Every finding on record at Yazoo City Rehabilitation and Healthcare Center

Based on record review, staff and resident representative interview, and facility policy review, the facility failed to implement an effective discharge planning process to ensure necessary durable medical equipment (DME) was arranged and received prior to discharge for one (1) of three (3) residents reviewed, Resident #1.The facility failed to ensure Resident #1, who required tracheostomy care including suctioning and nebulizer treatments, was discharged with necessary respiratory equipment. The resident was discharged home on 2/23/26 without a suction machine or nebulizer, resulting in the need for emergency medical services (EMS) intervention and subsequent hospitalization due to unsafe discharge conditions.The facility's failure to ensure a safe discharge process placed Resident #1 in a situation that was likely to cause serious harm, injury, impairment, or death.The State Agency (SA) identified an Immediate Jeopardy (IJ) that began on 2/23/26 when the facility failed to ensure necessary respiratory equipment was in place prior to discharge, resulting in the resident being unable to safely maintain airway clearance and requiring EMS intervention and hospitalization.IJ existed at: 42 CFR 483.15(c)(2) Discharge Process (F628)- Scope/Severity J.On 4/9/26 at 10:32 AM, the SA notified the Administrator of the Immediate Jeopardy and provided the facility with the IJ template. The facility submitted an acceptable Removal Plan on 4/9/26, in which they alleged all corrective actions were completed on 4/9/26 and the IJ was removed on 4/10/26.The SA validated the Removal Plan on 4/10/26 through record review and staff interview and determined the IJ was removed on 4/10/26, prior to exit. Therefore, the scope and severity for F628 was lowered from a J to a D while the facility continues to monitor systemic changes to ensure sustained compliance.Findings include:Record review of Facility Protocol: Safe Discharge Process, revealed It is the protocol of the facility to ensure that all residents are discharged in a safe and coordinated manner, with all necessary services, equipment, and supports in place prior to discharge.5. Durable Medical Equipment (DME): All required equipment must be ordered, coordinated, and verified as delivered and functional prior to discharge. Discharge will not occur until confirmed.Record review of the admission Record revealed that the facility admitted Resident #1 on 12/2/25 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, and Tracheostomy Status. Resident was discharged home on 2/23/26.A record review of Order Summary revealed Resident #1 required tracheostomy suctioning every four (4) hours and as needed and inhalation therapy via (by) nebulizer every six (6) hours with orders dated 12/2/25.Record review of a Psychosocial Note dated 1/29/26, revealed Social Services (SS) arranged discharge with home health services and durable medical equipment including a hospital bed, wheelchair, and bedside commode. The record lacked evidence that a suction machine or nebulizer was arranged or verified prior to discharge.Record review of hospital medical records dated 2/24/26, revealed Resident #1 presented to the hospital via emergency medical service (EMS) due to not having correct supplies for tracheostomy care at home and was admitted because it was unsafe to remain at home without necessary equipment.Telephone interview with Resident #1's Representative (RR) on 4/8/26 at 1:00 PM, revealed the resident did not receive a nebulizer or suction equipment at discharge, EMS had to be called to suction the resident, and the resident was hospitalized until equipment was obtained.Interview with Social Services (SS) on 4/8/26 at 3:15 PM, revealed she arranged DME and notified home health of tracheostomy needs but believed all equipment had been delivered and denied knowledge that suction or nebulizer equipment was not received.Telephone interview with Home Health Nurse #1 (HHN) on 4/8/26 at 4:30 PM, revealed the facility notified the agency of tracheostomy supplies and nebulizer needs but did not include a suction machine and confirmed that it was the facility's responsibility to ensure DME was ordered and delivered prior to discharge.Telephone interview with HHN #2 on 4/9/26 at 8:05 AM, revealed she was notified by the RR that required equipment had not been delivered and EMS was required to suction the resident, and she instructed the resident be sent to the hospital until equipment was received.Follow-up interview with SS on 4/9/26 at 8:45 AM, revealed she did not arrange for a suction machine or nebulizer and did not verify delivery of all required equipment prior to discharge, as she believed home health would provide those items.Interview with the Administrator on 4/9/26 at 8:50 AM, revealed it was the expectation that all required equipment be in place prior to discharge and acknowledged failure to provide necessary equipment could result in respiratory distress and/or death.Removal PlanThe facility failed to ensure an effective and safe discharge process for Resident #1 by not coordinating and verifying delivery of required DME, including suction equipment and a nebulizer machine, prior to discharge on [DATE]. This resulted in the resident being discharged home without necessary equipment to meet post-discharge needs.1. On 4/9/26, at approximately 10:30 AM, the Administrator developed a Discharge Durable Medical Equipment Verification Checklist to address resident-specific durable medical equipment requirements. This checklist encompasses nursing and therapy assessments, obtaining physician orders, confirmation of equipment delivery dates, receipt verification, home health referral and acceptance, education for family and responsible parties, transportation arrangements, and comprehensive discharge instructions.2. On 4/9/2026 at 11:46 AM, Staff Development Coordinator (SDC) contacted Ambulance service personnel to request medical records from 2/24/2026.3. On 4/9/2026 at approximately 11:48 AM, Medical Records contacted the hospital to request Resident #1 hospital records for 2/24/2026.4. On 4/9/2026 at approximately 12:15 PM, Social Services (SS) contact Resident #1 Responsible Party (RP) to verify Resident #1 wellbeing and ensure all Durable Medical Equipment was received. Resident #1 Responsible Party (RP) stated they had everything they needed, and Resident # 1 was doing fine.5. On 4/9/2026 at approximately 12:45 PM, Resident #1 medical records were received from the hospital and verified all necessary Durable Medical Equipment was not previously provided confirming allegation.6. On 4/9/2026 at approximately 1:30 PM the Staff Development Coordinator (SDC) conducted a one-to-one training with Social Services (SS) to ensure the discharge process is followed confirming all Durable Medical Equipment is not only ordered but received prior to discharged . Services are confirmed with the accepting provider, and documentation is completed in the medical records.7. On 4/9/2026 at approximately 1:46 PM, Quality Assurance Improvement Committee was held including Administrator, Asst. Administrator, Medical Director, Staff Development, Social Services Director, Infection Preventionist, Social Services Assistant and Director of Nursing Facility to discuss previous identified gap in the discharge process as it relates to ensuring all Durable Medical Equipment was ordered and received at the time of discharge and to include the systemic change utilizing mandatory discharge check list. 8. On 4/9/2026 at approximately 2:15 PM, in servicing was with all licensed nurses, social services, therapy and leadership staff on discharge planning requirements, including the coordination of all necessary Durable Medical Equipment prior to discharge to home was provided by Voice Friend via phone. 9. On 4/9/26, at approximately 2:15 PM, the Staff Development Coordinator provided education to all licensed nurses to ensure a hard stop is in place so that no resident is discharged without following the discharge checklist.10. On 4/9/2026, at approximately 2:24 PM, Human Resources will place a copy of the discharge planning check list in all new hire licensed nurses' orientation packets for completion.11. On 4/9/2026, at approximately 3:00 PM, a 100% audit of all residents discharged home from 2/23/26-4/09/2026 was completed by the Staff Development Coordinator (SDC) to ensure all Durable Medical Equipment was received as ordered. The results revealed no identified gaps.12. Facility alleged that all activities to remove the Immediate Jeopardy were completed as of 04/09/2026 and the Immediate Jeopardy was removed 04/10/2026. Validation:The SA validated on 4/10/26, through interview and record review that all corrective actions had been implemented as of 4/9/26, and the IJ was removed as of 4/10/26 prior to exit.

Based on record review, staff interview, and facility policy review the facility failed to administer ordered Lantus insulin for three (3) consecutive days for one (1) of three (3) resident reviewed for medication errors. Resident #2 Findings Included:Record review of the facility policy titled, Medication Administration reviewed and revised 3/5/26 revealed 4. Medications are administered according to prescriber orders and within the ordered time frames.Record review of Order Summary Report for Resident #2 revealed an order for Lantus SoloStar Subcutaneous Solution Pen-Injector 100 units/milliliter. Inject 10 units subcutaneously at bedtime with an order date of 1/16/26.Record review of the January 2026 Medication Administration Record (MAR) for Resident #2 revealed that on 1/16/26, 1/17/26, and 1/18/26, the resident did not receive the ordered dose of insulin.Record review of Progress Notes dated 1/16/26, for Resident #2, revealed Type: Orders - Administration Note, Note Text: Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML Inject 10 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65) - Pending pharmacy. There was no further documentation regarding why the medication was not given.Record review of Consolidated Delivery Sheets dated 1/16/26 revealed that Lantus Solostar 100 units/3ml was delivered to the facility on 1/16/26 and was signed for by two (2) nurses.Telephone interview with Licensed Practical Nurse (LPN) #1 on 4/09/26, at 4:00 PM, she stated she did not recall the resident or the medication and did not know what occurred.Interview with the Director of Nursing (DON) on 4/10/26, at 8:35 AM, she verified that Resident #2's insulin was not given on 1/16/26 through 1/18/26. She verified that the 1/16/26 progress note indicated that the medication was pending pharmacy, which indicated that the staff had not received the medication. She further explained that the Consolidated Delivery Sheets verified that the medication was sent on 1/16/26 from the pharmacy, but the nurses who signed for the medication worked a different unit and it was possible that it was not taken to the unit where Resident #2 resided. She agreed that failure to administer the medication as ordered could result in adverse outcomes such as hyperglycemia.Record review of the admission Record revealed that the facility admitted Resident #2 on 1/16/26 with a diagnosis of Type two (2) Diabetes Mellitus with Hyperglycemia.

