and Advanced Directive, with no negative findings. 9. The SA validated through record review and interview, that on [DATE], the Administrator met with the Hospice Company and the hospice charts were observed to have Notify Hospice with any change of condition, so there would be no misinterpretation of instructions. 10. The SA validated through interview and sign-in sheets, that on [DATE], an Ad H[NAME] Quality Assurance Performance Improvement (QAPI) meeting was held for failure to follow code status with an order for [REDACTED]. The facility CPR Policy and No Code Policy were reviewed with no changes. The SA validated that the facility implemented the following systems, as discussed in Ad H[NAME] QAPI, to ensure ongoing compliance on [DATE], by observation , interview and record review: a. Audit of all new admissions Advance Directive and code status system review to include code status order, Advance Directive, Care Plan and Kardex, MD Progress Note and color coded door tags, b. Colored door tags of red (DNR) and green (Full Code) are utilized to help identify code status for all residents, new residents door tag are applied upon admission or with an Advance Directive change, after verification to signed Advance Directive and physician's orders [REDACTED]. 11. The SA validated by in-service and sign-in sheets, that on [DATE], the direct care staff was in-serviced by the Administrator, DON, ADON, Corporate Nurse Specialist, SDC, Medical Records, and RT on the color coded door tags, implemented on [DATE], to assist the direct care staff in identifying the resident code status, red (DNR) and green (Full Code). The SA validated that all corrective actions to remove the IJ were completed on [DATE], and the Immediate Jeopardy removed on [DATE].

Based on resident interview, staff interview, record review and facility policy review, the facility failed to ensure a resident was free from verbal abuse for one (1) of 24 residents reviewed for abuse, Resident #14. On 4/3/19, at approximately 9:50 PM, Resident #14 reported an allegation of verbal abuse against Licensed Practical Nurse (LPN) #1. The allegation consisted of Resident #14 using derogatory names towards LPN #1. LPN #1 responded to the resident by using the same derogatory names. This occurred around the nursing station and was witnessed by other staff. LPN #3 stated she heard LPN #1 say If I'm a [***] , you are a [***] . It takes one to know one. LPN #2 stated she heard LPN #1 say Mother [***] . The Administrator was notified by LPN #2 at approximately 10:00 PM. LPN #1 was suspended, however, was allowed to return to work on 4/17/19, and allowed to work on the same assigned hall where Resident #14 resided. The resident refused to take medications from LPN #1, stating he did not trust her. The facility's failure to protect Resident #14 from verbal abuse and allow a staff member to work in the facility following investigation of an incident of witnessed verbal abuse, placed Resident #14 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 4/3/19, when the verbal abuse occurred. The facility's Administrator was notified of the IJ and SQC on 4/25/19, at 10:00 AM, and provided with the IJ template. An acceptable credible Removal Plan was provided by the facility on 4/26/19, in which the facility alleged all corrective actions were completed as of 4/25/19, and the IJ was removed on 4/26/19. The State Agency (SA) validated the Removal Plan and determined that the IJ was removed on 4/26/19, prior to exit. Therefore, the scope and severity for the IJ and SQC at 42 CFR(s): 483.12 (a)(1) F600 , Freedom from Abuse, Neglect, and Exploitation, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy entitled Abuse Prohibition Policy, Revision: 03/18/2019, revealed: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. Policy: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. Review of the facility's policy entitled Abuse Program, Revision 11/2017, revealed, Investigation: 1. The facility will thoroughly investigate all alleged violations and take appropriate actions. 2. The Abuse Coordinator will report such allegations to the state agency in accordance with state law. The Abuse Coordinator will report all allegations of abuse, .within two (2) hours of the allegation . Protection: 1. All residents will be immediately protected from harm . Statement of Policy, Regarding the Reporting of Abuse and Associate Acknowledgement, Remember our policy is all residents and patients of this nursing home are to be treated with dignity and respect at all times, under all circumstances. Mistreatment or abuse of any nature will not be tolerated . Review of a Facility Reported Incident (FRI), dated 4/5/19, revealed staff statements concerning an allegation of verbal abuse by an employee, Licensed Practical Nurse (LPN) #1, toward Resident #14 that occurred on 4/3/19. LPN #4 reported that on 4/3/19, at 9:50 PM, Resident #14 was tapping his hand on the counter to get the nurse's attention. Resident #14 wanted a snack and to use the cordless phone, but it was not charged. Resident #14 became agitated and began hitting the nurse's station desk loudly with the palm of his hand and snatched papers from a chart on the desk attempting to read them. Resident #14 cursed LPN #1 who cursed him in return. This was witnessed by LPN #2 and LPN #3, who stated that LPN #1 used profanity such as Mother [***] , and If I'm a [***] , you are a [***] . It takes one to know one. LPN #1 was suspended pending investigation. On 04/22/19, at 4:03 PM, during an interview with Resident #14, he stated, Everything is okay except for that woman who pushed me up against that wall. He stated this happened about two (2) weeks ago and her name was (LPN #1 Proper Name). He stated If y'all don't do anything about it, I will. Resident #14 stated that he did not trust LPN #1 after she shoved him into a wall and hurt his left foot. He said he refused to take any medication or receive any care from her after that stating, No telling what she might do. The resident had an angry tone and expression. He stated that he could not recall exactly what was said, but that he cursed her and she cursed him back. He stated that he stands by his original statement to LPN #4, given on 4/3/19. Review of the resident's statement, documented in the facility's investigation, taken by LPN #4 on 4/3/19 at 9:50 PM, revealed Resident #14 stated he was tapping his hand on the counter to get the nurse's attention. He stated the nurse got up from the desk and pushed his wheelchair into the wall by the DON's office on the 300 hall. Resident stated he hit his foot on the wall. Resident stated he cursed the nurse and the nurse cursed him back, got her purse, and left the building. On 04/23/19, at 8:04 PM, an interview with LPN #4 revealed that she was working on the hall and that she did not witness the alleged abuse but was told about it by LPN #2. She stated she obtained a statement from Resident #14. She stated that he reported he had cursed LPN #1 and that she cursed him back and pushed him into the wall, hurting his foot. LPN #4 stated that she examined the resident's foot and did not notice any injury or swelling that was unusual for him. She stated he always had [MEDICAL CONDITION], but there was no unusual swelling. On 04/23/19, at 8:16 PM, during a phone interview with LPN #2, she stated at approximately 8:15-8:20 PM, on 4/3/19, that she walked up to the nurse's station from the 200 Hall. LPN #1 was sitting at the desk working on charting and Resident #14 was sitting across from LPN #1 in his wheelchair at the nurse's station hitting the top of the desk with the palm of his hand very loudly. LPN #2 stated that she told Resident #14 that she had sensitive ears and that it was hurting her ears and asked him to stop and he stopped. She stated that LPN #1 had told her that Resident #14 was pulling orders out of charts and she had to move them. LPN #2 proceeded through the nurse's station and toward the 500 Hall to the treatment cart when she overheard LPN #1, say, [***] , I got your [***] , you Mother [***] . She stated that LPN #1 left the facility a few minutes later (no more than 5 minutes) and that she called the Administrator to report the incident and reported it to Resident #14's Charge Nurse, LPN #4. She stated that three (3) or four (4) other residents were sitting in the area. Resident #45 and Resident #13 were the ones she remembered. She stated Resident #45 might be interviewable, but Resident #13 wouldn't recall anything. Review of the signed and documented statement from LPN #2, from the facility's investigation, (not dated) revealed LPN #1 stated, Mother [***] , while at the nurse's station, but LPN #2 didn't know who she was talking to. It was noted in further documentation that LPN #2 saw another Resident at the station, (Resident #13), who had a documented interview by the Administrator on 4/4/19, in which the resident denied hearing profanity. Interview on 04/23/19, at 4:30 PM, with the Administrator confirmed that LPN #1 continued to work for the facility and was scheduled to work on 4/24/19, the 7 AM-7 PM shift. On 04/24/19, at 8:33 AM, during a further interview with the Administrator, she stated that she did feel that verbal abuse had occurred based upon the statements of LPN #2 and LPN #3 obtained during the investigation for the incident with Resident #14. She stated that she had requested termination of LPN #1 from corporate, but that request was denied by Human Resources. She stated that LPN #1 was suspended from 4/3/19 - 4/17/19, and then LPN #1 was allowed to return to work on 4/17/19, after the investigation was completed, because it was determined that abuse could not be substantiated on the part of the facility. The Administrator stated that LPN #1 had been re-assigned to Resident #14 since returning to work, stating that was the hall that LPN #1 was assigned to before she was suspended, so she was re-assigned to that hall upon return on 4/17/19. The Administrator stated that LPN #1 was issued a Final Warning due to a previous Verbal Warning for using profanity in the common area of a sister facility. Review of an electronic communication, documented by the Administrator on 4/8/19, revealed a subject: Suspension. The documentation included: Attached is an allegation of verbal abuse investigation that was reported to the state and AG .Based on the other 2 LPN's statements, I would like to request termination. Review of Resident #45's MDS, with an ARD of 1/24/19, revealed a BIMS of 15. Interview with Resident #45 revealed he did not recall what was said on 4/3/19 at the nurse's station between Resident #14 and LPN #1. Record review of the Daily Assignment Sheets for 4/17/19 - 4/21/19, revealed that LPN #1 was assigned to the 300/400 Hall. Resident #14 resided on the 300 Hall. Interview with LPN #1, on 4/24/19, at 11:10 AM, in the Medical Records building, revealed that she was removed from the 300-400 Hall assignment by the Administrator earlier that morning and re-assigned to file records in a separate building. She stated that on 4/3/19, she was working on charting at the nurse's station when Resident #14 came up in his wheelchair and asked for the phone. She stated that the phone was not charged and he became angry. She stated that she asked him to leave the desk so she could finish her work and he said, [***] you, [***] . She stated that she did move Resident #14 away from the nurse's station toward his room, but denied hitting his foot on a wall. She stated that the resident came back to the nurse's station and began banging his hand on the desk. LPN #1 stated that she never cursed Resident #14, and that she told him, You're cursing me out. If you want me to respect you, you've got to respect me, too. She stated that a couple of nurses walked by every now and then and Resident #45 rolled up, but that she did not know what he heard. She revealed that she had completed in-services on Abuse after coming back to work on 4/17/19. She stated that Resident #14 took meds from her on 4/17/19, but began refusing on 4/18/19, saying, I don't want to take it, I don't trust you. LPN #1 revealed that she had been assigned to Resident #14 on 4/17/19 - 4/24/19, (after returning to work from being suspended for abuse). Telephone interview with LPN #3 on 4/24/19 at 2:50 PM, revealed that she was down the hall when the incident occurred. She stated that she walked to the nurse's station to see what was going on because Resident #14 was beating on the desk. LPN #3 stated that LPN #1 was mad because she said Resident #14 had called her a [***] . LPN #3 stated LPN #1 was behind the desk and Resident #14 was on the other side of the desk in his wheelchair. She stated, She was saying something. They were going back and forth with each other but I don't recall exactly what was said. Review of the written facility investigative statement, dated 4/5/19, for LPN #3, documented by Interim DON #1, revealed that she had walked to the nurse's station and Resident #14 was beating his hand on the desk and LPN #1 was on the computer. Documentation of the statement included, He called her a [***] and she said, if I'm a [***] , you are a [***] , it takes one to know one. They were arguing back and forth. I couldn't hear exactly what they said. Record review of Progress Notes revealed, 4/18/19 14:05, Type: Gen Nurses Notes - narrative, Note Text: Writer approached the resident to give him his medication and he stated 'I am not taking them for you', writer in return asked Director of Nursing (DON) who was standing at the nurse's station and she gave the resident his medication, he took his medication just fine for me yesterday. Author: - LPN#1 (e-SIGNED). Review of Progress Notes revealed, 4/19/2019 14:45, Type: Gen Nurses Notes - narrative, Note Text: The resident continues to refuse to take his medications from me, other nurses have been giving him his medications for me, writer continues to maintain a professional level with him, he is stating to other staff and residents that he don't trust me and stating that I pushed him into the wall, which is not true. No acute distress noted, will continue to medicate and monitor per MD orders as the resident will allow. Author: LPN #1 (e-SIGNED). Review of LPN #1's personnel file revealed a Disciplinary Action Record, dated 4/24/19, that documented LPN #1 was suspended on 4/3/19, for using profanity in the presence of residents. A Disciplinary Action Record dated 4/25/19, documented LPN #1 was terminated related to the 4/3/19 incident of using profanity in the presence of residents. The personnel file contained a Corrective Action Plan, dated 6/27/18, for a verbal warning of using profanity in the common area of the facility. This indicated the facility was aware of LPN's verbal profanity in the past. Review of the In-service Attendance record dated 12/23/18, Topic: Neglect and Abuse in Healthcare Setting, revealed that LPN #1 attended this in-service. Review of the In-Service Training Log (General), Dated 4/17/19, In-Service Subject: Abuse/Neglect/Hand in Hand video, revealed LPN #1 signed the log and the Statement of Policy regarding Abuse. Record review of the Disciplinary Action Record for LPN #1, dated 4/25/19, revealed that the facility terminated her employment for using profanity in the presence of residents. Review of the Admission Record revealed the facility admitted Resident #14 on 10/7/15. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date (ARD) of 1/2/19, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognitive skills for daily decision making. The facility submitted an acceptable Removal Plan on 4/26/19, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit: 1. The facility failed to assure the resident was free from verbal abuse and failed to report the abuse within the required two (2) hour reporting period, failing to keep the resident safe. On (MONTH) 3, 2019, at approximately 10:00 PM, Resident #14 reported an allegation of verbal abuse against Licensed Practical Nurse (LPN) #1. The allegation consisted of the Resident #14 using a derogatory name towards LPN #1. LPN #1 responded to the resident by using the same derogatory name. This occurred around the nursing station. LPN #3 stated she heard LPN #1 say If I'm a [***] , you are a [***] . It takes one to know one at the nurses station. LPN #2 stated she heard LPN #1 say Mother [***] . The Administrator was immediately notified by LPN #2 at approximately 10:00 PM. LPN #1 was immediately suspended, abuse in-services and the abuse investigation was initiated. 