Based on record review, staff interview, and facility policy review the facility failed to ensure the physician or nurse practitioner was notified of an omitted medication for one (1) of three (3) residents reviewed for medication errors. Resident #2.Findings Included:Record review of the facility policy, titled Condition & Medical Doctor (MD)-Family Notification, 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 need to significantly alter treatment.Record review of Order Summary Report for Resident #2 revealed an order for Lantus SoloStar Subcutaneous Solution Pen-Injector 100 units/milliliter. Inject 10 units subcutaneously at bedtime with an order date of 1/16/26.Record review of the January 2026 Medication Administration Record (MAR) for Resident #2 revealed that on 1/16/26, 1/17/26, and 1/18/26, the resident did not receive the ordered dose of insulin.Record review of Progress Notes dated 1/16/26, for Resident #2, revealed documentation that insulin was pending pharmacy. There was no further documentation explaining the omission of the medication.Further record review of Progress Notes dated 1/16/26 through 1/18/26, for Resident #2, revealed no documentation that the Physician or Nurse Practitioner was notified that the insulin was not administered as ordered.Interview with the Director of Nursing (DON) on 4/10/26, at 8:35 AM, she verified that there was no documentation that the provider was notified that Resident #2 did not receive the ordered insulin. She agreed that failure to notify the provider prevented the opportunity for the provider to assess the resident's condition and alter treatment as necessary.Record review of the admission Record revealed that the facility admitted Resident #2 on 1/16/26 with a diagnosis of Type two (2) Diabetes Mellitus with Hyperglycemia.

Based on observation, resident and staff interview, and facility policy review, the facility failed to provide incontinence care in accordance with the resident's care plan for one (1) of 10 residents reviewed for activities of daily living (ADLs). Resident #1Findings Include:Record review of the facility policy titled Activities of Daily Living, Supporting 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.Appropriate care and services will be provided for residents who are unable to carry out ADLs independently.in accordance with the plan of care.including appropriate support and assistance with: c. elimination (toileting).Record review of the Care Plan Report for Resident #1 revealed The resident has and ADL self-care performance deficit related to Paraplegia, Hypertension (HTN), C5-C7 spinal cord injury. Interventions included: Toilet use: The resident requires total assistance times two (2) staff for toileting. Further review of reveled I have potential for impairment of my skin integrity.related to Paraplegia. Interventions included: Incontinent care as needed.Observation and interview on 12/2/25 at 8:19 AM, with Certified Nursing Assistant (CNA) #1 of Resident #1's incontinence pad and brief, she verified the presence of a light brown ring of dried urine and a saturated brief. She agreed that the discoloration and saturation were consistent with urine and likely occurred because the resident had not been changed throughout the night and confirmed that he had not been changed since her shift began at 7:00AM.In an interview with the Director of Nursing (DON) on 12/2/25 at 11:00 AM, she stated that the care plan is used so that staff know what care to provide to the resident. She agreed that facility failed to follow Resident #1's care plan when they failed to provide incontinent care throughout the night.Record review of the admission Record revealed that the facility admitted Resident #1 on 8/20/25 with a diagnosis of ParaplegiaRecord review of Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 8/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that Resident #1 was cognitively intact. Further review of the MDS revealed that Resident #1 was dependent with toileting.

Based on observation, resident and staff interview, and facility policy review the facility failed to provide Activities of Daily Living (ADL) assistance to a dependent resident related to incontinent care for one (1) of 10 residents reviewed for ADLs. Resident #1.Findings Include:Record review of the facility policy titled Activities of Daily Living, Supporting 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.Appropriate care and services will be provided for residents who are unable to carry out ADLs independently.including appropriate support and assistance with: c. elimination (toileting).On 12/2/25 at 8:15 AM, in an interview with Resident #1, he stated that a Certified Nursing Assistant (CNA) did not come in and change him during the night. He stated that if he is asleep, staff will not check or change him, and would they leave him wet.On 12/2/25 at 8:17 AM, an observation of Resident #1's incontinence pad and brief revealed a light brown colored ring of urine covering the pad and his incontinence brief was saturated with urine and spilling out onto the incontinence pad.On 12/2/25 at 8:19 AM, during an observation and interview with Certified Nursing Assistant (CNA) #1 who was assigned to Resident #1, confirmed that his incontinence pad and brief had a light brown ring of urine and his brief was saturated with urine. CNA #1 confirmed that the discoloration and urine saturation were consistent with the resident not being changed throughout the night. She stated he should have been changed him this morning already but hasn't.On 12/2/25 at 8:25 AM, in an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), they stated that residents should be checked and provided incontinent care at least every two (2) hours. They agreed that the light brown ring on the incontinence pad and the saturated brief indicated the resident had not been provided incontinent care timely.Record review of the admission Record revealed that the facility admitted Resident #1 on 8/20/25 with a diagnosis of Paraplegia.Record review of Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 8/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicated that Resident #1 was cognitively intact. Further review of the MDS revealed that Resident #1 was dependent with toileting.

Based on observation, interview, facility policy review, and record review, the facility failed to ensure effective supervision and accident prevention interventions were in place to mitigate the risk of falls for one (1) of three (3) residents reviewed for accidents (Resident #1). This deficient practice resulted in the resident sustaining a fall with a laceration and hematoma to the left eyebrow, requiring emergency department treatment. Top of Form Findings Include A review of the facility policy titled, “Fall Prevention Program,” review date 6/18/25 revealed: “All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of this assessment, specific interventions will be implemented to minimize falls, avoid repeat falls, and minimize falls resulting in significant injury… The resident's plan of care will be updated to reflect risk for falls and appropriate interventions… If a fall occurs… the plan of care will be updated to reflect interventions.” A record review of “Progress Notes” and “Incident Descriptions” revealed Resident #1 experienced five (5) falls between 11/2024 and 08/2025. This review revealed that on 11/23/2024 at 8:15 AM, the resident was found on the dining hall floor in front of his Geri-chair. He stated he missed the chair and did not recall where he was going. No injuries were noted. Again on 5/26/2025 at 8:25 AM, the resident was found lying on the floor of his room on his left side and stated that he rolled off the couch. No injuries were noted. On 6/17/2025 at 8:45 AM, the resident was found on the floor beside his bed. He stated he rolled out of bed. No injuries were noted. On 7/7/2025 at 5:04 PM, the resident was found lying on the floor of his room on the left side of the bed. No injuries were noted. And finally, on 8/14/2025 at 9:00 AM, the resident was found lying between the wall and bed, with his feeding pump overturned and his head turned to the side. There was blood around the resident's face, and he sustained a laceration and hematoma to the left eyebrow. The resident was unable to describe what occurred. He was transferred to the emergency room for evaluation and treatment. A record review of the “After Visit Summary” dated 8/14/2025 revealed the Resident #1 sustained a two (2) centimeter laceration to the left eyebrow, which was repaired using glue and steri-strips. A Computed Tomography Scan (CT) of the head without contrast noted “no acute intracranial abnormality,” but a “left forehead scalp contusion and/or small hematoma” was identified. On 9/16/2025 at 8:30 AM, during an interview with Licensed Practical Nurse #1 (LPN) she explained that Resident #1's bed had been positioned with the right side against the wall since she began working at the facility several months prior. She stated the room was set up that way, and the bed was placed against the wall due to the resident's fall history. She confirmed she was on duty on 8/14/2025 when the resident fell and explained that he had fallen between the wall and the bed, though she was unsure how it occurred. On 9/16/2025 at 10:26 AM, during a telephone interview, Certified Nurse Aide #1(CNA) explained she was assigned to the resident on 8/14/2025. She reported the bed had been locked and positioned against the wall prior to the fall. She added that the resident sometimes pushed against the wall, and she believed that is how the bed shifted, and the resident fell. A record review of the “Care Plan Report” for Resident #1 revealed a focus of “risk for falls” related to Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left dominant side, Hypertension, and blindness. The report listed individual entries acknowledging the five falls, but no new interventions were documented following any of the incidents on 11/23/2024, 5/26/2025, 6/17/2025, 7/7/2025, or 8/14/2025. On 9/16/2025 at 12:30 PM, during an interview and record review with the Assistant Director of Nursing (ADON), she confirmed the facility had not initiated new interventions following the resident's repeated falls but should have. Record review of the admission Record revealed the facility originally admitted Resident #1 on 4/1/24 with a diagnosis of Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease affecting the left dominant side.

Based on interview, record review and facility policy review, the facility failed to update a care plan after a residents falls for one (1) of three (3) resident care plans reviewed. Resident #1 Findings Include A review of the facility policy titled, “Fall Prevention Program,” revealed “All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter…The resident's plan of care will be updated to reflect risk for falls and appropriate interventions… If a fall occurs… the plan of care will be updated to reflect interventions.” A record review of the “Care Plan Report” for Resident #1 revealed a focus of “The resident is at risk for falls related to Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left dominant side, Hypertension, and blindness.” Interventions were listed for each of the residents' five (5) falls, but none were preventative interventions. The interventions were as follows: On 11/23/2024: “Unwitnessed fall without injury. Neuro checks initiated. Responsible Party (RP), Nurse Practitioner (NP), Director of Nursing (DON) aware.” On 5/26/2025: “Fall without apparent injury. Neuro checks initiated. NP and RP notified.” On 6/17/2025: “Fall without apparent injury. Neuro checks initiated. NP and RP notified.” On 7/7/2025: “Fall without apparent injury. Neuro checks initiated. NP and RP notified.” On 8/14/2025: “Fall. NP and RP notified. Sent to ER. Returned with steri-strips… Leave steri-strips in place and allow them to fall off on their own every day and night shift.” The care plan lacked documentation of any new or revised interventions to prevent repeat falls after any of these events. Record review of Progress Notes revealed on 8/14/2025 at 9:00 AM, the resident was found lying between the wall and bed, with his feeding pump overturned and his head turned to the side. There was blood around the resident's face, and he sustained a laceration and hematoma to the left eyebrow. The resident was unable to describe what occurred. He was transferred to the emergency room for evaluation and treatment. On 9/16/2025 at 12:30 PM, during an interview and record review with the Assistant Director of Nursing (ADON), she confirmed that the facility had not implemented new interventions or revised the resident's care plan following his falls on 11/23/2024, 5/26/2025, 6/17/2025, 7/7/2025, or 8/14/2025. She explained that the care plan should have been revised with new fall prevention strategies after each fall. She stated that the purpose of the care plan was to inform staff about the specific interventions required for each resident. She reported that it was her expectation that new interventions be added and the care plan updated following every fall incident. Record review of the admission Record revealed the facility admitted Resident #1on 7/31/25 with a diagnosis of Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease affecting the left dominant side.