2. The following parties were notified of the incident: · Responsible party was notified (MONTH) 4, 2019 at approximately 10:38 AM. · Primary Physician was notified (MONTH) 4, 2019 at 12:50 PM. · Medical Director was notified (MONTH) 4, 2019 at 11:44 AM. · Mississippi State Department of Health was notified (MONTH) 4, 2019 at 5:20 PM. · Mississippi State Attorney General was notified (MONTH) 4, 2019 at 5:01 PM. · Mississippi State Board of Nursing was notified (MONTH) 25, 2019 at 9:11 PM. 3. LPN #1 was brought back on (MONTH) 17, 2019, and received an inservice on abuse, neglect, and exploitation. She was then assigned to Resident #14, thus not protecting the residents in the facility from further abuse and the facility not following their policy for abuse. LPN #1 was subsequently suspended on (MONTH) 24, 2019, pending an investigation. LPN #1 was terminated on (MONTH) 25, 2019, for verbal abuse against Resident #14. 4. On (MONTH) 24, 2019, at approximately 9:00 AM, the Administrator removed LPN #1 from all resident care areas. 5. On (MONTH) 24, 2019, beginning at approximately 8:00 PM, the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC), and Assistant DON initiated education with staff, including Certified Nursing Assistants, licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff and administrative staff on Abuse and Neglect Prohibition Policy, Resident Rights, reporting abuse and/or neglect within the required two (2) hour time frame. Focus was placed on immediately removing the resident from the abuse situation; reporting all allegations of abuse, neglect and exploitation to the Administrator immediately; and that any staff member accused of abuse, neglect or exploitation will be suspended immediately pending investigation. No staff member will be allowed to return to work without completing required education. Currently, 76 of 88 staff members have completed required education. 6. On (MONTH) 24, 2019, beginning at approximately 8:45 PM, the Interim Director of Nursing, Corporate Clinical Specialist, Assistant Director of Nursing (ADON) and Staff Development Coordinator (SDC) provided posttest to employees in regards to Abuse and Neglect prohibition policy that was initiated on (MONTH) 24, 2019, to ascertain understanding of Abuse and Neglect prohibition policy training. Any employee that was not able to answer the posttest answers correctly was provided a one-to-one (1:1)re-education at that time. No staff will be allowed to return to work without completing the required education posttest. 7. On (MONTH) 24, 2019, beginning at approximately 9:15 PM, Social Worker, Human Resource Director, Business Office Manager (BOM), Respiratory Therapist, Assistant BOM, Activities Director, Minimum Data Set nurses, SDC, Registered Nurse (RN) Charge Nurse interviewed forty-five (45) residents in the facility at that time, with a Brief Interview of Mental Status (BIMS) of 12 or higher, in regards to had they ever experienced any verbal or physical abuse. Findings of the interviews were reviewed by the Administrator to determine any on-going or previously unidentified allegations of abuse and/or neglect; two (2) residents relayed information from a prior incident, which was investigated and reported. No abuse was substantiated. 8. On (MONTH) 24, 2019, beginning at approximately 9:00 PM, the Corporate Clinical Specialist, both MDS nurses and the Regional Case Mix Specialist reviewed clinical documentation for Resident #14, to determine any negative changes to daily routines, activity participation, socialization, meal intake; Resident #14 began refusing medication from LPN #1 on (MONTH) 18, 2019. No other changes where identified with Resident #14. 9. On (MONTH) 24, 2019 and (MONTH) 26, 2019, the Chief Operating Officer in-serviced the Director of Field Human Resources on the policy and procedures for Abuse and Neglect. 10. On (MONTH) 25, 2019 at approximately 12:30 PM, the grievance log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, and incident log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, were reviewed by the Administrator to identify potential allegations abuse/neglect for reporting potential. No grievances or incidence were identified as a potential allegation that had not already been reported. 11. On (MONTH) 25, 2019, at 2:00 PM, the Medical Director, Administrator, interim Director of Nursing, Social Services Director, Activities Director, BOM, SDC, ADON, Dietary Supervisor, Housekeeping Supervisor, Maintenance Director, HR director and Director of Rehab held a Quality Assurance Performance Improvement (QAPI) meeting following notification of Immediate Jeopardy to review steps initiated to identify any on-going or previously unreported allegations of abuse and/or neglect and to administer posttest to employees to determine understanding of education provided. There were no new policy or procedure changes. 12. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of (MONTH) 25, 2019, and the Immediate Jeopardy was removed (MONTH) 26, 2019. The State Agency (SA) validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ: 1. The SA validated that Resident #14 was not free from verbal abuse and the facility failed to report the abuse within the required two (2) hour reporting period, failed to keep residents safe. On (MONTH) 3, 2019, at approximately 10:00 PM, Resident #14 reported an allegation of verbal abuse against Licensed Practical Nurse (LPN) #1. The allegation consisted of the Resident #14 using a derogatory name towards LPN #1 and LPN #1 responded to the resident by using the same derogatory name. This occurred around the nursing station. The SA validated through interviews that LPN #3 stated she heard LPN #1 say If I'm a [***] , you are [***] . It takes one to know one at the nurses station. LPN #2 stated she heard LPN #1 say Mother [***] . The Administrator was notified by LPN #2. LPN #1 was suspended, abuse in-services and the abuse investigation was initiated. 2. The following parties were notified of the incident: · The SA validated through interview with the Responsible Party that she was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Primary Physician was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Medical Director that he was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Mississippi State Department of Health was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Mississippi State Attorney General was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Mississippi State Board of Nursing was notified (MONTH) 25, 2019, of the alleged abuse by LPN #1. 3. The SA validated through interview with LPN #1 and the Administrator and record review that LPN #1 was suspended and was brought back to work on (MONTH) 17, 2019, and received an inservice on abuse, neglect, and exploitation. She was then assigned to Resident #14, thus not protecting the residents in the facility from further abuse and the facility not following their policy for abuse. LPN #1 was subsequently suspended on (MONTH) 24, 2019, pending an investigation. The SA validated that LPN #1 was terminated on (MONTH) 25, 2019, for verbal abuse against Resident #14. 4. The SA validated through interview with the Administrator and LPN #1 and record review, that on (MONTH) 24, 2019, the Administrator removed LPN #1 from all resident care areas and placed her in another building with Medical Records duty. 5. The SA validated through interview with the Administrator, and staff from Nursing, Dietary, Social Services, Therapy, Business Office and Housekeeping/Maintenance and record review that on (MONTH) 24, 2019, beginning at approximately 8:00 PM, the Administrator, DON, SDC and ADON initiated education with staff, including Certified Nursing Assistants, licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff and administrative staff on Abuse and Neglect Prohibition Policy, Resident Rights, reporting abuse and/or neglect within the required two (2) hour time frame. Focus was placed on immediately removing the resident from the abuse situation; reporting all allegations of abuse, neglect and exploitation to the Administrator immediately; and that any staff member accused of abuse, neglect or exploitation will be suspended immediately pending investigation. No staff member was allowed to return to work, without completing required education. Currently, 76 of 88 staff members have completed required education. 6. The SA validated through interview with the Administrator and staff from Nursing, Dietary, Social Services, Therapy, Business Office and Housekeeping/Maintenance and record review that on (MONTH) 24, 2019, beginning at approximately 8:45 PM, the interim Director of Nursing, Corporate Clinical Specialist, Assistant Director of Nursing (ADON) and Staff Development Coordinator (SDC) provided posttest to employees in regards to Abuse and Neglect prohibition policy that was initiated on (MONTH) 24, 2019, to ascertain understanding of Abuse and Neglect prohibition policy training. Any employee that was not able to answer the posttest answers correctly was provided a one-to-one (1:1) re-education at that time. No staff was allowed to return to work without completing the required education posttest. 7. The SA validated through interview with the Administrator and record review that on (MONTH) 24, 2019, the Social Worker, Human Resource Director, Business Office Manager (BOM), Respiratory Therapist, Assistant BOM, Activities Director, Minimum Data Set nurses, SDC, Registered Nurse (RN) Charge Nurse interviewed forty-five (45) residents in the facility at that time, with a BIMS of 12 or higher, in regards to had they ever experienced any verbal or physical abuse. Findings of the interviews were reviewed by the Administrator to determine any on-going or previously unidentified allegations of abuse and/or neglect; two (2) residents relayed information from a prior incident, which was investigated and reported. The SA validated no abuse was substantiated. 8. The SA validated through interview with the Administrator, Corporate Clinical Specialist, and one (1) MDS nurse, that on (MONTH) 24, 2019, the Corporate Clinical Specialist, both MDS nurses and the Regional Case Mix Specialist reviewed clinical documentation for Resident #14, to determine any negative changes to daily routines, activity participation, socialization, meal intake; Resident #14 began refusing medication from LPN #1 on (MONTH) 18, 2019. No other changes where identified with Resident #14. The SA validated that Resident #14 did receive medication from other nurses. 9. The SA validated through interview with the Chief Operating Officer, and dated/signed in-service sheets, that the Director of Field Human Resources was educated on the abuse and neglect policy and procedures with emphasis of investigation and to err on the side of the resident. 10. The SA validated through interview with the Administrator and record review that on (MONTH) 25, 2019, the grievance log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, and incident log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, were reviewed by the Administrator to identify potential allegations abuse/neglect for reporting potential. No grievances or incidence were identified as a potential allegation that had not already been reported. 11. The SA validated through interview with the Administrator and record review that on (MONTH) 25, 2019, at 2:00 PM, the Medical Director, Administrator, interim Director of Nursing, Social Services Director, Activities Director, BOM, SDC, ADON, Dietary Supervisor, Housekeeping Supervisor, Maintenance Director, HR director and Director of Rehab held Quality Assurance Performance Improvement meeting following notification of Immediate Jeopardy to review steps initiated to identify any on-going or previously unreported allegations of abuse and/or neglect and to administer posttest to employees to determine understanding of education provided. There were no new policy or procedure changes. 12. The SA validated that all corrective actions were completed as of 4/25/19, and the IJ was removed as of 4/26/19.

Based on staff interview, record review, and facility policy review, the facility failed to implement their Abuse policy for protection of residents from verbal abuse, failed to protect other residents from abuse, and failed to report an allegation of abuse for one (1) of 24 residents, Resident #14. This was evidenced by allowing a staff member to return to work following an incident of witnessed verbal abuse toward Resident #14. The facility also failed to report the allegation of abuse to the required state agencies, per policy, within the two (2) hour timeframe, to ensure appropriate actions were taken. On 4/3/19, at approximately 9:50 PM, (according to written reports) Resident #14 reported an allegation of verbal abuse against Licensed Practical Nurse (LPN) #1. This occurred at the nurse's station. There were witnesses to the events. LPN #3 stated she heard LPN #1 say, If I'm a [***] , you are a [***] . It takes one to know one. LPN #2 stated she heard LPN #1 say Mother [***] . The Administrator was immediately notified by LPN #2 at approximately 10:00 PM, and LPN #1 was suspended on 4/3/19, however, she was allowed to return to work on 4/17/19, and allowed to work on the same assigned hall where Resident #14 resided. This resulted in the resident refusing to take medications from LPN #1, stating he did not trust her and didn't know what she might do. The facility did not report the allegation of abuse until 4/4/19, at approximately 5:20 PM, which was almost 20 hours after the allegation. The failure of the facility to protect residents from verbal abuse by allowing a staff member to return to work in the facility, with the same resident, following an investigation of witnessed verbal abuse; and failure to report the abuse within two (2) hours to the State Designated Agencies, per facility policy, placed Resident #14 and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 4/3/19, when the abuse occurred. The facility's Administrator was notified of the IJ and SQC on 4/25/19, at 10:00 AM, and the State Agency (SA) provided the facility with the IJ template. An acceptable credible Removal Plan was provided by the facility on 4/26/19, in which the facility alleged all corrective actions were completed as of 4/25/19, and the IJ was removed on 4/26/19. The State Agency (SA) validated the Removal Plan and determined that the IJ was removed on 4/26/19, prior to exit. Therefore, the scope and severity for IJ and SQC at 42 CFR 483.12(b)(1)-(3); Develop/Implement Abuse/Neglect Policies, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility's policy entitled Abuse Prohibition Policy, Revision: 03/18/2019, revealed Policy: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. Review of the facility policy Abuse Program, Revision 11/2017, revealed .Investigation: 1. The facility will thoroughly investigate all alleged violations and take appropriate actions. 2. The Abuse Coordinator will report such allegations to the state agency in accordance with state law. The Abuse Coordinator will report all allegations of abuse .within two hours of the allegation . Protection: 1. All residents will be immediately protected from harm. 2. All allegations involving staff will necessitate suspension without pay, pending investigation. 3. If the allegation is substantiated, the employee will be terminated immediately without pay retroactive to the date of removal from employment. Statement of Policy, Regarding the Reporting of Abuse and Associate Acknowledgement .Remember our policy is all residents and patients of this nursing home are to be treated with dignity and respect at all times, under all circumstances. Mistreatment or abuse of any nature will not be tolerated . During an interview with Resident #14 on 04/22/19, at 04:03 PM, he stated that about two (2) weeks ago, Licensed Practical Nurse (LPN) #1 cursed him and pushed him into a wall, hurting his left foot. He stated If y'all don't do anything about it, I will. Resident #14 had difficulty recalling exactly what was said but stated that he cursed her and she cursed him back. He also stated that he did not trust LPN #1 and he refused to take any medication or receive any care from her after she returned to work and was re-assigned to his hall. He stated, No telling what she might do. Review of a written report from the facility, dated 4/5/19, revealed that on 4/3/19 at 9:50 PM, Resident #14 alleged that LPN #1 cursed him and pushed his wheelchair against the wall hurting his toe. Witnesses, LPN #2 and LPN #3 wrote statements and confirmed LPN #1 used profane language toward Resident #14, saying things such as, Mother [***] , and [***] toward or in the presence of Resident #14. LPN #1 was suspended on 4/3/19. Record review of the Daily Assignment Sheets for 4/17/19 - 4/21/19, revealed that LPN #1 was assigned to the 300/400 Hall for these dates. LPN #1 was also assigned on the same hall on 4/24/19, prior to being re-assigned to another building to work in Medical Records. Resident #14 resided on the 300 hall and LPN #1 was assigned his care. On 04/23/19, at 4:30 PM, during an interview with the Administrator, she confirmed that LPN #1 continued to work for the facility after being suspended for verbal abuse from 4/3/19 - 4/17/19, and that LPN #1 was allowed to return to work on 4/17/19, after the investigation was completed. The Administrator stated that abuse could not be substantiated on the part of the facility, per corporate review. Further interview with the Administrator, on 04/24/19, at 8:33 AM, revealed that she did feel that verbal abuse had occurred to Resident #14 by LPN #1, based upon the statements of LPN #2 and LPN #3 that were obtained during the investigation. The Administrator stated she requested for LPN #1 to be terminated for verbal abuse, but was denied by Human Resources. She stated that LPN #1 was brought back and re-assigned to the same halls she worked prior to the suspension; this was the same hall upon which Resident #14 resided. She confirmed that the facility policy was not followed for protection of the resident. She stated that LPN #1 was terminated on 4/24/19, for verbal abuse of Resident #14. On 04/24/19, at 8:33 AM, during an interview with the Administrator, she stated that she was not aware of the regulation and thought she had 24 hours to report the allegation of abuse by LPN #1 to Resident #14. She confirmed the allegation was not reported to the Mississippi State Department of Health, Health Facilities Licensure and Certification within two (2) hours. Review of a Fax Call Report revealed that the incident of verbal abuse for Resident #14 was reported to the Mississippi State Department of Health Hotline number on 4/4/19, at 5:16 PM, which was almost 20 hours after the incident occurred. The facility submitted an acceptable Removal Plan on 4/26/19, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit: 1. The facility failed to assure the resident was free from verbal abuse and failed to report the abuse within the required two (2) hour reporting period, failing to keep the resident safe. On (MONTH) 3, 2019, at approximately 10:00 PM, Resident #14 reported an allegation of verbal abuse against Licensed Practical Nurse (LPN) #1. The allegation consisted of the Resident #14 using a derogatory name towards LPN #1. LPN #1 responded to the resident by using the same derogatory name. This occurred around the nursing station. LPN #3 stated she heard LPN #1 say If I'm a [***] , you are a [***] . It takes one to know one at the nurses station. LPN #2 stated she heard LPN #1 say Mother [***] . The Administrator was immediately notified by LPN #2 at approximately 10:00 PM. LPN #1 was immediately suspended, abuse in-services and the abuse investigation was initiated. 2. The following parties were notified of the incident: · Responsible party was notified (MONTH) 4, 2019 at approximately 10:38 AM. · Primary Physician was notified (MONTH) 4, 2019 at 12:50 PM. · Medical Director was notified (MONTH) 4, 2019 at 11:44 AM. · Mississippi State Department of Health was notified (MONTH) 4, 2019 at 5:20 PM. · Mississippi State Attorney General was notified (MONTH) 4, 2019 at 5:01 PM. · Mississippi State Board of Nursing was notified (MONTH) 25, 2019 at 9:11 PM. 3. LPN #1 was brought back on (MONTH) 17, 2019, and received an inservice on abuse, neglect, and exploitation. She was then assigned to Resident #14, thus not protecting the residents in the facility from further abuse and the facility not following their policy for abuse. LPN #1 was subsequently suspended on (MONTH) 24, 2019, pending an investigation. LPN #1 was terminated on (MONTH) 25, 2019, for verbal abuse against Resident #14. 4. On (MONTH) 24, 2019, at approximately 9:00 AM, the Administrator removed LPN #1 from all resident care areas. 5. On (MONTH) 24, 2019, beginning at approximately 8:00 PM, the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC), and Assistant DON initiated education with staff, including Certified Nursing Assistants, licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff and administrative staff on Abuse and Neglect Prohibition Policy, Resident Rights, reporting abuse and/or neglect within the required two (2) hour time frame. Focus was placed on immediately removing the resident from the abuse situation; reporting all allegations of abuse, neglect and exploitation to the Administrator immediately; and that any staff member accused of abuse, neglect or exploitation will be suspended immediately pending investigation. No staff member will be allowed to return to work without completing required education. Currently, 76 of 88 staff members have completed required education. 6. On (MONTH) 24, 2019, beginning at approximately 8:45 PM, the Interim Director of Nursing, Corporate Clinical Specialist, Assistant Director of Nursing (ADON) and Staff Development Coordinator (SDC) provided posttest to employees in regards to Abuse and Neglect prohibition policy that was initiated on (MONTH) 24, 2019, to ascertain understanding of Abuse and Neglect prohibition policy training. Any employee that was not able to answer the posttest answers correctly was provided a one-to-one (1:1)re-education at that time. No staff will be allowed to return to work without completing the required education posttest. 7. On (MONTH) 24, 2019, beginning at approximately 9:15 PM, Social Worker, Human Resource Director, Business Office Manager (BOM), Respiratory Therapist, Assistant BOM, Activities Director, Minimum Data Set nurses, SDC, Registered Nurse (RN) Charge Nurse interviewed forty-five (45) residents in the facility at that time, with a Brief Interview of Mental Status (BIMS) of 12 or higher, in regards to had they ever experienced any verbal or physical abuse. Findings of the interviews were reviewed by the Administrator to determine any on-going or previously unidentified allegations of abuse and/or neglect; two (2) residents relayed information from a prior incident, which was investigated and reported. No abuse was substantiated. 8. On (MONTH) 24, 2019, beginning at approximately 9:00 PM, the Corporate Clinical Specialist, both MDS nurses and the Regional Case Mix Specialist reviewed clinical documentation for Resident #14, to determine any negative changes to daily routines, activity participation, socialization, meal intake; Resident #14 began refusing medication from LPN #1 on (MONTH) 18, 2019. No other changes where identified with Resident #14. 9. On (MONTH) 24, 2019 and (MONTH) 26, 2019, the Chief Operating Officer in-serviced the Director of Field Human Resources on the policy and procedures for Abuse and Neglect. 10. On (MONTH) 25, 2019 at approximately 12:30 PM, the grievance log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, and incident log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, were reviewed by the Administrator to identify potential allegations abuse/neglect for reporting potential. No grievances or incidence were identified as a potential allegation that had not already been reported. 11. On (MONTH) 25, 2019, at 2:00 PM, the Medical Director, Administrator, interim Director of Nursing, Social Services Director, Activities Director, BOM, SDC, ADON, Dietary Supervisor, Housekeeping Supervisor, Maintenance Director, HR director and Director of Rehab held a Quality Assurance Performance Improvement (QAPI) meeting following notification of Immediate Jeopardy to review steps initiated to identify any on-going or previously unreported allegations of abuse and/or neglect and to administer posttest to employees to determine understanding of education provided. There were no new policy or procedure changes. 12. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of (MONTH) 25, 2019, and the Immediate Jeopardy was removed (MONTH) 26, 2019. The State Agency (SA) validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ: 1. The SA validated that Resident #14 was not free from verbal abuse and the facility failed to report the abuse within the required two (2) hour reporting period, failed to keep residents safe. On (MONTH) 3, 2019, at approximately 10:00 PM, Resident #14 reported an allegation of verbal abuse against Licensed Practical Nurse (LPN) #1. The allegation consisted of the Resident #14 using a derogatory name towards LPN #1 and LPN #1 responded to the resident by using the same derogatory name. This occurred around the nursing station. The SA validated through interviews that LPN #3 stated she heard LPN #1 say If I'm a [***] , you are [***] . It takes one to know one at the nurses station. LPN #2 stated she heard LPN #1 say Mother [***] . The Administrator was notified by LPN #2. LPN #1 was suspended, abuse in-services and the abuse investigation was initiated. 2. The following parties were notified of the incident: · The SA validated through interview with the Responsible Party that she was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Primary Physician was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Medical Director that he was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Mississippi State Department of Health was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Mississippi State Attorney General was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Mississippi State Board of Nursing was notified (MONTH) 25, 2019, of the alleged abuse by LPN #1. 3. The SA validated through interview with LPN #1 and the Administrator and record review that LPN #1 was suspended and was brought back to work on (MONTH) 17, 2019, and received an inservice on abuse, neglect, and exploitation. She was then assigned to Resident #14, thus not protecting the residents in the facility from further abuse and the facility not following their policy for abuse. LPN #1 was subsequently suspended on (MONTH) 24, 2019, pending an investigation. The SA validated that LPN #1 was terminated on (MONTH) 25, 2019, for verbal abuse against Resident #14. 4. The SA validated through interview with the Administrator and LPN #1 and record review, that on (MONTH) 24, 2019, the Administrator removed LPN #1 from all resident care areas and placed her in another building with Medical Records duty. 5. The SA validated through interview with the Administrator, and staff from Nursing, Dietary, Social Services, Therapy, Business Office and Housekeeping/Maintenance and record review that on (MONTH) 24, 2019, beginning at approximately 8:00 PM, the Administrator, DON, SDC and ADON initiated education with staff, including Certified Nursing Assistants, licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff and administrative staff on Abuse and Neglect Prohibition Policy, Resident Rights, reporting abuse and/or neglect within the required two (2) hour time frame. Focus was placed on immediately removing the resident from the abuse situation; reporting all allegations of abuse, neglect and exploitation to the Administrator immediately; and that any staff member accused of abuse, neglect or exploitation will be suspended immediately pending investigation. No staff member was allowed to return to work, without completing required education. Currently, 76 of 88 staff members have completed required education. 6. The SA validated through interview with the Administrator and staff from Nursing, Dietary, Social Services, Therapy, Business Office and Housekeeping/Maintenance and record review that on (MONTH) 24, 2019, beginning at approximately 8:45 PM, the interim Director of Nursing, Corporate Clinical Specialist, Assistant Director of Nursing (ADON) and Staff Development Coordinator (SDC) provided posttest to employees in regards to Abuse and Neglect prohibition policy that was initiated on (MONTH) 24, 2019, to ascertain understanding of Abuse and Neglect prohibition policy training. Any employee that was not able to answer the posttest answers correctly was provided a one-to-one (1:1) re-education at that time. No staff was allowed to return to work without completing the required education posttest. 7. The SA validated through interview with the Administrator and record review that on (MONTH) 24, 2019, the Social Worker, Human Resource Director, Business Office Manager (BOM), Respiratory Therapist, Assistant BOM, Activities Director, Minimum Data Set nurses, SDC, Registered Nurse (RN) Charge Nurse interviewed forty-five (45) residents in the facility at that time, with a BIMS of 12 or higher, in regards to had they ever experienced any verbal or physical abuse. Findings of the interviews were reviewed by the Administrator to determine any on-going or previously unidentified allegations of abuse and/or neglect; two (2) residents relayed information from a prior incident, which was investigated and reported. The SA validated no abuse was substantiated. 8. The SA validated through interview with the Administrator, Corporate Clinical Specialist, and one (1) MDS nurse, that on (MONTH) 24, 2019, the Corporate Clinical Specialist, both MDS nurses and the Regional Case Mix Specialist reviewed clinical documentation for Resident #14, to determine any negative changes to daily routines, activity participation, socialization, meal intake; Resident #14 began refusing medication from LPN #1 on (MONTH) 18, 2019. No other changes where identified with Resident #14. The SA validated that Resident #14 did receive medication from other nurses. 9. The SA validated through interview with the Chief Operating Officer, and dated/signed in-service sheets, that the Director of Field Human Resources was educated on the abuse and neglect policy and procedures with emphasis of investigation and to err on the side of the resident. 10. The SA validated through interview with the Administrator and record review that on (MONTH) 25, 2019, the grievance log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, and incident log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, were reviewed by the Administrator to identify potential allegations abuse/neglect for reporting potential. No grievances or incidence were identified as a potential allegation that had not already been reported. 11. The SA validated through interview with the Administrator and record review that on (MONTH) 25, 2019, at 2:00 PM, the Medical Director, Administrator, interim Director of Nursing, Social Services Director, Activities Director, BOM, SDC, ADON, Dietary Supervisor, Housekeeping Supervisor, Maintenance Director, HR director and Director of Rehab held Quality Assurance Performance Improvement meeting following notification of Immediate Jeopardy to review steps initiated to identify any on-going or previously unreported allegations of abuse and/or neglect and to administer posttest to employees to determine understanding of education provided. There were no new policy or procedure changes. 12. The SA validated that all corrective actions were completed as of 4/25/19, and the IJ was removed as of 4/26/19.