Based on resident and staff interviews, facility investigation review, record review and facility policy review, the facility failed ensure a residents right to be free from misappropriation for one (1) of five (5) residents reviewed for misappropriation of resident funds, Resident #2. A Certified Nursing Assistant (CNA) misappropriated money from the resident's trust fund account and Cash App account. Findings Include Findings Include Review of the facility policy titled Abuse Prohibition Policy latest review date 6/2/25, revealed, Intent . Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse .The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of resident property or finances of residents . Record review of the facility investigation revealed that on 6/12/25 Resident #2 notified the Administrator (ADM) that Certified Nursing Assistant (CNA) #1 had stolen money from her via her trust fund card and Cash App. Resident #2 stated that starting in November 2024 she would send CNA #1 money through Cash App to buy her food and that she would pay CNA #1 additional money to do so. She stated that in April 2025 she received her trust fund card, and she gave it to CNA #1 to continue buying food for her. Resident #2 reported that she started noticing additional charges that she had not authorized. In an interview with CNA #1, she told the ADM that she did not have a Cash App account. Review of screenshots provided by Resident #2 showed transactions between herself and “Proper Name and Cash App identification (ID),” which was identified as belonging to CNA #1. She also provided copies of her trust fund account transactions. CNA #1 was suspended pending investigation and was terminated on 6/17/25. An interview with the ADM on 9/15/25 at 11:00 AM revealed she received a complaint from Resident #2 on 6/12/25 stating that CNA #1 had stolen approximately $10,000 from her through Cash App and her trust fund card. The ADM stated that Resident #2 reported she had asked CNA #1 to purchase food for her and paid her additional money to do so. The ADM confirmed that Resident #2 gave her trust fund card to CNA #1 so that she could continue to purchase items, but she noticed unauthorized charges on the card. When confronted, CNA #1 denied the charges, and Resident #2 reported the matter. The ADM verified that CNA #1 was suspended pending investigation on 6/12/25 and terminated on 6/17/25 due to misappropriation. In an interview with Social Services (SS) and the Activity Director (AD) on 9/15/25 at 12:15 PM, they stated that it is the practice of the facility for SS or AD to shop for residents and staff are aware. They stated they do not take resident debit cards or receive money via Cash App, and that Resident #2 never asked them to shop for her. A record review of screenshots of Cash App transactions between Resident #2 and an account identified as belonging to CNA #1, which occurred between November 19, 2024, and June 2025, revealed a total of 106 transactions of varying amounts. The screenshots showed a total of $10,963.13 sent to CNA #1 that were identified on the Cash App subject as food, etc. A record review of Resident #2's trust fund account summary for 4/1/25 through 4/30/25 showed a total of 20 withdrawals, of varying amounts, totaling $964.77, that Resident #2 indicated were not authorized by her. A record review of Resident #2's trust fund account summary for 5/1/25 through 5/31/25 showed a total of 48 withdrawals, of varying amounts, totaling $2,460.56, that Resident #2 indicated were not authorized by her. An interview with Resident #2 on 9/15/25 at 12:21 PM revealed that sometime in November 2024 she started asking CNA #1 to shop for her. She stated that she would send her money via Cash App for the purchases, and that CNA #1 charged her additional fees for doing the shopping. She stated that in April 2025 she received her trust fund card and gave it to CNA #1 so she would have it to shop for her. Resident #2 stated that she started noticing additional charges on her trust fund card. She reported seeing one of CNA #1's Snapchat stories of her dining at a Mexican restaurant that coincided with one of the unauthorized charges. Resident #2 stated she reached out to CNA #1, who denied the unauthorized charges, so she reported the matter to the ADM. Resident #2 explained that she had no one else to shop for her and asked CNA #1 for help, but realized CNA #1 was taking advantage of her when the additional charges appeared. She stated she was not aware that Social Services or Activities would shop for residents. Resident #2 verified that the Cash App name and ID on the screenshots from November 19, 2024, through June 2025 belonged to CNA #1. She also verified that the transactions she circled on the April 2025 and May 2025 trust fund account summaries were not authorized by her and she believed they were made by CNA #1. Record review of the Quarterly Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 7/3/25 revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15, indicating she is cognitively intact. Record review of the “admission Record” revealed the facility admitted Resident #2 on 5/20/22 with a diagnosis of Quadriplegia, C1-C4 incomplete.

Based on observation, staff interview, record review and facility policy review, the facility failed to monitor frequently and have provided increased supervision to a resident who was identified by the facility as being at high risk for wandering for one (1) of seven (7) residents at risk. (Resident # 73). Findings Include: Record review of the facility policy titled, Wander Management Monitoring System and Resident Elopement Protocol, with a revision date of 1/17/18 revealed, Purpose: To monitor safety of residents at risk for elopement . Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible . Record review of facility investigation revealed that on 11/2/24 at 5:00 PM, the Administrator (ADM) was contacted by the Director of Nursing (DON) notifying her that Resident #73 had walked out the front door of the facility and was returned to the facility at approximately 5:30 PM. Resident #73 stated to the nurse that some people came in the front door of the facility so he went out the door to go visit his friends. Upon returning the resident inside the facility, it was noted that Resident #73's wander guard bracelet did not alarm. Investigation revealed that the wander guard bracelet appeared to have malfunctioned. Maintenance arrived and tested all the doors in the facility and the wander blue system. Resident #73's wander guard was replaced, and he was placed on one-on-one monitoring. The malfunctioning of the bracelet was noted to be sudden, and the previous checks did not reveal any issues. Record review of elopement assessment dated [DATE], revealed a score of 25, indicating Resident #7 was high risk for wandering, but did not indicate that the resident required more frequent monitoring. Licensed Practical Nurse (LPN) #1 was interviewed on 11/12/24 at 11:00 AM and stated that she last saw Resident #73 on 11/2/24 around 12:45 PM, during lunch. She stated that Resident #73 walks around the facility, spending time on the first and second floors, often sitting on the couch on the first floor close to the door. LPN #1 reported that earlier in the day, she had checked Resident #73's wander guard by testing it near the front door, where it triggered the alarm, so she knew the wander guard had worked earlier in the day. LPN #1 confirmed that she did not look for the resident again until around 4:15 PM when she needed to check his blood sugar. LPN #1 stated that the facility doesn ' t have to document on the medical record that they have seen the resident throughout the day other than when it is time for his blood sugar checks at mealtimes or medications to be given. An interview with Certified Nursing Assistant (CNA) #1 on 11/12/24 at 11:15 AM, confirmed that Resident #73 walks around the facility, spending time on the first and second floors and confirmed that she did not attempt to locate the resident before her shift ended at 3:00 PM. An interview on 11/13/24 at 8:30 AM with the Administrator confirmed that staff failing to check on the location of Resident #73, who was at high risk for wandering, from 12:45 PM until 4:15 PM could place him at risk of accidents and/or injury. Record review of the Admission Record revealed the facility admitted Resident # 73 on 7/12/2024 with diagnoses that included Cognitive Communication Deficient. Record review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 10/19/24 revealed a Brief Interview of Mental Status score of 9, indicating that Resident #73 has moderate cognitive impairment.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide the necessary services to maintain grooming and personal hygiene for residents who are unable to self-perform activities of daily living (ADL's) for (2) two of 161 residents observed for ADL's. (Resident # 38 and #80) Findings include: Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, revised March 2018 revealed, Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain grooming and personal hygiene . Resident #38 On 11/12/24 at 12:15 PM, an observation and interview revealed that Resident #38 had long, jagged nails with a brown substance under each of her nails and facial hair. Resident #38 stated the staff sometimes trim and clean her nails and shave her at times, but it's been a while. An observation and interview with Resident #38 on 11/13/24 at 2:10 PM, revealed the resident continued to have long, jagged, dirty nails and facial hair. She stated she wanted her nails to be trimmed and to be shaved and she had told some of the staff, but it had not been done. On 11/13/24 at 2:20 PM, during an interview and observation with Resident #38 and the Director of Nursing (DON) , the DON asked the resident about her nails and facial hair and the resident stated she told the staff she wanted to be shaved and have her nails trimmed, but it had not been done. The DON stated it was the responsibility of the staff to ensure nails were trimmed and clean and that the residents were shaven as they preferred since each resident needed to be cared for and happy with their appearance. She also stated the jagged nails could cause harm to the skin. She confirmed the facility failed to ensure the activities of daily living (ADL) care for a dependent resident was done as desired by the resident. Record review of Resident #38's Admission Record revealed the facility admitted the resident on 9/24/19 and diagnoses that included Epilepsy and Intellectual Disabilities. Record review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/12/24, revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had a moderate cognitive impairment. 47157 Resident #80 On 11/12/24 at 11:00 AM, an interview and observation of Resident #80 revealed the residents' fingernails to be approximately three-fourths (3/4) inch long past the tips of the fingers, jagged in appearance, with a thick dark brown substance under all the nail beds. He stated he could not remember the last time his nails were cut. He then stated he would like to have them cut and cleaned. He stated he has asked staff several times to trim his nails, but it has not been done. An observation of Resident #80's fingernails on 11/13/24 at 10:15 AM, revealed no change in the resident's fingernails. On 11/13/24 at 10:25 AM, an interview with Licensed Practical Nurse #2 she confirmed Resident #80's fingernails were very long, jagged and had some type of brown substance under the nails. She revealed that one of the concerns from the nails not being cleaned and trimmed was that he could scratch himself. On 11/13/24 at 11:00 AM, an interview with the Infection Control Nurse , she confirmed that with Resident #80's nails being long and dirty then the resident could scratch himself and possibly get a skin infection. In an interview with the Director of Nursing 11/13/24 at 2:36 PM, she revealed Resident #80 stated he wanted his nails trimmed and cleaned today. Record review of the Task Care Guide for November 2024 for Resident #80 revealed no documentation of refusals of care. Review of the Admission Record revealed Resident #80 was admitted by the facility on 7/12/19 with diagnoses of Quadriplegia and Need for Assistance with personal hygiene. Record review of Resident #80's Section C of the MDS with an ARD of 8/15/24 revealed in Section C a BIMS score of 15, indicating the resident was cognitively intact.