Based on staff interview, record review, and facility policy review, the facility failed to prevent further potential abuse and mistreatment from occurring after an allegation of abuse had been made and substantiated for one (1) of 24 residents reviewed, Resident #14. The facility failed to report the allegation of abuse within the required two (2) hour timeframe, and failed to take appropriate corrective action to protect residents from further abuse, by allowing Licensed Practical Nurse (LPN) #1 to continue working with Resident #14, after the witnessed verbal abuse occurred. On 4/3/19 at approximately 9:50 PM, Licensed Practical Nurse (LPN) #1 was witnessed to verbally abuse Resident #14. She used words such as Mother [***] and statements such as, If I'm a [***] , then you're a [***] , because it takes one to know one. Resident #14 also accused LPN #1 of hurting his foot by pushing his wheelchair into the wall. LPN #1 was suspended on 4/3/19, however, she was allowed to return to work on 4/17/19, and continued to work until 4/24/19, on the same unit and was assigned the same room as Resident #14 resided. Resident #14 refused to take medications from the LPN and he made statements such as he wouldn't take medications from her, he didn't trust her, and that he didn't know what she would do. The allegation of abuse was not reported within the two (2) hour timeframe as required, but was reported the next day, almost 20 hours after the incident. The failure of the facility to report the allegation of abuse within the appropriate timeframe and by not protecting residents from further verbal abuse by allowing a staff member to work in the facility following a witnessed verbal abuse to a resident, with a history of profanity in the presence of residents, placed Resident #14 and other residents at risk for the likelihood of serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 4/3/19, when the allegation of abuse occurred. The facility's Administrator was notified of the IJ and SQC on 4/25/19, at 10:00 AM, and the SA provided the facility with the IJ template. An acceptable credible Removal Plan was provided on 4/26/19, in which the facility alleged all corrective actions were completed as of 4/25/19, and the IJ was removed on 4/26/19. The State Agency (SA) validated the Removal Plan, and determined that the IJ was removed on 4/26/19, prior to exit. Therefore, the scope and severity for IJ and SQC at 42 CFR 482.12(c)(2)-(4), F610, Investigate/Prevent/Correct Alleged Violation, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility's policy entitled Abuse Prohibition Policy, Revision: 03/18/2019, revealed Policy: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. Review of the facility policy Abuse Program, Revision 11/2017, revealed, Investigation: 1. The facility will thoroughly investigate all alleged violations and take appropriate actions. 2. The Abuse Coordinator will report such allegations to the state agency in accordance with state law. The Abuse Coordinator will report all allegations of abuse, .within two hours of the allegation . Protection: 1. All residents will be immediately protected from harm. 2. All allegations involving staff will necessitate suspension without pay, pending investigation. 3. If the allegation is substantiated, the employee will be terminated immediately without pay retroactive to the date of removal from employment. Statement of Policy, Regarding the Reporting of Abuse and Associate Acknowledgement, Remember our policy is all residents and patients of this nursing home are to be treated with dignity and respect at all times, under all circumstances. Mistreatment or abuse of any nature will not be tolerated . During an interview with Resident #14 on 04/22/19, at 4:03 PM, he reported everything was fine except with that woman who still worked at the facility and named LPN #1. He stated that about two (2) weeks ago, LPN #1 cursed him and pushed him into a wall, hurting his left foot. He stated If y'all don't do anything about it, I will. Resident #14 had difficulty recalling exactly what was said but stated that he cursed her and she cursed him back. He also stated that he did not trust LPN #1 and he refused to take any medication or receive any care from her after LPN #1 returned to work and was re-assigned to his hall stating, No telling what she might do. Review of the facility's investigative report, dated 4/5/19, revealed on 4/3/19 at 9:50 PM, Resident #14 reported he was tapping his hand on the desk to get the nurse's attention. He stated the nurse got up and pushed his wheelchair down the hall and hit his toe on the wall. He stated he cursed the nurse and she cursed him back. The investigation documented interviews from LPN #2 and LPN #3, confirming LPN #1 cursed the Resident, making statements such as, Mother [***] and If I'm a [***] , you are a [***] . It takes one to know one. The report documented another resident was around the desk, but interview revealed she could not recall profanity used. LPN #1 was suspended at that time. On 04/23/19, at 8:16 PM, in a phone interview with LPN #2, she stated that on 4/3/19, around 8:15-8:20 PM, she walked to the nurse's station from the 200 Hall where LPN #1 sat at the desk working on charting and Resident #14 was sitting across from LPN #1 in his wheelchair at the nurse's station. She stated that Resident #14 was hitting the top of the desk with the palm of his hand very loudly. LPN #2 stated that she asked Resident #14 to stop and he stopped. She stated that LPN #1 had told her that Resident #14 was pulling orders out of charts and looking at them and she had to move everything. LPN #2 stated that she proceeded through the nurse's station toward the 500 Hall to the treatment cart when she overheard LPN #1, say [***] , I got your [***] , you Mother [***] . She stated that LPN #1 left the facility a few minutes later (no more than 5 minutes) and that she called the Administrator to report the incident and also reported it to Resident #14's charge nurse, LPN #4. On 04/23/19, at 4:30 PM, in an interview with the Administrator, she confirmed that LPN #1 was suspended, then allowed to return to work at the facility on 4/17/19, and was assigned to the 300/400 Hall on which Resident #14 resided. Assignment sheets verified LPN #1 worked from 4/17/19-4/21/19 on the 300/400 hallway. During a further interview with the Administrator, on 04/24/19, at 8:33 AM, she stated that she felt Resident #14 was verbally abused based upon the statements of LPN #2 and LPN #3, obtained during the investigation. She stated that Human Resources had denied her request to terminate LPN #1. She stated that LPN #1 was suspended from 4/3/19 - 4/17/19, and that she was allowed to return to the facility on [DATE], after the investigation was completed. The Administrator stated that LPN #1 had been re-assigned to Resident #14, since that was the hall that she was assigned to before she was suspended, so she was reassigned to that hall upon return on 4/17/19. The Administrator confirmed the policy was not followed for protection of the resident when LPN #1 returned to work after verbally abusing Resident #14. The Administrator stated that LPN #1 was issued a Final Warning upon return, due to a previous Verbal Warning at a sister facility for using profanity in the common area. Review of a documented e-mail, dated 4/8/19, by the Administrator, revealed a request to terminate LPN #1, based on the statements from two (2) LPNs. Attached is an allegation of verbal abuse investigation that was reported to the state and AG. The LPN is (LPN #1's name). Review of LPN #1's personnel file revealed a Corrective Action Plan, dated 6/27/18, for a verbal warning of using profanity in the common area of the facility. A Disciplinary Action Record, dated 4/24/19, that documented LPN #1 was suspended on 4/3/19, for using profanity in the presence of residents. A further Disciplinary Action Record dated 4/25/19, documented LPN #1 was terminated related to the 4/3/19 incident of using profanity in the presence of residents. During an interview, on 4/24/19, at 11:10 AM, LPN #1 revealed that she had been assigned to Resident #14 upon return to the facility on [DATE], until this morning (4/24/19), when she was removed from the 300/400 Hall and told to go to Medical Records, which is in a separate building. She stated that Resident #14 took medication from her on 4/17/19, but began refusing on 4/18/19, telling her, I don't want to take it, I don't trust you. LPN #1 denied verbally abusing Resident #14 on 4/3/19. Record review of Progress Notes revealed, 4/18/19 14:05, Type: Gen Nurses Notes - narrative, Note Text: Writer approached the resident to give him his medication and he stated 'I am not taking them for you', writer in return asked DON who was standing at the nurses station and she gave the resident his medication, he took his medication just fine for me yesterday. Author: (Proper Name) LPN#1 (e-SIGNED). Record review of Progress Notes revealed, 4/19/2019 14:45, Type: Gen Nurses Notes - narrative, Note Text: The resident continues to refuse to take his medications from me, other nurses have been giving him his medications for me, writer continues to maintain a professional level with him, he is sating to other staff and residents that he don't trust me and stating that I pushed him into the wall which is not true. No acute distress noted, will continue to medicate and monitor per MD orders as the resident will allow. Author: (Proper Name) LPN #1 (e-signed). Record review of the Daily Assignment Sheets dated 4/17/19 - 4/21/19, revealed that LPN #1 was assigned to the 300/400 Hall. She was also initially assigned on 4/24/19, and was moved to another building for Medical Records. Resident #14 resided on the 300 Hall. The facility submitted an acceptable Removal Plan on 4/26/19, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit: 1. The facility failed to assure the resident was free from verbal abuse and failed to report the abuse within the required two (2) hour reporting period, failing to keep the resident safe. On (MONTH) 3, 2019, at approximately 10:00 PM, Resident #14 reported an allegation of verbal abuse against Licensed Practical Nurse (LPN) #1. The allegation consisted of the Resident #14 using a derogatory name towards LPN #1. LPN #1 responded to the resident by using the same derogatory name. This occurred around the nursing station. LPN #3 stated she heard LPN #1 say If I'm a [***] , you are a [***] . It takes one to know one at the nurses station. LPN #2 stated she heard LPN #1 say Mother [***] . The Administrator was immediately notified by LPN #2 at approximately 10:00 PM. LPN #1 was immediately suspended, abuse in-services and the abuse investigation was initiated. 2. The following parties were notified of the incident: · Responsible party was notified (MONTH) 4, 2019 at approximately 10:38 AM. · Primary Physician was notified (MONTH) 4, 2019 at 12:50 PM. · Medical Director was notified (MONTH) 4, 2019 at 11:44 AM. · Mississippi State Department of Health was notified (MONTH) 4, 2019 at 5:20 PM. · Mississippi State Attorney General was notified (MONTH) 4, 2019 at 5:01 PM. · Mississippi State Board of Nursing was notified (MONTH) 25, 2019 at 9:11 PM. 3. LPN #1 was brought back on (MONTH) 17, 2019, and received an inservice on abuse, neglect, and exploitation. She was then assigned to Resident #14, thus not protecting the residents in the facility from further abuse and the facility not following their policy for abuse. LPN #1 was subsequently suspended on (MONTH) 24, 2019, pending an investigation. LPN #1 was terminated on (MONTH) 25, 2019, for verbal abuse against Resident #14. 4. On (MONTH) 24, 2019, at approximately 9:00 AM, the Administrator removed LPN #1 from all resident care areas. 5. On (MONTH) 24, 2019, beginning at approximately 8:00 PM, the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC), and Assistant DON initiated education with staff, including Certified Nursing Assistants, licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff and administrative staff on Abuse and Neglect Prohibition Policy, Resident Rights, reporting abuse and/or neglect within the required two (2) hour time frame. Focus was placed on immediately removing the resident from the abuse situation; reporting all allegations of abuse, neglect and exploitation to the Administrator immediately; and that any staff member accused of abuse, neglect or exploitation will be suspended immediately pending investigation. No staff member will be allowed to return to work without completing required education. Currently, 76 of 88 staff members have completed required education. 6. On (MONTH) 24, 2019, beginning at approximately 8:45 PM, the Interim Director of Nursing, Corporate Clinical Specialist, Assistant Director of Nursing (ADON) and Staff Development Coordinator (SDC) provided posttest to employees in regards to Abuse and Neglect prohibition policy that was initiated on (MONTH) 24, 2019, to ascertain understanding of Abuse and Neglect prohibition policy training. Any employee that was not able to answer the posttest answers correctly was provided a one-to-one (1:1)re-education at that time. No staff will be allowed to return to work without completing the required education posttest. 7. On (MONTH) 24, 2019, beginning at approximately 9:15 PM, Social Worker, Human Resource Director, Business Office Manager (BOM), Respiratory Therapist, Assistant BOM, Activities Director, Minimum Data Set nurses, SDC, Registered Nurse (RN) Charge Nurse interviewed forty-five (45) residents in the facility at that time, with a Brief Interview of Mental Status (BIMS) of 12 or higher, in regards to had they ever experienced any verbal or physical abuse. Findings of the interviews were reviewed by the Administrator to determine any on-going or previously unidentified allegations of abuse and/or neglect; two (2) residents relayed information from a prior incident, which was investigated and reported. No abuse was substantiated. 8. On (MONTH) 24, 2019, beginning at approximately 9:00 PM, the Corporate Clinical Specialist, both MDS nurses and the Regional Case Mix Specialist reviewed clinical documentation for Resident #14, to determine any negative changes to daily routines, activity participation, socialization, meal intake; Resident #14 began refusing medication from LPN #1 on (MONTH) 18, 2019. No other changes where identified with Resident #14. 9. On (MONTH) 24, 2019 and (MONTH) 26, 2019, the Chief Operating Officer in-serviced the Director of Field Human Resources on the policy and procedures for Abuse and Neglect. 10. On (MONTH) 25, 2019 at approximately 12:30 PM, the grievance log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, and incident log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, were reviewed by the Administrator to identify potential allegations abuse/neglect for reporting potential. No grievances or incidence were identified as a potential allegation that had not already been reported. 11. On (MONTH) 25, 2019, at 2:00 PM, the Medical Director, Administrator, interim Director of Nursing, Social Services Director, Activities Director, BOM, SDC, ADON, Dietary Supervisor, Housekeeping Supervisor, Maintenance Director, HR director and Director of Rehab held a Quality Assurance Performance Improvement (QAPI) meeting following notification of Immediate Jeopardy to review steps initiated to identify any on-going or previously unreported allegations of abuse and/or neglect and to administer posttest to employees to determine understanding of education provided. There were no new policy or procedure changes. 12. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of (MONTH) 25, 2019, and the Immediate Jeopardy was removed (MONTH) 26, 2019. The State Agency (SA) validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ: 1. The SA validated that Resident #14 was not free from verbal abuse and the facility failed to report the abuse within the required two (2) hour reporting period, failed to keep residents safe. On (MONTH) 3, 2019, at approximately 10:00 PM, Resident #14 reported an allegation of verbal abuse against Licensed Practical Nurse (LPN) #1. The allegation consisted of the Resident #14 using a derogatory name towards LPN #1 and LPN #1 responded to the resident by using the same derogatory name. This occurred around the nursing station. The SA validated through interviews that LPN #3 stated she heard LPN #1 say If I'm a [***] , you are [***] . It takes one to know one at the nurses station. LPN #2 stated she heard LPN #1 say Mother [***] . The Administrator was notified by LPN #2. LPN #1 was suspended, abuse in-services and the abuse investigation was initiated. 2. The following parties were notified of the incident: · The SA validated through interview with the Responsible Party that she was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Primary Physician was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Medical Director that he was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Mississippi State Department of Health was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Mississippi State Attorney General was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Mississippi State Board of Nursing was notified (MONTH) 25, 2019, of the alleged abuse by LPN #1. 3. The SA validated through interview with LPN #1 and the Administrator and record review that LPN #1 was suspended and was brought back to work on (MONTH) 17, 2019, and received an inservice on abuse, neglect, and exploitation. She was then assigned to Resident #14, thus not protecting the residents in the facility from further abuse and the facility not following their policy for abuse. LPN #1 was subsequently suspended on (MONTH) 24, 2019, pending an investigation. The SA validated that LPN #1 was terminated on (MONTH) 25, 2019, for verbal abuse against Resident #14. 4. The SA validated through interview with the Administrator and LPN #1 and record review, that on (MONTH) 24, 2019, the Administrator removed LPN #1 from all resident care areas and placed her in another building with Medical Records duty. 5. The SA validated through interview with the Administrator, and staff from Nursing, Dietary, Social Services, Therapy, Business Office and Housekeeping/Maintenance and record review that on (MONTH) 24, 2019, beginning at approximately 8:00 PM, the Administrator, DON, SDC and ADON initiated education with staff, including Certified Nursing Assistants, licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff and administrative staff on Abuse and Neglect Prohibition Policy, Resident Rights, reporting abuse and/or neglect within the required two (2) hour time frame. Focus was placed on immediately removing the resident from the abuse situation; reporting all allegations of abuse, neglect and exploitation to the Administrator immediately; and that any staff member accused of abuse, neglect or exploitation will be suspended immediately pending investigation. No staff member was allowed to return to work, without completing required education. Currently, 76 of 88 staff members have completed required education. 6. The SA validated through interview with the Administrator and staff from Nursing, Dietary, Social Services, Therapy, Business Office and Housekeeping/Maintenance and record review that on (MONTH) 24, 2019, beginning at approximately 8:45 PM, the interim Director of Nursing, Corporate Clinical Specialist, Assistant Director of Nursing (ADON) and Staff Development Coordinator (SDC) provided posttest to employees in regards to Abuse and Neglect prohibition policy that was initiated on (MONTH) 24, 2019, to ascertain understanding of Abuse and Neglect prohibition policy training. Any employee that was not able to answer the posttest answers correctly was provided a one-to-one (1:1) re-education at that time. No staff was allowed to return to work without completing the required education posttest. 7. The SA validated through interview with the Administrator and record review that on (MONTH) 24, 2019, the Social Worker, Human Resource Director, Business Office Manager (BOM), Respiratory Therapist, Assistant BOM, Activities Director, Minimum Data Set nurses, SDC, Registered Nurse (RN) Charge Nurse interviewed forty-five (45) residents in the facility at that time, with a BIMS of 12 or higher, in regards to had they ever experienced any verbal or physical abuse. Findings of the interviews were reviewed by the Administrator to determine any on-going or previously unidentified allegations of abuse and/or neglect; two (2) residents relayed information from a prior incident, which was investigated and reported. The SA validated no abuse was substantiated. 8. The SA validated through interview with the Administrator, Corporate Clinical Specialist, and one (1) MDS nurse, that on (MONTH) 24, 2019, the Corporate Clinical Specialist, both MDS nurses and the Regional Case Mix Specialist reviewed clinical documentation for Resident #14, to determine any negative changes to daily routines, activity participation, socialization, meal intake; Resident #14 began refusing medication from LPN #1 on (MONTH) 18, 2019. No other changes where identified with Resident #14. The SA validated that Resident #14 did receive medication from other nurses. 9. The SA validated through interview with the Chief Operating Officer, and dated/signed in-service sheets, that the Director of Field Human Resources was educated on the abuse and neglect policy and procedures with emphasis of investigation and to err on the side of the resident. 10. The SA validated through interview with the Administrator and record review that on (MONTH) 25, 2019, the grievance log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, and incident log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, were reviewed by the Administrator to identify potential allegations abuse/neglect for reporting potential. No grievances or incidence were identified as a potential allegation that had not already been reported. 11. The SA validated through interview with the Administrator and record review that on (MONTH) 25, 2019, at 2:00 PM, the Medical Director, Administrator, interim Director of Nursing, Social Services Director, Activities Director, BOM, SDC, ADON, Dietary Supervisor, Housekeeping Supervisor, Maintenance Director, HR director and Director of Rehab held Quality Assurance Performance Improvement meeting following notification of Immediate Jeopardy to review steps initiated to identify any on-going or previously unreported allegations of abuse and/or neglect and to administer posttest to employees to determine understanding of education provided. There were no new policy or procedure changes. 12. The SA validated that all corrective actions were completed as of 4/25/19, and the IJ was removed as of 4/26/19.