Based on observation, resident and staff interview, record review, and facility policy review the facility failed to implement a care plan related to implementing Enhanced Barrier Precautions (EBP) (Resident #20) and performing activities of daily living (ADL) (Resident's #38 and #80) for three (3) of 30 resident care plans reviewed. Findings include: Review of facility policy titled Care Plans, Comprehensive Person-Centered, reviewed 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 . Resident #20 Record review of Resident #20's Care Plan revealed that she had a deep tissue injury to the left heel and revealed, This resident is on Enhanced Barrier Precautions and Use EBP when providing wound care . On 11/13/24 at 11:20 AM. observation and interview revealed Resident #20 had an EBP sign on their room door. Observed Licensed Practical Nurse (LPN) #4 complete wound care to Resident #20's left heel without donning a gown prior to the wound care being performed. LPN #4 revealed that she knew she was suppose to use EBP with wound care but she got nervous and forgot. She revealed that the purpose of EBP was to prevent the spread of infection, and it was to protect the residents as well as the staff. On 11/13/24 at 11:43 AM An interview with Registered Nurse (RN) #2, confirmed that Resident #20 was on EBP because she had a urinary catheter and a wound. She revealed that EBP was supposed to be followed to protect the residents from the possible spread of infection. Record review of Resident #20's Admission Record revealed an admitted [DATE] and that she had diagnoses that included Malignant Neoplasm of Uterus, Pressure - Induced Deep Tissue Damage of Left Heel, and Type 2 Diabetes Mellitus. Record review of Resident #20's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/30/24 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 14 which indicated that she was cognitively intact. Resident #38 Record review of Resident #38's care plan, date initiated 9/24/19 revealed, The resident has an ADL self-care performance deficit. Interventions included Personal hygiene: shave facial hair as requested by resident or RP (Responsible Party) as needed and Bathing/showering: check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Shave as needed. During an observation and interview on 11/12/24 at 12:15 PM, it was noted that Resident #38 had long, jagged nails with a brown substance noted under her nails and some facial hair. Resident #38 stated the staff would trim and clean her nails and shave her at times, but it had not been done lately. During an interview and observation with Resident #38 and the Director of Nursing (DON) on 11/13/24 at 2:20 PM, confirmed the resident needed nail care and shaved. She confirmed the facility failed to ensure the ADLs for a dependent resident was done as desired by the resident, therefore, the care plan for ADL care for this resident was not followed. During an interview on 11/13/24 at 3:40 PM, the Minimum Data Set (MDS) Director stated the care plan provided a guide for the residents' care and Resident #38 had a care plan developed for her ADL care. She confirmed the care plan related to nail care and shaving for this resident was not implemented. Record review of Resident #38's Admission Record revealed the facility admitted the Resident #38 on 9/24/19 with medical diagnoses that included Epilepsy and Intellectual Disabilities. Record review of Resident #38's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/12/24, revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. 47157 Resident #80 Record review of Resident #80' s care plan titled, The resident has an ADL self-care performance deficit r/t (related to) left side hemiparesis, Impaired balance, revealed, interventions: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . An interview and observation with Resident #80 on 11/13/24 at 11:00 AM, revealed the residents' fingernails to be approximately three-fourths (3/4) inch long, jagged in appearance, with a thick dark brown substance under all the nail beds. He stated he could not remember the last time his nails were cut. In an interview with Licensed Practical Nurse #2 on 11/13/24 at 10:25 AM, she confirmed Resident #80's fingernails were very long, jagged and had some type of brown substance under the nails. An interview with the MDS Coordinator on 11/13/24 at 10:53 AM, revealed after review of Resident #80's ADL care plan that staff did not implement his care plan intervention related to nail care. She then revealed the purpose of the comprehensive care plan is to direct the resident specific care needed for each resident. Review of the Admission Record revealed Resident #80 was admitted by the facility on 7/12/19 with medical diagnoses that included Quadriplegia and Need for Assistance with personal hygiene. Record review of Resident #80's Section C of the MDS with an ARD of 8/15/24 revealed a BIMS score of 15, indicating the resident was cognitively intact.

Based on staff interview and record review, the facility failed to ensure a resident's code status was accurate in the physician orders for one (1) of 40 residents reviewed for advanced directives during initial pool. Resident #135 Findings Include: The facility provided a statement on letterhead signed by the Administrator that read, This facility does not have a policy for discrepancies between advance directive and physician order. Record review of Resident #135's Consent for Cardiopulmonary Resuscitation (CPR) dated, [DATE] revealed, Decline CPR: I understand that CPR constitutes an extraordinary measure and SHOULD NOT be performed was checked and signed by Resident #135's family member. Record review of Resident #135's Physician Order Detail revealed an order dated [DATE], CPR (Cardiopulmonary Resuscitation). An interview with Registered Nurse (RN) #1 on [DATE] at 10:58 AM, revealed in case of an emergency event, the staff would check Resident #135's Electronic Medical Record (EMR) under the orders to determine the resident's code status. She confirmed, after looking at the EMR, the resident was a full code and would be resuscitated should something happen. An interview with the Admission's Coordinator on [DATE] at 11:30 AM, revealed she went over the advanced directives with Resident #135's family member, which elected for the resident to be a DNR (do not resuscitate). She revealed the physician order, and the advanced directive consent should match for the resident and families wishes to be honored in an emergency event. An interview with Social Services #1 on [DATE] at 1:14 PM, revealed if Resident #135's physician order and the advanced directive consent do not match, the resident could be resuscitated when the resident and family did not want that. Record review of the Admission Record revealed the facility admitted Resident #135 on [DATE] with a medical diagnosis of Cerebral Infarction.

Based on observation, staff interview, and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment for two (2) of three (3) survey days. Findings include: Record review of the facility policy titled, Homelike Environment revised February 2021, revealed under the policy statement, Residents are provided with a safe, clean, comfortable and homelike environment room [ROOM NUMBER]-P An observation on 11/12/24 at 3:23 PM of room [ROOM NUMBER]-P revealed the smell of urine when standing at the bedside. An observation on 11/13/24 at 1:29 PM in room [ROOM NUMBER]-P revealed areas of a dark brown liquid scattered around the lid of the commode and multiple large areas of dark brown liquid scattered across the bathroom floor and on the resident's recliner. An observation on 11/13/24 at 2:02 PM in room [ROOM NUMBER]-P revealed had a dried dark brown substance smeared on the bathroom floor that appeared to have been attempted to be cleaned. This observation revealed the scattered dried dark brown substance remaining on the commode and recliner. An interview with Housekeeper #6 on 11/13/24 at 2:04 PM, revealed that they clean the rooms twice a day and sometimes three times. She stated that she had already been in this room twice today cleaning. She confirmed that she observed the dark brown substance that she thought was diarrhea in the room earlier. She stated, But we aren't supposed to clean that up and that the Certified Nursing Assistants (CNA) do it with housekeeping sanitizing afterwards. The housekeeper confirmed that she had already mopped the room earlier today, but she didn't mop the bathroom. An interview on 11/13/24 at 2:06 PM, with CNA #3 confirmed that the diarrhea was scattered across the bathroom floor in room [ROOM NUMBER]-P. She stated that she had attempted to clean it up from the floor, commode and recliner but that she didn't have any cleaner. She revealed that the housekeepers tell us that we have got to clean up bowel movement. An interview on 11/13/24 at 2:15 PM, with Housekeeping #1 stated that it is our policy to let the CNAs clean it up and we just go behind them and sanitize. An interview on 11/13/24 at 2:18 PM, with Housekeeping #4 and Housekeeping #1, Housekeeping #4 stated that We don't clean up bodily fluids because we don't know what the resident might have, aids, hepatitis. We haven't been trained on how to do that, we let the aids do it. Housekeeping #1 confirmed that it is not a homelike environment to allow bowel movement to stay on the floor so long that it dries. An interview on 11/14/24 at 9:10 AM, with the Director of Nurses (DON) confirmed that her CNA's don't have chemicals to clean up bowel movement in a resident's bathroom. She stated that if they are in the room changing a resident then they are expected to clean up incontinent briefs and take out the trash, but we don't have them cleaning the resident's bathrooms up when a resident messes it up. 46013 room [ROOM NUMBER] During an initial tour on 11/12/24 at 10:10 AM, an observation in room [ROOM NUMBER] revealed a large dried brown substance smeared approximately 6 inches by 6 inches on the base of the front of the toilet bowl. During an interview and observation on 11/12/24 at 11:30 AM, CNA #2 confirmed that the front of the toilet bowl had a large area of dried feces, and it looked like it had been there for a while. CNA #2 revealed that housekeeping had just finished cleaning room [ROOM NUMBER], but housekeeping does not clean any stool up; rather, the CNAs are responsible for cleaning it. room [ROOM NUMBER] An observation on 11/12/24 at 10:20 AM and again at 2:25 PM in room [ROOM NUMBER] revealed a dark brown substance on the floor under the head of the bed. The privacy curtain was hanging off approximately (approx.) eight (8) hooks and drooped resulting in it touching the floor on the left side. An observation of room [ROOM NUMBER]'s exterior door frame revealed a thick black substance around the frame and side of the wall. An observation on 11/13/24 at 8:49 AM revealed the condition of room [ROOM NUMBER] remained the same as the prior day's observation. During an interview and observation on 11/13/24 at 1:30 PM, Housekeeper #5 confirmed that room [ROOM NUMBER] had a large dark brown substance behind the head of the bed, He stated that it was dirty and possibly from the floor waxing. He confirmed the privacy curtain was off some of the hooks and touching the floor on the left side and that there was a black substance around the bottom door frame of the exterior door and wall. He revealed the floors need good buffing and the room needs to be cleaned. 45598 room [ROOM NUMBER]-W An observation on 11/12/24 at 10:43 AM in room [ROOM NUMBER]-W revealed an air conditioner unit to the right side of the bed with multiple areas of a black substance on the upper front surface of the air flow vents and on the temperature control panel. An observation on 11/13/24 at 10:32 AM and at 11:30 AM in room [ROOM NUMBER]-W, revealed an air conditioner unit with black substance on the surface of the air flow vents across the upper front of the unit and control panel. An observation and interview with Registered Nurse (RN) Supervisor on 11/13/24 at 11:35 AM, confirmed the black substance on the front covering of the air conditioner unit and he revealed that it looked like black dirt. He revealed that it should have been cleaned by housekeeping to maintain a clean environment. He revealed that the black substance in the air vent could be breathed in and could cause a respiratory infection. An interview with Housekeeper #1 on 11/13/24 at 11:38 AM, revealed that they deep cleaned two resident rooms a day and that each resident room was deep cleaned once a month. She confirmed the black substance on the air conditioner unit and stated, It looks like black lent. She revealed that deep cleaning included bed rails, furniture, and the outer surface of the air conditioner including the air flow vents. She revealed that she didn't know when this room was last deep-cleaned and confirmed that this should have been noticed and cleaned. An interview on 11/13/24 at 2:27 PM, with Housekeeping #4 confirmed that resident rooms were deep cleaned once a month, and this included the surface of the air conditioner units. 47874 An observation at the end of the 200 hall by the exit door, on 11/12/24 at 12:04 PM revealed a large brown discolored area on the ceiling tiles that measured approximately 2-foot x 1 foot. An observation and interview with Housekeeping Supervisor #1 on 11/13/24 at 11:20 AM, confirmed the area on the ceiling and described the area as, looks like something is leaking up there. An observation and interview with Maintenance #2 on 11/13/24 at 11:26 AM revealed, the discolored area on the ceiling tile was from the air conditioning unit, which was stored above the ceiling, being stopped up and leaking. He revealed he was not aware that it had leaked onto the ceiling tiles. He confirmed the residents and visitors would expect the building to be in good repair and a homelike environment.

Based on observation, staff interviews, record review, and facility policy review the facility failed to ensure that Enhanced Barrier Precautions (EBP) was implemented for a resident that required EBP for (1) of five (5) direct care areas observed. Findings Include: Record review of the facility policy, Enhanced Barrier Precautions (EBP) dated 04/01/24 revealed that EBP are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected . The policy also revealed that gloves and gowns are to be donned when performing wound care. An observation on 11/13/24 at 11:20 AM, revealed Licensed Practical Nurse (LPN) #4, completed wound care to Resident #20's left heel without donning a gown prior to the wound care being performed. LPN #4 revealed that she knew to use EBP with wound care, but she got nervous and forgot. She revealed that the purpose of EBP was to prevent the spread of infection, and it was to protect the residents as well as the staff. There was EBP signage on the resident's door. An interview on 11/13/24 at 11:43 AM, with Registered Nurse (RN) #2, revealed that Resident #20 was on EBP because she had a urinary catheter and a wound. She revealed that EBP was supposed to be followed to protect the residents from the possible spread of germs or infection. RN #2 confirmed that LPN #4 should have worn gloves and a gown when she provided wound care for Resident #20. Record review of Resident #20's Order Summary Report dated 11/08/24 revealed an order to cleanse the deep tissue injury to her left heel with povidone-iodine and leave open to air. Record review of Resident #20's Care Plan revealed that she had a deep tissue injury to the left heel and revealed, This resident is on Enhanced Barrier Precautions and Use EBP when providing wound Record review of Resident #20's Admission Record revealed an admitted [DATE] and that she had diagnoses that included Malignant Neoplasm of Uterus, Pressure - Induced Deep Tissue Damage of Left Heel, and Type 2 Diabetes Mellitus. Record review of Resident #20's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/30/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated that she was cognitively intact.

Based on staff interviews, record review, and facility policy review, the facility failed to monitor a resident receiving anticoagulant medication for signs of bruising and bleeding for one (1) of five (5) residents reviewed for unnecessary medication. Resident #47 Findings include: Record review of the facility policy titled Anticoagulation-Clinical Protocol with a revision date of November 2018 revealed under, Monitor and Follow-Up: 5 . The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems . Record review of Resident #47's Order Summary Report revealed an order dated 9/23/2024, Apixaban oral tablet 2.5 mg (milligrams) Give 1 tablet by mouth two times a day related Peripheral Vascular Disease. Record review of the Order Summary Report and the Medication Administration Record (MAR) for Resident #47 revealed there was not a monitoring tool for staff to monitor for signs of bruising and bleeding with the anticoagulant (blood thinner) medication Apixaban. An interview with Licensed Practical Nurse (LPN) #5 on 11/14/24 at 8:10 AM, confirmed that Resident #47 is on an anticoagulant medication. She confirmed the facility did not have a monitoring task implemented on the resident's MAR for bruising or signs of bleeding. She revealed that it is very important to monitor a resident that is on a blood thinner. In an interview on 11/14/24 at 9:05 AM, the Director of Nurses (DON) confirmed that Resident #47 is on an anticoagulation medication, and he should be monitored for bruising or signs of bleeding. She confirmed the resident was not being adequately monitored for the potential outcomes associated with the use of anticoagulation medications, and he should be. Record review of the Admission Record revealed Resident #47 was admitted to the facility on [DATE] with medical diagnoses that included Peripheral Vascular Disease.

Based on observation, staff interviews, and facility policy review the facility failed to ensure the proper storage of drugs as evidenced by a medication cart being left unlocked during medication administration for one (1) of four (4) medication carts observed. Findings Include: Record review of the facility policy titled Storage of Medications with reviewed date of July 2024 revealed under policy statement, The facility stores all drugs and biologicals in a safe, secure, and orderly manner .9. Unlocked medication carts are not left unattended An observation on 11/13/24 at 8:20 AM, revealed Licensed Practical Nurse (LPN) #3, administer medications to a resident in room [ROOM NUMBER]. LPN #3 left the medication cart outside of room [ROOM NUMBER] with the medication drawers facing the outside of the door. At 8:35 AM, upon exiting room [ROOM NUMBER], an observation revealed that the medication cart was unlocked while unattended. There was a resident sitting beside the cart in a wheelchair and two residents who self propelled themselves by the cart during this timeframe. LPN #3 confirmed that the medication cart was unlocked and revealed that residents could have come up to the medication cart and took what they wanted out of the drawers. She confirmed that the medication cart was supposed to be locked at all times unless the nurse was present and preparing medications for administration. An interview on 11/13/24 at 2:36 PM, with Registered Nurse (RN) #2, revealed that the medication carts were supposed to be locked at all times to prevent anyone from getting into the carts while unattended. She revealed that the only time the medication cart should be unlocked was if the nurse was standing at the cart getting medications out. RN #2 confirmed that LPN #3 should have locked the medication cart prior to entering room [ROOM NUMBER].

Based on observation, resident and staff interviews, record review and facility policy review, the facility failed to provide a resident with a dignified existence as evidenced by leaving a urinary catheter bag uncovered for one (1) of five (5) sampled residents with urinary catheters. Resident #20. Findings Include: Review of the facility policy titled, Protocol for Keeping Catheter Bags Covered for Dignity Purposes in a Nursing Home with no revision date revealed under Objective .To maintain the dignity, privacy, and comfort of residents with catheter bags by ensuring that catheter bags are properly covered . 2. Proper Covering of Catheter Bags .Catheter bags should be covered with an appropriate, discreet cloth or garment. Record review of the facility form, Resident Rights that is provided to residents when admitted to the facility, revealed that residents were to be treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care of his personal needs . An observation on 11/12/24 at 11:19 AM, revealed Resident #20 sitting up in her wheelchair in her room watching television. There was an uncovered urinary catheter bag hooked on the wheelchair frame and there was amber urine visible. An observation and interview on 11/13/24 at 10:28 AM, with Resident #20 revealed her lying in her bed eating breakfast. There was an uncovered urinary catheter bag hanging on the bed frame with 900 milliliters of urine in the bag and it was visible from the hallway. Resident #20 revealed that it bothered her a little for her urine to be visible and stated, It makes me feel kinda icky. She revealed that she would like her catheter bag to be covered. Record review of Resident #20's Order Summary Report revealed an order effective 10/31/24 for a privacy bag or covering over urine collection bag for dignity. An interview on 11/13/24 at 10:47 AM, with Licensed Practical Nurse (LPN) #4, revealed that they usually had blue privacy urinary bags on all residents with catheters. She confirmed that Resident #20 did not have a privacy catheter bag in use and that she would get it changed out. An interview with Registered Nurse (RN) #2 on 11/13/24 at 10:53 AM, revealed that they used blue privacy urinary catheter bags and that the catheter bag that Resident #20 had must have come from the hospital. She confirmed that Resident #20's catheter bag did not have a privacy covering and that visible urine was a dignity issue. She also agreed that someone should have caught this and changed it. Record review of Resident #20's Admission Record revealed an admitted [DATE] and that she had diagnoses that included Malignant Neoplasm of the Uterus and Type 2 Diabetes Mellitus. Record review of Resident #20's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/30/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated that she was cognitively intact.