Based on staff interview, record review and facility policy review, the facility failed to report an allegation of staff to resident abuse within the two (2) hour required timeframe, for one (1) of 24 residents reviewed, Resident #14. On 4/3/19 at approximately 9:50 PM, Resident #4 and Licensed Practical Nurse (LPN) #1 had a verbal altercation, with subsequent verbal abuse by LPN #1. Resident #14 called LPN #1 derogatory names, such as [***] , and the LPN responded back that if she was a [***] , that he was too, because it took one to know one. LPN #1 was also witnessed to use the phrase, Mother [***] . Facility administration was notified immediately, however, it was not reported to the required state agencies until 4/4/19, at approximately 5:20 PM. the Mississippi State Attorney General's office was notified on 4/7/2019, at 7:56:48 PM. The State Board of Nursing was not notified until 4/25/19 at approximately 9:11 PM. LPN #1 was allowed to return to work on 4/17/19, and continued to work at the facility, with Resident #14 and other residents, until 4/24/19. The failure of the facility to notify the appropriate state agencies in a timely manner of an allegation of abuse, to ensure proper measures had been addressed; and allowing the staff member to return to work with the same resident and other residents after the verbal abuse of a resident, placed Resident #14 and other residents at risk for the likelihood of serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 4/3/19, when the allegation of abuse occurred. The facility's Administrator was notified of the IJ and SQC on 4/25/19, at 10:00 AM and provided the facility with the IJ template. An acceptable credible Removal Plan was accepted on 4/26/19, in which the facility alleged all corrective actions were completed as of 4/25/19, and the IJ was removed on 4/26/19. The State Agency (SA) validated the Removal Plan and determined that the IJ was removed on 4/26/19, prior to exit. Therefore, the scope and severity for IJ and SQC at CFR 483.12(c)(1)(4) F609, Reporting of Alleged Violations,was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy entitled Abuse Prohibition Policy, Revision: 03/18/2019, revealed Policy: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. Review of the facility policy Abuse Program, Revision 11/2017, revealed, Investigation: 1. The facility will thoroughly investigate all alleged violations and take appropriate actions. 2. The Abuse Coordinator will report such allegations to the state agency in accordance with state law. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation . Protection: 1. All residents will be immediately protected from harm. 2. All allegations involving staff will necessitate suspension without pay, pending investigation. 3. If the allegation is substantiated, the employee will be terminated immediately without pay retroactive to the date of removal from employment. Statement of Policy, Regarding the Reporting of Abuse and Associate Acknowledgement, Remember our policy is all residents and patients of this nursing home are to be treated with dignity and respect at all times, under all circumstances. Mistreatment or abuse of any nature will not be tolerated . Review of a facility investigation revealed that an incident of verbal abuse was alleged by Resident #14 on 4/3/19 around 9:50 PM. The allegation was not reported to the appropriate state agencies until 4/4/19 around 5:20 PM, almost 20 hours after the allegation. On 04/24/19, at 08:33 AM, during an interview with the Administrator, she stated that the allegation of abuse for Resident #14, by LPN #1, was not reported to the Mississippi State Department of Health, Health Facilities Licensure and Certification within two (2) hours. She stated that she was not aware of the regulation and thought she had 24 hours to report. She stated that she had misinterpreted the facility policy for reporting abuse. Record review of the Facility Reported Incident (FRI) dated 4/5/19, and staff written statements concerning an incident of verbal abuse on 4/3/19 by LPN #1, revealed LPN #4 reported that on 4/3/19, at 9:50 PM, Resident #14 was tapping his hand on the counter to get the nurse's attention. Resident #14 asked for a snack and to use the cordless phone, but it was not charged. Resident #14 became agitated and began hitting the nurse's station desk loudly with the palm of his hand. He also grabbed papers from a chart on the desk attempting to read them. Resident #14 cursed LPN #1 who cursed him in return. This was witnessed by LPN #2 and LPN #3, who stated that LPN#1 used profanity such as Mother [***] , and If I'm a [***] , you are a [***] . It takes one to know one. LPN #1 was suspended pending investigation. Record review of the Fax Call Report revealed that the incident of verbal abuse for Resident #14 was reported to the Mississippi State Department of Health Hotline number on 4/4/19, at 5:16 PM. Record review of the Fax Call Report revealed that the facility faxed a copy of the allegation of verbal abuse of Resident #14 (by LPN #1) to the Mississippi State Attorney General on 4/7/2019, at 7:56:48 PM. Review of records revealed the MS State Board of Nursing was notified of LPN #1's verbal abuse to Resident #14, on 4/25/19 at approximately 9:11 PM. The facility submitted an acceptable Removal Plan on 4/26/19, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit: 1. The facility failed to assure the resident was free from verbal abuse and failed to report the abuse within the required two (2) hour reporting period, failing to keep the resident safe. On (MONTH) 3, 2019, at approximately 10:00 PM, Resident #14 reported an allegation of verbal abuse against Licensed Practical Nurse (LPN) #1. The allegation consisted of the Resident #14 using a derogatory name towards LPN #1. LPN #1 responded to the resident by using the same derogatory name. This occurred around the nursing station. LPN #3 stated she heard LPN #1 say If I'm a [***] , you are a [***] . It takes one to know one at the nurses station. LPN #2 stated she heard LPN #1 say Mother [***] . The Administrator was immediately notified by LPN #2 at approximately 10:00 PM. LPN #1 was immediately suspended, abuse in-services and the abuse investigation was initiated. 2. The following parties were notified of the incident: · Responsible party was notified (MONTH) 4, 2019 at approximately 10:38 AM. · Primary Physician was notified (MONTH) 4, 2019 at 12:50 PM. · Medical Director was notified (MONTH) 4, 2019 at 11:44 AM. · Mississippi State Department of Health was notified (MONTH) 4, 2019 at 5:20 PM. · Mississippi State Attorney General was notified (MONTH) 4, 2019 at 5:01 PM. · Mississippi State Board of Nursing was notified (MONTH) 25, 2019 at 9:11 PM. 3. LPN #1 was brought back on (MONTH) 17, 2019, and received an inservice on abuse, neglect, and exploitation. She was then assigned to Resident #14, thus not protecting the residents in the facility from further abuse and the facility not following their policy for abuse. LPN #1 was subsequently suspended on (MONTH) 24, 2019, pending an investigation. LPN #1 was terminated on (MONTH) 25, 2019, for verbal abuse against Resident #14. 4. On (MONTH) 24, 2019, at approximately 9:00 AM, the Administrator removed LPN #1 from all resident care areas. 5. On (MONTH) 24, 2019, beginning at approximately 8:00 PM, the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC), and Assistant DON initiated education with staff, including Certified Nursing Assistants, licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff and administrative staff on Abuse and Neglect Prohibition Policy, Resident Rights, reporting abuse and/or neglect within the required two (2) hour time frame. Focus was placed on immediately removing the resident from the abuse situation; reporting all allegations of abuse, neglect and exploitation to the Administrator immediately; and that any staff member accused of abuse, neglect or exploitation will be suspended immediately pending investigation. No staff member will be allowed to return to work without completing required education. Currently, 76 of 88 staff members have completed required education. 6. On (MONTH) 24, 2019, beginning at approximately 8:45 PM, the Interim Director of Nursing, Corporate Clinical Specialist, Assistant Director of Nursing (ADON) and Staff Development Coordinator (SDC) provided posttest to employees in regards to Abuse and Neglect prohibition policy that was initiated on (MONTH) 24, 2019, to ascertain understanding of Abuse and Neglect prohibition policy training. Any employee that was not able to answer the posttest answers correctly was provided a one-to-one (1:1)re-education at that time. No staff will be allowed to return to work without completing the required education posttest. 7. On (MONTH) 24, 2019, beginning at approximately 9:15 PM, Social Worker, Human Resource Director, Business Office Manager (BOM), Respiratory Therapist, Assistant BOM, Activities Director, Minimum Data Set nurses, SDC, Registered Nurse (RN) Charge Nurse interviewed forty-five (45) residents in the facility at that time, with a Brief Interview of Mental Status (BIMS) of 12 or higher, in regards to had they ever experienced any verbal or physical abuse. Findings of the interviews were reviewed by the Administrator to determine any on-going or previously unidentified allegations of abuse and/or neglect; two (2) residents relayed information from a prior incident, which was investigated and reported. No abuse was substantiated. 8. On (MONTH) 24, 2019, beginning at approximately 9:00 PM, the Corporate Clinical Specialist, both MDS nurses and the Regional Case Mix Specialist reviewed clinical documentation for Resident #14, to determine any negative changes to daily routines, activity participation, socialization, meal intake; Resident #14 began refusing medication from LPN #1 on (MONTH) 18, 2019. No other changes where identified with Resident #14. 9. On (MONTH) 24, 2019 and (MONTH) 26, 2019, the Chief Operating Officer in-serviced the Director of Field Human Resources on the policy and procedures for Abuse and Neglect. 10. On (MONTH) 25, 2019 at approximately 12:30 PM, the grievance log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, and incident log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, were reviewed by the Administrator to identify potential allegations abuse/neglect for reporting potential. No grievances or incidence were identified as a potential allegation that had not already been reported. 11. On (MONTH) 25, 2019, at 2:00 PM, the Medical Director, Administrator, interim Director of Nursing, Social Services Director, Activities Director, BOM, SDC, ADON, Dietary Supervisor, Housekeeping Supervisor, Maintenance Director, HR director and Director of Rehab held a Quality Assurance Performance Improvement (QAPI) meeting following notification of Immediate Jeopardy to review steps initiated to identify any on-going or previously unreported allegations of abuse and/or neglect and to administer posttest to employees to determine understanding of education provided. There were no new policy or procedure changes. 12. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of (MONTH) 25, 2019, and the Immediate Jeopardy was removed (MONTH) 26, 2019. The State Agency (SA) validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ: 1. The SA validated that Resident #14 was not free from verbal abuse and the facility failed to report the abuse within the required two (2) hour reporting period, failed to keep residents safe. On (MONTH) 3, 2019, at approximately 10:00 PM, Resident #14 reported an allegation of verbal abuse against Licensed Practical Nurse (LPN) #1. The allegation consisted of the Resident #14 using a derogatory name towards LPN #1 and LPN #1 responded to the resident by using the same derogatory name. This occurred around the nursing station. The SA validated through interviews that LPN #3 stated she heard LPN #1 say If I'm a [***] , you are [***] . It takes one to know one at the nurses station. LPN #2 stated she heard LPN #1 say Mother [***] . The Administrator was notified by LPN #2. LPN #1 was suspended, abuse in-services and the abuse investigation was initiated. 2. The following parties were notified of the incident: · The SA validated through interview with the Responsible Party that she was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Primary Physician was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Medical Director that he was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Mississippi State Department of Health was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Mississippi State Attorney General was notified (MONTH) 4, 2019, of the alleged abuse. · The SA validated through interview with the Administrator and record review that the Mississippi State Board of Nursing was notified (MONTH) 25, 2019, of the alleged abuse by LPN #1. 3. The SA validated through interview with LPN #1 and the Administrator and record review that LPN #1 was suspended and was brought back to work on (MONTH) 17, 2019, and received an inservice on abuse, neglect, and exploitation. She was then assigned to Resident #14, thus not protecting the residents in the facility from further abuse and the facility not following their policy for abuse. LPN #1 was subsequently suspended on (MONTH) 24, 2019, pending an investigation. The SA validated that LPN #1 was terminated on (MONTH) 25, 2019, for verbal abuse against Resident #14. 4. The SA validated through interview with the Administrator and LPN #1 and record review, that on (MONTH) 24, 2019, the Administrator removed LPN #1 from all resident care areas and placed her in another building with Medical Records duty. 5. The SA validated through interview with the Administrator, and staff from Nursing, Dietary, Social Services, Therapy, Business Office and Housekeeping/Maintenance and record review that on (MONTH) 24, 2019, beginning at approximately 8:00 PM, the Administrator, DON, SDC and ADON initiated education with staff, including Certified Nursing Assistants, licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff and administrative staff on Abuse and Neglect Prohibition Policy, Resident Rights, reporting abuse and/or neglect within the required two (2) hour time frame. Focus was placed on immediately removing the resident from the abuse situation; reporting all allegations of abuse, neglect and exploitation to the Administrator immediately; and that any staff member accused of abuse, neglect or exploitation will be suspended immediately pending investigation. No staff member was allowed to return to work, without completing required education. Currently, 76 of 88 staff members have completed required education. 6. The SA validated through interview with the Administrator and staff from Nursing, Dietary, Social Services, Therapy, Business Office and Housekeeping/Maintenance and record review that on (MONTH) 24, 2019, beginning at approximately 8:45 PM, the interim Director of Nursing, Corporate Clinical Specialist, Assistant Director of Nursing (ADON) and Staff Development Coordinator (SDC) provided posttest to employees in regards to Abuse and Neglect prohibition policy that was initiated on (MONTH) 24, 2019, to ascertain understanding of Abuse and Neglect prohibition policy training. Any employee that was not able to answer the posttest answers correctly was provided a one-to-one (1:1) re-education at that time. No staff was allowed to return to work without completing the required education posttest. 7. The SA validated through interview with the Administrator and record review that on (MONTH) 24, 2019, the Social Worker, Human Resource Director, Business Office Manager (BOM), Respiratory Therapist, Assistant BOM, Activities Director, Minimum Data Set nurses, SDC, Registered Nurse (RN) Charge Nurse interviewed forty-five (45) residents in the facility at that time, with a BIMS of 12 or higher, in regards to had they ever experienced any verbal or physical abuse. Findings of the interviews were reviewed by the Administrator to determine any on-going or previously unidentified allegations of abuse and/or neglect; two (2) residents relayed information from a prior incident, which was investigated and reported. The SA validated no abuse was substantiated. 8. The SA validated through interview with the Administrator, Corporate Clinical Specialist, and one (1) MDS nurse, that on (MONTH) 24, 2019, the Corporate Clinical Specialist, both MDS nurses and the Regional Case Mix Specialist reviewed clinical documentation for Resident #14, to determine any negative changes to daily routines, activity participation, socialization, meal intake; Resident #14 began refusing medication from LPN #1 on (MONTH) 18, 2019. No other changes where identified with Resident #14. The SA validated that Resident #14 did receive medication from other nurses. 9. The SA validated through interview with the Chief Operating Officer, and dated/signed in-service sheets, that the Director of Field Human Resources was educated on the abuse and neglect policy and procedures with emphasis of investigation and to err on the side of the resident. 10. The SA validated through interview with the Administrator and record review that on (MONTH) 25, 2019, the grievance log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, and incident log, beginning (MONTH) 1, 2019 through (MONTH) 25, 2019, were reviewed by the Administrator to identify potential allegations abuse/neglect for reporting potential. No grievances or incidence were identified as a potential allegation that had not already been reported. 11. The SA validated through interview with the Administrator and record review that on (MONTH) 25, 2019, at 2:00 PM, the Medical Director, Administrator, interim Director of Nursing, Social Services Director, Activities Director, BOM, SDC, ADON, Dietary Supervisor, Housekeeping Supervisor, Maintenance Director, HR director and Director of Rehab held Quality Assurance Performance Improvement meeting following notification of Immediate Jeopardy to review steps initiated to identify any on-going or previously unreported allegations of abuse and/or neglect and to administer posttest to employees to determine understanding of education provided. There were no new policy or procedure changes. 12. The SA validated that all corrective actions were completed as of 4/25/19, and the IJ was removed as of 4/26/19.

Based on observation, interview, record and document review, the facility staff failed to take appropriate steps to protect the resident from harm for one (1) of four (4) residents in the sample (Resident #1). The staff was not supervised during transfer of a resident and used the wrong equipment to transfer the resident. A Certified Nurse Aide (CNA) failed to obtain assistance, utilized the wrong transfer lift and failed to follow the plan of care directing transfer interventions for Resident #1. This single person inappropriate transfer subjected Resident #1 to sustain a fracture to her leg as a result of the transfer. Findings include: On 8/1/14 the facility reported that on 7/28/14 Certified Nurse Aide (CNA) #1 transferred Resident #1 alone, using the stand-up lift. The report reflected that CNA #1 reported to LPN #1 that Resident #1's knees buckled during the transfer and CNA #1 immediately eased the resident to the floor. The report reflected that CNA #1 did not use the correct lift, and used the lift without assistance. Review of the admission comprehensive assessment, completed on 5/28/14, revealed a need for total transfer, and Resident #1's plan of care with a problem onset dated 5/21/14 reflected a need for a Hoyer lift, two person assist with a medium sling. The daily care guide listed ten (10) interventions to be used by care givers. Number five (5) reflected "Requires total assist with X2 (times two) staff via Hoyer lift (Role CNA). Observation on 7/28/14 at 4:30 PM revealed LPN #1 recorded Resident #1 was alert, up in a wheelchair, and stated she did not feel well. Vital signs were taken and axillary (under the armpit) temperature reflected 99.3 degrees. Tylenol was given for fever and the RN Supervisor was notified, "continue to monitor". Review of the next nurse's note on 7/28/14 recorded at 7:45 PM by LPN #1 reflected Resident #1 was lowered to the floor with stand-up lift. The note reflected that Resident #1 complained of weakness, and was assisted back to bed with assistance of two (2), with complaints of "gen. (general) pain", that as needed medications were administered for pain and monitoring will continue. The RN was again notified. Review of a nurse's note on 7/28/14 by LPN #1 at 9:00 PM revealed Resident #1 in bed, resting quietly with no signs/symptoms of discomfort with a temperature of 97.5 degrees. Review of the nurse's note recorded at 1:00 PM on 7/29/14 when the physician was notified regarding Resident #1's complaint of pain with assessment revealing some edema and tenderness to the left knee, with the physician ordering a transfer to the emergency room of the hospital. Interview with RN #2 on 8/11/14 at 12:50 PM revealed that Resident #1 had surgery for [REDACTED]. On 8/11/14 at 1:50 PM an interview with LPN #1 revealed she was called to Resident #1's room and found Resident #1 on the floor, on her buttocks, with her left side next to the bed and both feet and legs outstretched in front of her. LPN #1 stated CNA #1 had summoned her and said during the transfer Resident #1 got weak and she (CNA) lowered Resident #1 to the floor. LPN #1 stated Resident #1 agreed that was what happened. LPN #1 related she then notified the RN Supervisor and Resident #1 was assessed and there were no skin tears, no bruises, and Resident #1 moved both arms and legs and only complained of general pain, no specific area. LPN #1 stated that Resident #1 did not complain of pain when transferred back to bed. The Director of Nursing (DON) on 8/11/14 at 2:05 PM submitted the facility investigation, which included a 24 hour report form for 7/28/14. Six residents were listed with status changes. Resident #1 was number six with a note, "had weak spell, pulse up, took pain pill, resting quietly now". There was no indication of finding the resident on the floor. Interview with the DON at 2:05 PM on 8/11/14 revealed that she reviews the 24 hour report every morning and was unaware of a fall. The DON stated after investigating it on 8/29/14 when the RN reported Resident #1's complaint of pain, and having to be sent out to the hospital, she (DON) gave a warning to both the LPN #1 and RN #1 for failure to put it on the 24 hour report; and, she suspended the CNA and mailed termination notice to the CNA, who could not be reached by phone. The DON related she began in-service training for all nurses regarding proper recording of incidents, and all CNAs, all shifts, regarding use of proper lifts, and assisting with transfers. An attempt, by telephone, to reach CNA #1 on 8/11/14 at 5:05 PM was unsuccessful. A recorded message related "The number you dialed is not reachable" Review of documentation presented by the Administrator on 8/11/14 revealed that CNA #1 had signed and dated a job description on 6/12/14 indicating that she had demonstrated an understanding of safety measures and the proper use of equipment. CNA #1 signed and dated a Lift Policy, noting she had read and understood procedures on 6/12/14, and had observed the lift policy video and understood the policies and procedures, signed and dated 6/12/14. Attempts to reach the RN Supervisor were unsuccessful. The DON stated she was part-time, on call only. Review of a recorded statement by RN #1 dated 7/28/14 revealed that on the night of the incident involving Resident #1 she was doing treatments when LPN #1 came to her and said Resident #1 needed a dressing change because she had soiled the one that was on her. RN #1 recorded that LPN #1 told her that Resident #1 had a weak spell while in the lift and that the CNA had lowered her to the floor, and the resident had a bowel movement. She recorded that the LPN told her they had gotten her back into bed. RN #1 recorded that she went into Resident #1's room approximately 15 minutes later, that Resident #1 was lying supine in bed with eyes closed, and stated she was "so-so" but that the Resident did not elaborate and appeared "groggy". RN #1 recorded that she explained that she was going to put on a new dressing and asked Resident #1 if she could turn to the side, that Resident #1 said yes; that she grabbed the side-rail with her hand and rolled to her left side with minimal assist. RN #1 recorded that Resident #1 did not complain of pain or discomfort, and that there was no noted swelling to bilateral extremities and no complaints of pain. RN #1 stated that she asked if an incident report had been filled out when she got to the nursing station and the LPN told her it was not a fall, she was eased to the floor and no incident report was required. The admission assessment for Resident #1, completed 5/28/14 revealed a BIMS score of 14 (Brief Interview for Mental Status) with 13-15 indicating cognitively intact. Resident #1 could not be interviewed but staff interviews and record reviews reflected good ability for decision-making. Review of a final report from the hospital, obtained at 5:55 PM on 8/11/14 revealed "an acute obliquely oriented fracture of the distal left femoral diaphysis, with displacement, angulation of the fracture site with stranding soft tissue swelling present. Osteoarthritis of the knee is present involving the medial malleolus". Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].

Based on interview, record review and facility document review, one (1) CNA, trained in transfer techniques, failed to follow the care plan for mechanical lift transfer and failed to obtain assistance from another staff to assist with the transfer for one (1) of four (4) residents in the sample (Resident #1). This failure subjected the resident to a [MEDICAL CONDITION] leg, requiring surgery. Findings include: Review of Resident #1's care plan dated 5/21/14 for self care deficit intervention included "Resident requires total assist with two staff members using a Hoyer lift with a medium sling" Review of nurse's notes, dated 7/28/14, at 7:45 PM revealed Resident #1 was lowered to the floor with a standing lift. Review of an x-ray report, dated 7/29/14, revealed "Indication: Injury, Hip and Thigh and Pelvis. Impression: Acute fracture with displacement, angulation of the distal left femoral shaft. Interview with the Licensed Practical Nurse #1 at 8/11/14 at 1:50 PM revealed she was called to Resident #1's room and found Resident #1 on the floor, on her buttocks, with her left side next to the bed and both feet and legs outstretched in front of her. LPN #1 stated CNA #1 had summoned her and said during the transfer after Resident #1 got weak and she (CNA) lowered Resident #1 to the floor. Review of hospital report for Resident #1, dated 7/30/14, revealed, Chief complaint: She (Resident #1) apparently fell last night and sustained a left femur fracture. Review of the incident report, dated 7/30/14, revealed on 7/28/14 Certified Nurse Aide (CNA) #1 was transferring Resident #1 using the stand-up lift. The report reflected that CNA #1 did not use the correct lift, and used the lift without assistance. The facility failed to ensure CNA #1 followed the care plan as evidenced the use of the incorrect lift and transferring with assistance.