Based on observation, staff and resident interview, and facility policy review, the facility failed to ensure a call light device was accessible for a dependent resident for one (1) of 32 sampled residents. Resident #7 Findings include: Record review of the facility policy titled, Resident Call System, with review date of 3/28/23, revealed, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation .1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. During an observation and interview on 11/13/24 at 8:30 AM, Resident #7 stated he used the call light to receive the assistance needed for his care, but his call light was not within reach. An observation revealed the resident was lying in his bed and the call light cord was twisted around the bed frame under the foot of the resident's bed and the call light button was not within the resident's reach. On 11/13/24 at 8:33 AM, an observation and interview with Certified Nursing Assistant (CNA) #4 in Resident #7's room, when asked about the call light, she stated the staff were to ensure the light was within each resident's reach, and this one was not where the resident could reach it. Observed her untangling the cord and laying it at the foot of the bed. Registered Nurse (RN) #2 entered the resident's room and confirmed with CNA #4 that the call light was not accessible for the resident, and it should have been secured within his reach. RN #2 stated this resident was cognitive and used the light to receive the care he needed, and it was necessary for the light to be within his reach. During an interview on 11/13/24 at 2:00 PM, the Director of Nursing (DON) confirmed that the staff members were to clip the light to the bedding within the resident's reach. She acknowledged this resident was cognitive and was able to use the call light to receive care. She confirmed the facility failed to ensure the call light was accessible for this resident. Record review of Resident #7's Admission Record revealed the facility admitted the resident on 8/17/2012 with the most recent admission being 7/11/19. His diagnoses included Type 2 Diabetes Mellitus, Hypertensive Heart Disease with heart failure, Chronic Obstructive Pulmonary Disease, and Repeated Falls. Record review of Resident #7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/20/24, revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to resolve grievances related to missing clothes items for four (4) of six (6) residents in the resident council meeting. Resident #15, Resident #115, Resident #124, and Resident #126. Findings include: Record review of the facility policy titled, Filing Grievances/Complaints, with a revision date of 6/2024, revealed, Our facility will assist residents, their representatives (Sponsors), other interested family members, or advocates in filing grievances or complaints when such request are made .3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing (if requested), including a rationale for the response . A record review of the Resident Council minutes revealed there were complaints regarding missing clothes for the meeting dates of 5/2/24, 6/4/24, 8/2/24, 9/5/24, and 11/1/24. Interviews with residents during the Resident Council meeting on 11/13/24 at 10:03 AM, revealed Resident #15 (Resident Council President), Resident #115, Resident #124, and Resident #126 had concerns that they were still missing clothes. They unanimously voiced that the discussion of missing clothes had been addressed in almost every Resident Council meeting for months. Resident #15 revealed that he has had some compression socks missing for a long time and they tell him they will replace them, but they never do. Resident #126 stated that when he was admitted he had a jogging suit that is still missing. Resident #115 revealed that the shirt she has on now had gone missing a year ago and she had just received it back. She stated that her daughters gave her some new ankle socks for Mother's Day, but she refuses to wear them because she is afraid they won't return from laundry. An interview with the Activity Director on 11/13/24 at 11:04 AM, confirmed that missing clothes has been going on for a long time and they discuss it in almost every Resident Council meeting. She stated that she notifies the Licensed Social Worker (LSW) and laundry when the issue is discussed in the meetings. She revealed that she didn't know what was going on to cause this issue and confirmed that it still had not been resolved. An interview on 11/14/24 at 8:20 AM, with Housekeeper/Laundry #6 confirmed that they do get complaints of missing clothes. She stated that she thinks the biggest issue is that laundry gets backed up and they don't put their names on their clothes. In an interview on 11/14/24 at 8:45 AM, the LSW confirmed that the laundry issue with missing clothes had been an ongoing problem. In an interview on 11/14/24 at 9:23 AM, the Administrator confirmed that missing clothing had been an issue for a while. She admitted that she had been aware of the problem and had worked on some things, but it had not been resolved Resident #15 A review of the Admission Record revealed that the resident was admitted to the facility on [DATE]. Record review of Resident #15's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9-13-2024 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Resident #115 A review of the Admission Record revealed that Resident #15 was admitted to the facility on [DATE]. Record review of Resident #115's MDS with an ARD of 9-24-2024 revealed in Section C a BIMS score of 15, which indicated the resident was cognitively intact. Resident #124 A review of the Admission Record revealed that Resident #124 was admitted to the facility on [DATE]. Record review of Resident #124's MDS with an ARD of 8-15-2024 revealed in Section C a BIMS score of 15, which indicated the resident was cognitively intact. Resident #126 A review of the Admission Record revealed that Resident #126 was admitted to the facility on [DATE]. Record review of Resident #126's MDS with an ARD of 10-10-2024 revealed in Section C a BIMS score of 14, which indicated the resident was cognitively intact.