Based on observation, staff interview, record review and policy review, the facility failed to: A. Provide adequate supervision for residents who were assessed for wandering for one (1) of eight (8) residents reviewed for wandering (Resident #A); and, B. Failed to properly store medication for one (1) of two (2) days of survey. A. Resident #A left the building on [DATE] at 10:00 a.m. with a (Local Funeral Home Employee). Resident #A was signed out by the funeral home employee who was not the responsible party without knowledge of the nursing staff. Documentation indicated Resident #A was witnessed leaving the nursing facility by a Certified Nursing Assistant (CNA) #A. Resident #A went to the (Local Funeral Home) to make pre-need arrangements. After the arrangements were completed, the Funeral Home employee took Resident #A to (Local Cemetery) and left her there un-attended. Resident #A was observed by a Cemetery Employee getting into a red truck with a male. Through investigation it was discovered Resident #A had spent the night at a local motel. Resident #A was found by the local police who escorted her back to the facility on [DATE] at 2:45 p.m. Prior to Resident #A's return the facility conducted a search for her on [DATE] and [DATE] including going to local businesses and casinos. Resident #A was placed on the national registry for missing persons. The lack of adequate supervision and visual monitoring failed to prevent Resident #A from exiting the building without staff supervision was deemed an Immediate Jeopardy to begin on [DATE] at 10:00 a.m. and was removed on [DATE]. The Administrator and Director of Nursing were notified of the IJ on [DATE] at 1:10 p.m. The facility provided a credible Allegation of Compliance (AoC) on [DATE] at 3:15 p.m. Based on verification of the facility's implementation of corrective actions though observations, staff interviews, and in-service reviews, the IJ was removed and the scope and severity was lowered on [DATE] to a "D" level, which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings include: Resident #A: The facility submitted the following information the State Agency: In reference to an Unusual Occurrence Report "(Resident #A) is a 62 (sixty-two) year old white female who was admitted to the facility on [DATE] from (Mental Health Facility). (Resident #A) has [DIAGNOSES REDACTED]. Review of the admission history and physical indicate a past committal to the state hospital at (State Hospital). On the morning of [DATE], (Resident #A) utilized the facility phone in social services office to call (Local Funeral Home) and request them to come pick her up. She wanted to make some funeral arrangements. (Funeral Home Employee (#1)), a representative of (Funeral Home), arrived at approximately 10 a.m. (Resident #A) left with (Funeral Home Employee #1) to go to (Funeral Home). (Funeral Home Employee #1) is an employee of (Funeral Home) in (City and State), and a former deputy with the (County) Sheriff's Department. (Funeral Home Employee #1) is also well known to the facility as a grandson of another resident of the facility. On [DATE] at approximately 12:45 p.m., (Cemetery Employee #1), an employee of (Cemetery), telephoned the facility questioning if the facility was aware that (Resident #A) had been dropped off at the cemetery by (Funeral Home) staff. (Cemetery Employee) stated that (Resident #A) had been observed near her son's headstone. The administrator went to (Cemetery) and conducted a visual search for (Resident #A). On [DATE] at approximately 2:45 p.m. the primary physician/medical director and responsible party were informed of the events involving (Resident #A). On [DATE] at approximately 3:30 p.m. the local Sheriff's Office was notified of the events involving (Resident #A), (Funeral Home) staff and (Cemetery) staff. On [DATE] at approximately 5:00 p.m., Administrator and staff of the facility conducted further visual searches at the local casinos, visited residences of known contacts of (Resident A), conducted visual search again of (Cemetery) and (Local Business) in an attempt to locate (Resident #A). On [DATE] at approximately 5:53 p.m., Clinical Services Coordinator telephoned (Sheriff) of the (County) Sheriff's Department for an update and their continued involvement in the search. (Sheriff) indicated that he was well aware of (Resident #A) and her family. (Sheriff) further stated that he would contact (Clinical Services Coordinator), CSC for any updates involving (Resident #A). On [DATE] at approximately 6:00 p.m. (County) Sheriff's department entered (Resident #A) into the national data base for missing persons. On [DATE] at approximately 9:00 a.m. the Administrator made verbal report to the Mississippi Department of Health hotline as well as on-line reporting to the Mississippi Attorney General's office. On [DATE], the facility was notified that the resident was found to be at the (local Motel) in (City). (Resident #A) returned to the facility by the Sheriff at approximately 3:00 p.m." Review of the State Agency Intake Detail: "On [DATE] (Resident #A) (original admitted [DATE] from geripsych) called the funeral home and requested they come and pick her up. They did around 10:00 a.m. At about 12:45 p.m. employee from (local Cemetery) called facility noting resident had been dropped off at the cemetery by the funeral home. Admin (Administrator) went to cemetery and other places and could not locate resident. At 6:00 p.m. (County) Sheriff Dept. (Department) entered (Resident #A) into national database missing persons. On [DATE] (Resident #A) was found at (local Hotel) in (City) and returned to the facility at 3:00 p.m." The weather history was obtained at weather.com for [DATE], revealed the low was 55 degrees Fahrenheit and the high was 84 degrees Fahrenheit. The weather history on [DATE], revealed the low was 61 degrees Fahrenheit and the high was 86 degrees Fahrenheit. On [DATE], there were eight (8) residents who had been identified for elopement risk. Resident #A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #A's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed a score of 99 on a Brief Interview for Mental Status (BIMS). A score of 99 indicated "the resident was unable to complete the interview". The MDS with an ARD of [DATE] further revealed that Resident A was coded for "Disorganized thinking." The mood evaluation indicated Resident A was "feeling down, depressed, or hopeless", and the behavior evaluation revealed Resident A rejected evaluation or care daily. Review of Resident A's History and Physical dated [DATE] by Physician #C, revealed under History of Present Illness: "This is a (age and race of Resident A) who denies any history of psychiatric illness, even though she has been treated at the State Hospital before. She is a court commit. She has had a decline in functioning and behavior. She presented with agitation, anger, and irritability. She has not been taking her medication. She again has been treated at the State Hospital before, but she denies any of that." Review of Resident A's Psychiatric Evaluation dated [DATE] by Physician #B, revealed Resident #A "...was brought in on court commitment for allegedly being a danger to herself and others because of mental illness." Under Past Psychiatric History Resident #A "...was at the State Hospital four years ago. She is not on any medications. She has not followed up at the mental health center." Bipolar Disorder versus Schizoaffective Disorder by history was noted under the Impression section. Review of Resident A's Discharge Summary dated [DATE] by Physician #C, revealed "HOSPITAL ADMISSION: This is the first (Geriatric Psychiatric Facility) admission for this (age, race and gender of Resident #A). She denied any psychiatric history even though she had been at the state hospital before. She had had a decline in functioning. She presented with a great deal of anger, agitation, and irritability....HOSPITAL COURSE: She is going to be discharged to (Nursing Facility)" Review of the "Admission Agreement", dated [DATE], revealed Resident #A's name was signed on the agreement. An additional "Admission Agreement", dated [DATE], was also signed by Resident A's sister as "Signature of Responsible Party." Resident/Family Consent for Cardiopulmonary Resuscitation document was completed as follows: "I understand CPR (Cardiopulmonary Resuscitation) constitutes an extraordinary measure and SHOULD NOT be done on (Resident #A)." This consent was signed by Resident A's (Responsible Party) on [DATE]. A DNR (Do Not Resuscitate) sticker was affixed to the front of Resident #A's chart. Review of Resident #A's handwritten physician telephone order dated [DATE] revealed "DNR" . This order was signed by the Physician. Review of Resident #A's [DATE] printed Physician Orders revealed an order initiated [DATE] "Code Status: DNR". Record review of Resident A's Initial Nursing Summary, dated [DATE], revealed Resident A was confused, withdrawn, and sad. The summary also revealed Resident A wouldn't cooperate during assessment. Review of Resident #A's [DATE] Medication Administration Record (MAR) revealed ",[DATE] 11:30 p Wanderguard not located on Resident. Resident states "I threw it away." The MAR further revealed Resident #A was refusing her medications. Review of Resident A's Social Services Interdisciplinary Notes, dated [DATE], revealed "Had a conversation w/ (with) (Resident #A) per her request. (Resident A) asked questions about religion & (and) forgiveness. (Resident #A) discussed her personal feelings and stated she hears voices and wants them to stop." Review of Resident #A's Nurses Notes, dated [DATE] at 1:30 p.m., revealed "Res. (Resident) removed wanderguard." Review of the Resident #A's Care Plan titled "I am exhibiting symptoms of psychosis-Hallucinations/Delusions" revealed the care plan was dated effective until ,[DATE]. The care plan was also updated on [DATE] to reflect Resident #A had a history of [REDACTED].#A had a history of [REDACTED]. Review of a Monthly Nursing Review dated [DATE] and [DATE] revealed Resident #A was coded a "3" under the Orientation/Memory Section. A "3" indicated (=) "Complete disorientation or incoherence." Under the Elopement section Resident #A was coded a "1" which indicated (=) "Requires immediate staff intervention one to four days per month." Interview with the Administrator on [DATE] at 10:12 a.m., revealed "(Resident #A) was admitted to the facility from Geri-psych. She is not her own Responsible Party (RP). (Resident #A) has a (family member) in (State) who is her RP. (Resident #A) was very mentally unstable when she got here. She wouldn't eat. She began to improve and get better. She comes from a very dysfunctional family. She came in initially for Medicare and did not have a skill. She didn't have anywhere else to go. She made a call and asked (Funeral Home) staff to come pick her up on Tuesday ([DATE]) to go make pre-need funeral arrangements. (Funeral Home Employee #1) who is also a retired deputy came and signed her out. There is no conservatorship for her and she is not declared mentally incompetent. We were notified by (Cemetery Employee #1) that (Resident #A) had been seen getting into a red truck. We searched for her in the casinos and (local Business). I went out to her house and reluctantly got information. These people have a criminal history." The DON was also present during this interview. Observation on [DATE] at 10:55 a.m., revealed Resident #A lying in her bed. She was wearing green slacks and a green shirt clothes. A wander guard bracelet was observed on her left wrist. There was an artificial flower at her bedside. Resident #A did not initiate conversation and only answered questions. Interview with Resident #A on [DATE] from 10:55 a.m. until 11:20 a.m., revealed Resident #A confirmed she had left the faciity on [DATE] with Funeral Home Employee #1 from (Funeral Home). Resident #A initially reported that the Social Worker made the call to the funeral home for the transportation to the funeral home. She then reported "No, I did call. I called from the social worker's office." Resident #A reported that the Social Worker had come to her room and told her "the man from the funeral home is here. I went to the front and left with the man to make arrangements. I got the man from the funeral home to drop me off at the cemetery. I visited my son's grave then I walked to the (Restaurant) and ate. I tried to get them to call me a bus but they said the bus stopped at the mall. Then I walked across to the mall. I called a cab from there. I went to the (Local Hotel) and got a room. I was on the second floor. I was by myself the whole time. I took a shower. The next morning I called a cab to take me to the bank to get some money. While I was at the bank a policeman came and got me and took me back to the hotel to get my stuff and then brought me back to the nursing home." Resident #A was not able to recall the time she left the facility, name of the cemetery, the name of the funeral home employee, how long she was at the funeral home, the name of business she went into to make the call to the cab, the name of the cab company. Resident #A would not disclose the amount of money that she was trying to withdraw from the bank. Resident #A reported when asked about signing out "I don't remember signing out." Interview with the Director of Nursing (DON) on [DATE] at 12:10 p.m., reported that she was not in the facility when Resident #A left the building. The DON reported "I left the facility at approx. (approximately) 12:10 p.m. to take my father who was having chest pain to (City). At that moment I had no knowledge (Resident #A) had left the building. I rec'd (received) a text message from the ADON (Assistant Director of Nursing/Employee #B) saying call her when I could call. When I called she told me what had happened." (ADON) was told that (Funeral Home Employee #1) had called the facility and talked to (Employee #A/Business Office Manager) to check on (Resident #A). At that point they realized he (Funeral Home Employee #1) had signed her out. They checked the book. (Business Office Manager (BOM)) referred the call to (Administrator). ADON told me that (Funeral Home Employee #1) didn't bring her back. He left her at the cemetery. I called (Administrator) on the way back from the doctor's office and he told me to go to the facility and be the person who answered the phone and that's what I did and to notify him if she returned. The Administrator told me he had various (dept) department heads out looking for her. No one found her and (Administrator) returned to the facility. He talked to Corporate. The local authorities continued to search...The next day the search continued. (Administrator) told me that the local authorities had found her at (hotel) and they were about to return her to the facility. When she returned (ADON) and myself tried to get her to let us do a body audit and she refused. We tried to get her to go to the ER (emergency room ) and she refused. She refused vital signs. I called (Nurse Practitioner) and told her (Resident A) was back and she told me to call (Physician #A). (Physician #A) was notified and he said he would call (Physician #B) @ (at) (Geriatric Psychiatric facility) and see if they would evaluate or admit and (Geriatric Psychiatric facility) declined. We then put her on 1:1 (one to one) monitoring until yesterday afternoon. We explained to her that if she wanted to leave the facility she needed to talk to the nurse or social worker so we would know her plans. (Resident #A) said 'OK'." Observation on [DATE] at 2:00 p.m. of the alleged route by Resident #A reported that she took on [DATE] from the cemetery to (local Restaurant) to local mall where she reported she called a cab. The distance from the cemetery to (local Restaurant) was 0.8 mile in an automobile. The local outlet mall was another 0.1 mile from the restaurant. The highway is a four (4) lane highway. Interview with Hotel Employee #1 on [DATE] at 2:50 p.m., revealed Resident A was a guest in this hotel on [DATE]. Hotel Employee #1 reported Resident #A paid cash for her stay and that Resident #A's room was on the second floor. "She was dropped off. It was only her who came in." A receipt from the hotel with Resident #A's signature was obtained. Interview with Employee #A on [DATE] at 3:50 p.m., reported that she took a call at approximately 12:45 p.m. from Cemetery Employee #1. Employee #A reported the following, "(Cemetery Employee #1) stated he worked at (Cemetery) here in (City). He was calling to ask if we were aware that (Resident #A) was there in the cemetery to see her son's headstone. He said that someone from (Funeral Home) had dropped her off at the cemetery. About that time I stopped (Cemetery Employee #1) and gave the call to the Administrator who had just walked into my office. Before I gave the phone to (Administrator), (Cemetery Employee #1) had said that a grounds worker had seen (Resident #A) get into a red truck with someone. At that point (Administrator) took phone call. While (Administrator) was on the phone I took it on myself to call (Funeral Home) to see if she (Resident #A) had been there. (Funeral Home Employee #2) answered the phone and I asked her about (Resident #A). She said (Resident #A) had been at their facility the day before ([DATE]) to do the pre-needs burial paperwork and that (Resident A) had called her that morning to come get her so she could finish the burial paperwork. (Funeral Home Employee #2) stated (Funeral Home Employee #1) had picked up (Resident #A) per her request about 10 o'clock. She did not know 100% sure. (Funeral Home Employee #2) stated that (Resident #A) wanted them to take her to the cemetery afterword (the paperwork was done.) (Funeral Home Employee #1) dropped her off at the cemetery and (Resident #A) told (Funeral Home Employee #1) that someone from (Nursing Facility) would pick her up." Interview with Funeral Home Employee #1 on [DATE] at 8:40 a.m., reported he was a full time employee of the funeral home. He reported he has been in law enforcement for 26 ? (twenty-six and one-half) years. "(Resident #A) came to the funeral home on [DATE] to pre pay for her funeral arrangements. About half way through she decided she wanted to finance instead of pay the full amount. The next day ([DATE]) she called the funeral home and said she wanted someone to come get her so she could finish the paperwork from yesterday. I went down and got her about 10:30 a.m. or so I think. I picked her up and took her to the funeral home. We completed the paperwork we had started the day before. She told me she wanted to go to the cemetery and take care of the opening and closing. I took her to the