Based on staff interviews, resident interviews, observations, record reviews, and facility policy and procedure reviews, the facility failed to provide supervision to prevent the elopement of a delusional resident who voiced and was identified by the facility as being at high risk for elopement. Resident #1 was one (1) of six (6) Residents that the facility had identified as at risk for elopement. (Resident #1) The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) Past Non-Compliance (PNC) which began on [DATE], when the facility allowed Resident #1 to leave the facility through his disassembled bedroom window unsupervised and unwitnessed. Resident #1 was found several miles away by local Law Enforcement at a store. He was assumed by the facility to be away from his bedroom for approximately five and a half (5.5) hours. Resident #1 was last seen by Certified Nursing Assistant (CNA #1) on [DATE] at approximately 12:30 A.M. and was not seen again until his return to the facility at approximately 6:00 A.M. The facility's failure to provide supervision placed Resident #1 and other residents identified elopement risk placed the residents with likelihood of serious injury, harm, impairment, or death. On [DATE] at 2:00 P.M. the SA informed the facility's Administrator (ADM) of the Immediate Jeopardy (IJ) and provided the IJ Template. The facility provided an acceptable Removal Plan-Past Non-Compliance (PNC) on [DATE], in which the facility alleged all corrective actions were completed to remove the IJ (PNC) on [DATE], prior to the SA entering the building on [DATE]. The (SA) validated the Removal Plan on [DATE]-[DATE] and determined the IJ (PNC) was removed on [DATE], prior to SA's entering the building on [DATE]. The Scope and Severity (S/S) for F689-Accidents/Hazards/Supervision, was lowered from a K to an E due to the facility being recently cited for the same deficiency on [DATE]. Findings Include: The facility policy and procedure titled Wander Management, Monitoring System and Resident Elopement Protocol dated Revised [DATE] Reviewed ,d+[DATE] read: To monitor safety of residents at risk for elopement. To provide a system to alert staff that a resident may be attempting to leave the facility. It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents, so identified, will have these issues addressed in their individual care plans. Interview on [DATE] at 9:50 A.M. with the facility Administrator (ADM) revealed that Resident #1 had made an attempt to leave the facility on [DATE] with staff following close behind him which prevented Resident #1 from leaving the front porch of the facility after he voiced that he needed to leave to get a job. On [DATE] Resident #1 had a Brief Mental Status Score (BIMS) of 14 which indicated that he was cognitively intact, but he did voice delusional statements such as he needed to return to his job and/or report for a job interview. Resident #1 had written large documents in a note book that he explained to staff were his resume' documents and that he needed to leave to take his resume' with him to job interviews. The ADM stated that Resident #1 had been admitted to the facility from another nursing home. The ADM stated that Resident #1 had a known history of wandering and was an elopement risk. The ADM stated that Resident #1 was identified as one (1) of six (6) residents living in the facility that were wanderers and high risk for elopement. The ADM stated that Resident #1 had been given a wander guard to sound when Resident #1 got close to the exit doors. The ADM stated that the wander guards do not work on the windows, but on [DATE] after midnight that Resident #1 left the facility through his disassembled bedroom window and he had taken his wander guard off and left it on his bedroom dresser. The ADM provided pictures made with her cell phone of the disassembled window, a broken and bent window screen, and the window taken completely out of its frame and sitting on top of room air conditioner inside Resident #1's private room. The ADM stated that when Resident #1 eloped undetected and unsupervised from the facility on [DATE] after midnight, he took with him a roll of toilet tissue, his note book of writings/resume', an extra pair of black tennis shoes and a black hooded sweat shirt that he had wrapped around his body as a make-shift back pack. Resident #1 was wearing a white T-shirt, olive green cargo pants, eye glasses and blue tennis shoes. Resident #1 was last seen by a Certified Nursing Assistant (CNA#1), at 12:30 A.M. on [DATE] and at approximately 2:00 A.M. on [DATE] LPN #1 discovered that Resident #1 had disassembled his bed room window and had left out his window unsupervised and undetected. The local Law Enforcement contacted the ADM at approximately 5:44 A.M. that Resident #1 was at the Dispatch Office waiting for the facility to come and pick him up. The ADM and the DON drove to the Dispatch office and obtained Resident #1 and brought him back to the facility at approximately 6:00 A.M. The DON and nursing staff assessed Resident #1 and found him to be delusional but not physically injured. The facility placed Resident #1 on one to one (1:1) close observation with documented visual accountability every 15 minutes. The wander guard was re-placed on Resident #1 and his bedroom window was re-paired and fastened with screws drilled into the frame by the Maintenance Department. Resident #1 has remained on 1:1 since his return to the facility and his 1:1 will remain in place until he is discharge on [DATE] to a locked unit at another facility. Interview and observation of Resident #1 on [DATE] at 10:15 A.M. revealed Resident #1 made no attempts at conversation. Resident #1 stated that he was getting in his exercise. Observation of his room revealed that he was in a private room with no roommate, the bedroom window was securely attached and in working order. The window would not open all the way but provided approximately six (6) inches of an opening for fresh air. The screen on the outside of the window was attached. Resident #1 had an over bed table in front of a straight back chair that contained a note book and a pen for writing. The note book appeared to be filled with Resident's personal writings. The ADM demonstrated to surveyor how the window was now securely screwed in to the frame of the window and that it would no longer lift out of the frame. The windows were large and were designed to slide from side to side in order to open. The windows were currently secured as not to slide from side to side but only open approximately six (6) inches. Resident #1 was not present when the ADM demonstrated the current status of his bedroom window. Resident #1 was walking all about the facility with a staff member. Interview on [DATE] at 10:30 A.M. with the Director of Nursing (DON) revealed that she had ridden to the Dispatch Office with the ADM to pick up Resident #1 on [DATE] at approximately 6:00 A.M. The DON stated that the weather conditions on [DATE] were not good and that it was raining and hot. Upon returning Resident #1 to the facility on [DATE] at approximately 6:00 A.M. the DON, along with other nursing staff, LPN #1 and RN Supervisor #2, assessed Resident #1 and all identified wanderers and found no physical injuries and wander guards were in place and functioning properly. The DON stated that she over saw the verification and accountability of all residents per the census of 149 residents. DON stated that Resident #1 had been assessed upon his admission to be at high risk for elopement and a wander guard was put in place. The DON stated that she re-assessed Resident #1 on [DATE] and documented his High Risk for Wandering on the Wander Data Collection form. The DON stated that the Maintenance department had been at the facility on [DATE] and had secured the bedroom window of Resident #1's room prior to 7:00 A.M. on [DATE]. The DON stated that she also re-assessed Resident #1 for his high risk for wandering again on [DATE]. The DON confirmed that on [DATE] the Quality Assurance (QA) committee members met and discussed the events of Resident #1's elopement. The DON stated that all corrections had been completed on [DATE]-[DATE]. The DON stated that Resident #1 had been on 1:1 close observation with a staff ,d+[DATE] since the elopement on [DATE] and would remain on 1:1 until his discharge to a locked unit at another facility. The DON stated that the immediate dangers of the elopement were corrected on [DATE] when Resident #1 was returned safely, placed on 1:1 close observation with a new functioning wander guard system and the window of Resident #1's room secured and repaired by Maintenance. The facility continued with in-servicing of staff and assessing of residents, and the first QA meeting was on [DATE]. The Psychiatric Nurse Practitioner came to the facility on [DATE] and re-assessed Resident #1 and wrote orders to continue the 1:1. Interview on [DATE] at 2:40 P.M. with Certified Nursing Assistant (CNA #1) revealed that she was a new employee to the facility that was hired on [DATE]. She stated that on the night of Resident #1's elopement she and two (2) other CNA's were working on the unit and two (2) LPN's. CNA #1 stated that there was plenty of staff working on the unit. She stated that Resident #1 was his normal self and was not acting like he was going to leave and he had not voiced anything unusual to her. Resident #1 was assigned to her and she had been checking on him throughout the night. CNA #1 saw Resident #1 sleeping in his bed at 12:30 A.M. on [DATE] in his private room. Then the LPN #1 went at 2:00 A.M. to check on him and he was gone. The entire staff began to look for Resident #1. CNA #1 stated that Resident #1 had not expressed to her that he wanted to leave the facility. CNA #1 stated that Resident #1 eloped through his bed room window. Interview on [DATE] at 3:28 P.M. with the Licensed Social Worker (LSW) , revealed that she had been the LSW at the facility during Resident #1's admission. LSW stated that Resident #1 had delusions and that he had voiced exit seeking behaviors. Resident #1 believed that he needed to get a job and that he must get a job to survey the land and water. The LSW stated that Resident #1 had made an attempt to leave the facility on [DATE] when he left out the front door by pushing the door open as another resident entered from the front porch. There were staff members and the receptionist with him and they eventually were able to talk resident into coming back into the building. The LSW stated that she updated the incidents on Resident #1's care plan and had obtained an evaluation at a geriatric psychiatric facility as a result of his exit attempt on [DATE]. The psychiatric facility came and picked Resident #1 up to transport him to the psychiatric facility and while in transit Resident #1 became combative and the transport van turned around and brought Resident #1 back to the facility on [DATE]. The LSW provided the care plan documentation outlining the events of [DATE] and [DATE]. The LSW verified that the facility staff had been attending in-services since the elopement attempt on [DATE]. The LSW stated that Resident #1 is active and strong bodied and walks several miles per day throughout the facility for exercise and he continues to believe he has a job. The LSW stated that Resident #1 had a diagnosis of frontal lobe traumatic brain injury and that he does not have the ability to reason and he does have a delusional thought process. The LSW stated that Resident #1 would better benefit on a locked unit with memory care. The LSW stated that the psychiatric facilities would not consent to admit Resident #1 because he would not give his consent for treatment. The LSW stated that Resident #1's family do not want Resident #1 to be discharged and the family does not come to visit the facility often but they do call Resident #1 and he does talk to family on the telephone. The LSW stated that the family was in agreement with his discharge to a locked unit with memory care. The LSW stated that Resident #1 will remain on 1:1 until his anticipated discharge on [DATE]. LSW stated that she updated the wandering information and high risk for elopement residents list and made sure that the books with their information were all updated and current as well as accessible to all staff. Interview and observation on [DATE] at 4:00 P.M. with Resident #1, revealed that he was sitting in his private room with his feet up in a reclining chair watching television. Resident was dressed in olive green cargo pants with black tennis shoes and a black t-shirt. Sitting across from Resident #1 in a chair with an over bed table was a Certified Nursing Assistant (CNA) charting on the resident every thirty (30) minutes. Resident #1 stated to surveyor that he was watching a preacher on the TV but was unable to recall what the preacher's name was or what the sermon was about. Resident's speech was pressured and rapid and he was talking about his resume' and his job interviews that he had arranged. Resident's thoughts were loose and his sentences were disconnected. He rapidly changed from subject to subject and his thought process was disconnected from his answers. The writings were not comprehendible. On [DATE] at 4:00 P.M. Resident #1 told surveyor that he needed to leave in order to get to work. Resident #1 presented as ambulatory and agile. Resident had an agenda and he expressed that he was leaving. Resident was unable to recall ever being in an accident. Resident said that his brain had been cut open and taken out and cleaned and sewed back in his head. Resident rambled on in a rapid and repetitive manner. Resident was oriented to self, but was not oriented to situation, time, place, or date. Interview on [DATE] at 5:30 P.M. with the evening Receptionist #1, revealed that she worked the front desk and was in charge of the front door exiting and entering. She worked Monday -Friday 5:00 P.M.-7:00 PM and she worked weekends 8:00 A.M. -7:00 P.M. She stated that she was at the front desk on [DATE] at approximately 6:00 P.M. when Resident #1 attempted to leave the facility. She stated that she attempted to hold the door shut when Resident #1 pushed her and the door open. Resident #1 got out on the front porch but staff were able to distract him and coax him back in to the building. She stated that Resident #1 walked constantly and that he walked approximately ,d+[DATE] miles per day throughout the facility. Interview on [DATE] at 7:07 P.M. with Registered Nurse (RN#1). She stated that she was the supervisor for the night shift at the facility on [DATE] when Resident #1 eloped. She stated that there were plenty of staff in the building and that the unit that housed Resident #1 contained three (3) CNA's and two (2) LPN's and one (1) RN supervisor. She stated that she was called to report Resident #1 was missing at approximately 2:00 A.M. on [DATE]. She stated that she saw the window in his room removed from the frame and the screen broken out and Resident #1 was no where in the facility. The entire staff immediately began searching for Resident #1. RN#1 stated that she was at the facility when Resident #1 was returned on [DATE] at approximately 7:00 A.M. RN #1 stated that the weather conditions on [DATE] were rainy and hot. RN #1 stated that Resident #1 had a fixed delusion that he was going to leave and go to work. When Resident #1 returned to the facility she assessed him and other residents. RN#1 began in-services with staff on [DATE]. All residents were accounted for and unharmed. Interview on [DATE] at 8:55 A.M. with Registered Nurse (RN#3) revealed she was responsible for compiling the care plans for all the residents along with the LSW. She stated that she and the LSW revised and updated Resident #1's care plan. She stated that all staff have access to the care plans and that the care plan information was available to the CNA's through the care giver guide that the CNA's maintained on each unit. RN#3 confirmed that after the failed elopement attempt of Resident #1 on [DATE] the care plan was updated and after his combative episode on the transportation van, the Care Plan of Resident #1 was updated and again after the elopement on [DATE] the Care Plan of Resident #1 was updated. Interview on [DATE] at 9:15 A.M. with Maintenance revealed that he was called to the facility on [DATE] in the early morning hours and told that Resident #1 had left the facility through the window of his room. He came to the facility at approximately 2:30 A.M. and assisted with the search of Resident #1. The weather was rainy and visibility was poor. The maintenance man was surprised to see the window taken out of the frame and the screen bent back. Maintenance stated that he never would have thought that someone would be able to remove the window from the frame and leave the facility. Maintenance stated that Resident #1 was brought back to the facility between 6:00 A.M. and 7:00 A.M. on [DATE]. Maintenance had placed the window back and screwed the frame into the wall preventing the window to slide out of its track. Resident #1 was placed on 1:1 with staff at his side ,d+[DATE]. Interview on [DATE] at 9:30 A.M. with Licensed Practical Nurse (LPN #1) revealed that she had worked at the facility for about four (4) years as the night LPN. She stated that Resident #1 would wake up during the night several times and come up to the nursing station asking for snacks to eat. LPN #1 stated that she thought it odd that he had not been up to the desk asking for his snacks so about 2:00 A.M. she took a snack to Resident #1's room and found him gone and the window removed. LPN #1 stated that there were plenty of staff working at the facility on [DATE] during the evening shift. LPN #1 called the ADM and DON and the Resident's Representative and the nurse practitioner to report the elopement. LPN #1 stated that CNA #1 had reported seeing Resident #1 in his bed sleeping at approximately 12:30 A.M. and that CNA #1 was the last person to see him. LPN #1 stated that Resident #1 was returned to the facility at approximately 6:30 A.M. on [DATE] with the ADM and the DON. The local Sheriff 's office had found Resident #1. It was approximately 5.5 hours that Resident #1 was reported to be missing from the facility. No one saw him leave and no one knew what time it was when he eloped. Interview and observation on [DATE] at 2:30 P.M. with Receptionist #2 of the front desk and front door of the facility revealed that she sits at the front desk monitoring the front door from 8:00 A.M. - 5:00 P.M. Monday through Friday and she had the high risk for elopements book at the desk with her and she knew the names and faces of all six (6) residents on the list. Receptionist #2 showed surveyor the high risk for elopement binder with all the information on all six (6) wanderers. The wander guard system was tested with a wander guard and it sounded loudly when it reached the front door. Wander guard system intact and working properly. The front door was observed to be locked and the Receptionist #2 was observed to push a button or use a code on a punch pad to open the door to let visitors and residents and staff in and out. No resident was observed to use the punch pad entering a code to release the door. Only staff were observed using the punch pad to enter and exit. Record review of the Face Sheet of Resident #1 revealed that he had an admitted to the facility of [DATE]. Resident #1's admitting diagnoses were Traumatic Subdural Hemorrhage without loss of Consciousness; Epilepsy; Frontal Lobe and Executive Function Deficit; Mild Cognitive Impairment; Confusion Arousals; Difficulty Walking; Lack of Coordination; Muscle Weakness; among other diagnoses. Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated he was not cognitively impaired. Record review of the facility's assessment for Risk of Elopement dated [DATE], [DATE], and [DATE] revealed that Resident #1 was assessed as a High risk for Wandering. Record review of the psychiatric Nurse Practitioner's assessment of Resident #1 dated [DATE] revealed: Resident is referred by staff for severe confusion, delusions, and wandering/leaving facility. The note indicated Multiple redirections required throughout visit but thoughts return to severe delusions .I cannot recommend that 1:1 observation be discontinued at this time as risk of elopement remains high. Recommendations: Add diagnosis of Vascular Dementia with Psychotic disturbance. Record review of the care plan for Resident #1 dated [DATE] revealed that he was care planned as at high risk for elopement/wanderer r/t (in reference to) that he wanders aimlessly throughout the facility. Interventions on the care plan documented on [DATE] Resident presented with exit seeking behaviors, Resident continues attempts to elope. Wander evaluation scored as high risk. [DATE] While a resident was entering the building, this resident pushed the receptionist and exited the building. Staff remained with resident the entire time. Resident refused to come back in the door. Resident sat on bench accompanied by nurse after calming down. [DATE] -SW was notified the resident was unable to receive treatment from Freedom behavior due to the resident being combative and transportation having to stop during transport. Encourage me to participate in activities; Observe for signs of agitation, pacing, repetitive verbalizations of wanting to leave/go home, restlessness. IJ Removal Plan On [DATE] at 2:00 P.M. the State Agency (SA) notified the facility Administrator of Immediate Jeopardy (IJ). State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. Facility respectfully submits this removal plan. Brief Summary of Events On [DATE] at approximately 2:00 A.M. it was discovered that Resident # 1 exited the building through his window by disassembling the window from the frame. Resident #1 had a wander guard on which he removed prior to exiting. The wander guard was properly functioning but does not alarm when removed nor if exiting through a window or other means of egress. The facility failed to provide supervision to prevent the elopement of Resident # 1, who was deemed an elopement risk and left the facility unattended. This failure allowed Resident # 1 to be away from the facility unnoticed and unsupervised on [DATE] from 12:30 A.M. until 5:44 A.M., when the facility was alerted by the Sheriff's department that the resident had been located. This was approximately 5.5 hours after Resident #1 was last observed in the facility by Certified Nursing Assistant (CNA) #1. The facility picked up Resident #1 at the local sheriff dispatch office at 5:51 A.M. Corrective Actions 1. On [DATE] at 2:00 A.M., LPN (Licensed Practical Nurse) #1 made rounds and Resident #1 was not present in his room and his window was disassembled. 2. On [DATE] at 2:02 A.M., LPN #1 initiated a facility elopement drill. Resident #1 was not located in the facility and all residents were accounted for. 3. On [DATE] at approximately 2:19 A.M., the Administrator was notified by LPN #1 of Resident #1 missing from facility. 4. On [DATE] at approximately 2:24 A.M., the Director of Nurses was notified by the Administrator of Resident #1 missing from the facility. 5. On [DATE] at approximately 2:25 A.M., the local Police Department was notified by RN (Registered Nurse) Supervisor #1 of Resident #1 missing from the facility. 6. On [DATE] at approximately 5:44 A.M., the facility Administrator was notified by the Sheriff Department that Resident #1 had been located. 7. On [DATE] at approximately 5:51 A.M., the Administrator and Director of Nurses picked up Resident #1 at local dispatch office. 8. On [DATE] at approximately 6:00 A.M., the RN (Registered Nurse) Supervisor #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns. Resident #1 had no negative skin issues or concerns. 9. On [DATE] at about 6:00 A.M., the DON oversaw verification of all residents in facility using census. The census in the facility was 149 with 2 residents in the hospital. All 149 residents were accounted for or verified. 10. On [DATE] at approximately 6:15 A.M., Resident #1 was placed on 1:1 monitoring. 11. On [DATE] at approximately 6:15 A.M., the wander guard bracelet was verified to work properly by checking function with door alarm by DON, and then placed on Resident #1's left wrist. 12. On [DATE] at approximately 6:20 A.M., the facility staff was interviewed by the Administrator to determine the timeline of events leading up to Resident #1's exit of facility. Statements were collected. 13. On [DATE] at approximately 6:30 A.M., staff present in the facility during the time of Resident #1 exit, received immediate in-service by the DON and Administrator on the Elopement procedures, Abuse/Neglect, Vulnerable Adult Act and Rounding. 14. On [DATE] at approximately 6:40 A.M., all required state agencies were notified of Resident #1 elopement. 15. On [DATE] at approximately 7:00 A.M., Maintenance assessed Resident # 1's window. Window glass appeared intact and window stopper in place. Maintenance reassembled window and inserted additional safety mechanisms to prevent window from being disassembled in the future by Resident #1. 16. On [DATE] approximately 7:15 A.M., the LPN #1 initiated facility-based incident reporting on Resident #1. 17. On [DATE] at about 7:20 A.M., Maintenance initiated an audit of all 1st floor windows to ensure they are intact and functioning properly. All windows were intact and functioning properly. Maintenance initiated adding additional safety mechanisms to prevent window from being disassemble from frame. 18. On [DATE] at approximately 07:27 A.M., the Nurse Practitioner (NP) was notified by the RN Supervisor #1 of Resident #1 elopement and return to the facility. 19. On [DATE] at approximately 07:27 A.M., Resident #1 Responsible Party was notified by the Administrator that Resident #1 had been returned to the facility. 20. On [DATE] at approximately 08:36 A.M., licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs. 21. On [DATE] at 7:04 P.M., the DON completed a post Elopement incident. Resident #1 remains high risk for Elopement. 22. On [DATE] at approximately 08:21 A.M., the Social Services Director followed up on resident's psychosocial needs and will continue for the next 72 hours. 23. On [DATE] at approximately 12:00 P.M., the Social Services Director reviewed the wander and elopement binders to ensure all are reflective of results. 24. On [DATE] at approximately 12: 43 P.M., Resident #1 was assessed by Psychiatric NP. 25. On [DATE] at approximately 2:00 P.M., a Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Director of Nursing/Infection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction. 26. On [DATE] at approximately 6:00 P.M., the Assistant Director of Nursing audited current high-risk wander patients to review orders and care plans for accuracy. There are currently six (6) wander patients. 27. On [DATE] at approximately 7:25 P.M., the RN Supervisor #2 performed an elopement drill to review and educate night shift on policies and procedures on elopement. 28. On [DATE] at approximately 11:15 P.M., the RN Supervisor # 1 performed an elopement drill to review and educate evening shift on policies and procedures on elopement. 29. The facility could not anticipate that the resident would dissemble his window and leave the facility. The facility feels like the IJ's were removed on [DATE]. The facility alleged that all activities to remove the IJ were completed on [DATE] prior to the SA entering the building on [DATE]. State Agency (SA) Validations were made onsite during the complaint investigation, CI MS #25237. On [DATE], the SA validated through interviews and record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on [DATE] prior to the SA entering the building on [DATE].