cemetery. I got out and told the guy who worked there what she wanted to do. I told the guy she didn't need to leave with anyone but (Nursing Home). The guy from the cemetery (Cemetery Employee #1) called me and told me that when he went in to get the paperwork, she walked off. (Cemetery Employee #1) said one of his workers had seen her getting into a red pick- up truck." Funeral Home Employee #1 reported "I don't know what the procedure is to sign anyone out from the nursing home. I don't remember anybody making me sign her out." Interview with Physician #A on [DATE] at 9:50 a.m., revealed he is Resident #A's primary physician but the Nurse Practitioner primarily takes care of the patients. Physician A made rounds on Wednesday when he saw Resident #A's picture on television. Physician A was then notified by the facility of the incident with Resident #A. Physician A reported that on Wednesday or Thursday he asked Physician B if the (Geriatric Psychiatric Facility) would re-admit Resident A. Physician B informed Physician A that a family member of Resident A filed papers on Resident A for committal purposes. Interview with the facility Administrator on [DATE] at 10:15 a.m., reported the search for Resident A was not continued through the night by facility staff. The facility Administrator reported the local authorities searched through the night and the facility began searching again the next morning ([DATE]). Interview with the Director of Nursing (DON) on [DATE] at 10:30 a.m., related to the sign out procedure, reported "Whoever is going to take the Resident is supposed to check in at the desk and get permission for them to go. If they are not their own RP then the RP should be called for permission for them to go." In response to a question should Resident #A's RP have been called before she left ([DATE]); the DON responded "The RP should have been called." Interview with the Licensed Social Worker (LSW) on [DATE] at 11:15 a.m., reported Resident #A was very religious oriented and wanted to know about forgiveness and God. Resident #A did not want to answer LSW's questions and Resident #A heard voices that told her what to do. Resident #A reported to a social services intern who did Resident #A's assessment that God gave her a message during her shower. Resident #A told LSW she did not want to be here. Resident #A paced a lot, but not initially. Resident #A would pace back and forth down the hall in front of LSW's office, but LSW didn't get up to see where Resident #A went. The LSW was out of town on [DATE] and her office door was locked. LSW did not set up the meeting for Resident #A to go the funeral home on [DATE]. Interview with Certified Nursing Assistant (CNA) #A on [DATE] at 12:03 p.m., reported she was not assigned to take care of Resident #A on [DATE]. CNA #A stated "I was bringing smokers back in and I saw (Resident #A) with (Funeral Home Employee #1). I knew who (Funeral Home Employee #1) was. I saw him go to the desk and get the sign out book and he signed her out and I witnessed it. I did not notify anyone that she had left with (Funeral Home Employee #1). I assumed everyone knew it.... After she (Resident #A) returned I went to her room because she needed 1:1. I stayed about 5 (five) minutes until they got (another C.N.A.) to sit with her." Interview with Maintenance on [DATE] at 12:30 p.m., reported "The charge nurse notified me that (Resident #A) wanted a ride to the funeral home. I took her (Resident #A) to (Funeral Home) on (City Street) about 10:45 a.m. and (CNA #A) was with me. I dropped them off....Around 11:15 a.m. I was told by the funeral home staff that the funeral home staff had already took (Resident #A) and (CNA #A) back to the facility." Maintenance reported that there was not a sign up about visitors letting Residents out prior to [DATE]. Interview with Resident #A's Responsible Party (RP) on [DATE] at 4:15 p.m., reported on [DATE] "one of the nurses at the convalescent home called me and said she (Resident #A) had left and did not come back. I asked them what they had done. They said they were going to wait and see if she was going to come back." The RP reported that the facility had sent her admission papers to sign for Resident #A. She reported that she had signed them and returned them as soon as she signed them by (Shipping Company). The RP reported "I did not ask them to put her on the national data base." Interview with the Assistant Director of Nursing (ADON/Employee #B) on [DATE] at 5:08 p.m., reported she had taken her lunch break about 1:00 p.m. and when she came back she was handed a piece of paper by the charge nurse. The ADON reported "the paper that she gave me was (Funeral Home Employee #1's) statement. That's when I first became aware." (Resident #A had left the building with Funeral Home Employee #1). The ADON reported she "went on in the nursing office and called the (RP).... I started in-servicing staff on the proper sign out procedure.... I then went to (Local Casino) to look for (Resident #A)." The ADON reported "The wander guard was not on her wrist when she returned." Interview with Recreational Therapist (RT/Employee #F) on [DATE] at 5:15 p.m., reported "I did not see her (Resident #A) leave with (Funeral Home Employee #1). Around 2 p.m. I was made aware (Resident #A) was missing. I got all the residents in from outside and (Administrator) and myself went to the cemetery. I drove (Administrator). We met some of the deputies down there. Then we stopped by (gas store) because we saw a red truck. We came back to the facility and I went back and drove through the cemetery and I check (local Business). Then came on back and stayed around the facility until about 7:30 p.m. On [DATE] (Administrator) called me and told me to go back by the cemetery before I came to work." Interview with the Dietary Manger (DM/Employee #K) on [DATE] at 5:45 p.m., reported "On admission I attempted to interview (Resident #A). She (Resident #A) told me she did not want anything. She (Resident #A) would not take anything that was opened, so I gave her foods like applesauce & (and) yogurt that were sealed." Interview with Employee #D on [DATE] at 6:00 p.m., reported "On [DATE] I did not see (Resident #A) leave with (Funeral Home Employee #1). I didn't find out until later that afternoon. I don't remember the time. I did go search for her. I went to (local Casino) and didn't find her. Interview with Cemetery Employee (CE) #1 on [DATE] at 2:47 p.m., revealed Resident #A was dropped off at the cemetery by Funeral Home Employee #1. CE #1 reported "(Resident #A) wanted to pre-pay for opening and closing of her grave. She walked from the office to her son's maker. I went in the office to gather up a few things and within five (5) minutes she was gone. I looked all around the cemetery for her. The guy who works here saw her walking toward a red truck." Interview with Registered Nurse (RN/Employee #L) on [DATE] at 3:15 p.m., reported Resident #A is usually asleep on her shift. The only time she ever sees Resident #A up on their shift is to go to the bathroom. Employee #L reported Resident #A is not her own Responsible Party. RN stated that "When (Resident #A) was first admitted she heard voices. She (Resident #A) said 'I can't talk to you right now. They are still talking to me'." Interview with MDS Nurse (Employee #G) on [DATE] at 3:20 p.m., reported she does Minimum Data Set (MDS) assessments. MDS Nurse stated that on admission Resident #A "wouldn't answer any questions." MDS Nurse reported that the interdisciplinary team determined Resident #A "may be an exit risk." A wander guard was placed on Resident #A on admission. Review of the facility policy "Accidents and Incidents" revealed "2. Unusual Occurrence or Event a. Any event not consistent with routine resident care; b. An event or happening involving a resident or visitor with unintended, undesirable or unexpected results or outcomes." The facility provided a credible Allegation of Compliance (AoC) on [DATE] at 3:15 p.m. Allegation of Compliance "Resident #A, a [AGE] year old female was admitted to the facility on [DATE] at 10 a.m. from Geriatric Psychiatric facility. admitting [DIAGNOSES REDACTED]. Review of the admission history and physical indicates she was previously treated at a Psychiatric hospital. Review of psychiatric evaluation from Geriatric Psychiatric facility reveals documentation of a court committal to the Geriatric Psychiatric facility. During her admission process, Resident #A refused body audit. She refused participation in Brief Interview for Mental Status (BIMS), therefore BIMS score was 99. Resident #A refused to participate in Cognitive Performance Scale. On [DATE], Employee #F was able to complete an Activity Assessment and on [DATE] the Licensed Social Worker was able to complete Social History Assessment with Resident #A. Upon admission, Resident #A stated she was hearing voices and receiving messages. She refused meals, personal hygiene assistance, food and was reclusive. During her course of stay, resident improved as evidenced by social dining, participation in activities, agreeing to and then requesting baths and increased communication with staff and other residents. Resident #A began to take a more active role in management of her own personal affairs. On [DATE] at approximately 10:00 a.m. Resident #A was observed leaving the facility with Funeral Home Employee #1 by C.N.A. #A and C.N.A. #B through the front door of the facility for an outing pre-arranged by Resident #A with Funeral Home Employee #1. Resident was signed out on pass by Funeral Home Employee #1 on [DATE] at 10 a.m. On [DATE] at approximately 12:45 p.m. Employee #A received a phone call from Cemetery Employee #1 questioning if the facility was aware that Resident #A had been dropped off at the cemetery by Funeral Home Employee #1. Cemetery Employee #1 stated Resident #A had been observed near Resident #A's son's headstone. On [DATE] at approximately 1:45 p.m. Administrator telephoned Funeral Home Employee #1 to get verbal statement and requested a written statement regarding Resident #A. On [DATE] at approximately 2:15 p.m. Administrator went to the cemetery to conduct a visual search of the cemetery for Resident #A. On [DATE] at approximately 2:45 p.m. Responsible Party #A and Physician #A were notified of Resident #A leaving facility on pass with Funeral Home Employee #1 and being dropped off at the cemetery by Funeral Home Employee #1. On [DATE] at approximately 3:30 p.m. Sheriff's Office Employee #1 was telephoned by Administrator and notified of occurrence with Resident #A. On [DATE] at approximately at 3:45 p.m. Administrator directed Employee #C if Resident #A returned to the facility to conduct full body audit and place on one to one monitoring. On [DATE] between approximately 4:45 p.m. and 7 p.m. Administrator, Employee #B, Employee #D, Employee #E, Employee #F, Employee #G and Employee #H searched potential locations of Resident #A throughout the community. Locations searched included cemetery, area casinos, local stores and prior places of residence. On [DATE] at approximately 5:45 p.m. Clinical Services Coordinator telephoned the Sheriff regarding facility's search efforts and confirmed Sheriff's office was and would continue to search for Resident #A until located. On [DATE] at approximately 7:40 a.m., the Clinical Services Coordinator telephoned the Sheriff to obtain update on search for Resident #A. On [DATE] at approximately 7:45 a.m. Administrator telephoned Sheriff's Employee #1 and was given an update regarding search of Resident #A On [DATE] at approximately 9:39 a.m. Administrator telephoned Responsible Party #A to provide her with an update and continued search by Sheriff's office employees. On [DATE] at approximately 9 a.m. Administrator made verbal report to the (Name of State) State Department of Health and at approximately 10:30 a.m. the electronic submission was made to the Attorney General Office. On [DATE] at approximately 2:38 p.m. the facility was notified by the Sheriff's office that Resident #A had been located at the hotel. At 2:45 p.m. Resident #A was returned to the facility ambulatory and in escort of Sheriff Office Employee #1, #2, and #3. On [DATE] at approximately 2:45 p.m. Responsible Party #A and Physician #A were notified of return to facility. Upon return, Resident #A refused to be transferred to the emergency room for evaluation and also refused vitals signs and body audit. Resident #A was placed on one to one monitoring upon her return and a replacement alarm bracelet was placed on resident. On ,[DATE]/

CI MS #9249 Based on observation, staff interview, clinical record and facility policy and document review, the facility failed to follow the facility's freedom from neglect policy, the facility's mechanical lift policy and the Resident's plan of care for one (1) of four (4) residents in the sample (Resident #1) to prevent injury from falls. This failure allowed Resident #1 to fall to the floor, sustaining fractures to both legs. Findings Include: Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Referenced Date (ARD) of 3/2/11 revealed that Resident #1 was cognitively intact. Resident #1 was dependent on the use of a wheelchair for locomotion and required the use of a full lift for transfers using a large sized sling. Review of the resident's daily care guide dated 4/22/11 addressed an intervention to use hoyer lift assisted by two (2) staff members with a large sling. Review of the Resident #1's care plan dated 4/12/11 reflected a problem with a high risk of falls and an approach that required total assistance with transfers using hoyer lift with large sling assisted by two (2) staff members. Review of an incident report dated 4/12/11 reflected that at 9:30 p.m. on 4/11/11 Resident #1 was on the lift and it tipped over and Resident #1 was found on his back on the floor. The facility notified the state agency on 4/18/11 that Resident #1 was transferred from the wheelchair to the bed with the total lift by CNA #1 and during the transfer, the lift slipped over to the right and the resident fell feet first while still in the sling. The report also addressed that investigation outcome was that CNA #1 admitted to using the lift without assistance and admitted awareness of the lift policy, that the CNA was suspend and then terminated. A review of a nurse's note dated 4/11/11 at 9:30 p.m. revealed that the nurse was summoned to Resident #1's room by CNA #1. The nurse noted the resident lying on the floor with pads underneath the head and pillows underneath the knees. The mechanical lift was noted tilted over on the side with the resident still attached to the lift. The nurse wrote that CNA #1 voiced that as she was lifting the resident the lift turned over. The nurse added that the resident was alert and verbally responsive and voiced that his feet hit the floor. The resident denied hitting his head. Resident "voiced that the only pain he feels right now are now his legs and feet because he could not stretch his legs completely out due to the position on him on floor and the furniture." "Moderate swelling noted to bil (bilateral) feet." The next entry in the nursing note was made on 4/12/11 at 3:15 a.m. stating: "Summoned to room per CNA. Softball sized swelling noted to (left) knee. Knee warm to touch. No redness noted. (Right) knee slightly swollen. Ice packs applied to both knees. Resident does not want to be turned due to c/o (complaints of ) pain in knees, monitoring." On 4/12/11 at 3:20 a.m. "[MEDICATION NAME] 50 mg tabs (2) given p.o. (by mouth) for pain relief." On 4/12/11 at 4:20 a.m. "Pain medication ineffective. Swelling continues to be present in knees. (Name of Physician) called and notified. N. O. (new order) noted to transfer to ER for evaluation r/t swollen knees...". The Resident #1 was transferred to the hospital at 3:20 a.m. on 4/12/11 and admitted to the hospital. The Impression stated: "(1) Displaced [MEDICAL CONDITION] tibial and fibula". Attempts to interview CNA #1 by telephone at 11:20 a.m. on 5/5/11 led to receipt of a message that the prescriber called is not able to receive calls at this time. The number was verified by the DON who stated she had gotten the same message. The DON added that when she interviewed CNA #1, the CNA admitted that she did the transfer alone and knew it was to be two (2) people. Interview with the Resident #1 on 5/5/11 at 10:20 a.m. revealed that CNA #1 did the transfer "by herself" and she put the sling on then, when she tried to turn it tilted and that he slid down with his feet hitting the floor first, then slid more and his "butt" hit the floor. The Physical Therapist came into the resident's room on 5/5/11 at 10:30 a.m. with three (3) CNA's to complete the first transfer from bed since the incident. The therapists used the procedure to teach the staff how to protect the legs, which were both in braces and wrapped in Ace bandages and protected by pillows. The Physical Therapist informed staff that they must be careful where they hold the legs and cautioned them regarding not extending the leg at the knee nor bending it too far. The transfer was smooth and the resident was calm and responsive to commands. Review of the facility's policy for freedom from neglect dated as revised 7/07 reflected that it is the policy of this facility that each resident has the right to be free from neglect by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individual. Neglect is defined in the 7/07 policy as deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being and that this presumes that instances of neglect cause physical harm or pain. Review of the facility undated injury prevention program on reflected that the facility requires the use of lifts and transfer devices. It reflected that all employees are required to be trained to use lift devices and that any employee who improperly lifts a resident resulting in an injury could be grounds for immediate termination. The AIT (Administrator In Training) stated at the exit on 5/5/11 at 2:15 p.m. that CNA #1 was terminated and had been trained in transfers.

CI MS #9249 Based on observation, staff interview, clinical record and facility policy and document review, the facility failed to prevent an accident causing injuries with lift and transfer equipment which was improperly used by a staff member for one (1) of four (4) residents in the sample (Resident #1). This failure enabled the Resident #1 to fall and sustain fractures to both legs. Findings Include: Cross refer findings to F-224 for the facility's failure to follow policy and procedure, care plans and daily care guide instructions to prevent an accident that occurred to Resident #1 during a transfer using a lift.. .