Based on staff interview, record review, and facility policy review the facility failed to revise the care plan for a severely cognitively impaired resident who eloped from the facility for one (1) of nine (9) sampled residents. (Resident #1) The SA identified an Immediate Jeopardy (IJ) which began 3/31/24 when the facility allowed Resident #1 to exit the facility unsupervised and was found approximately eight-tenths of a mile from the facility by police. He was away from the facility for 81 minutes. The facility's failure to provide supervision resulted in elopement and places cognitively impaired residents at risk, and in a situation which was likely to cause serious injury, harm, impairment, or death. On 4/3/24 at 5:31 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and provided the IJ Template. The facility provided an acceptable Removal Plan on 4/4/24, in which the facility alleged all corrective actions were completed to remove the IJ on 4/4/24. The State Agency (SA) validated the Removal Plan on 4/5/24 and determined the IJ was removed on 4/5/24, prior to exit, and the scope and severity for 42 CFR 483.21 (b)(2) Care Plan Timing and Revision (F657) was lowered from a J to a D, while the facility monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Resident #1 Cross reference F 689 Review of facility policy titled Care Plans, Comprehensive Person-Centered, reviewed January 2023, revealed, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Care plans are revised as information about the residents and the residents' conditions change. Record review of Resident #1's Care Plan, with latest revision 11/02/23, revealed the resident likes to leave/sign out Leave of Absence (LOA) for personal outings. The Care Plan goal read, I will exhibit understanding and recognition of risk vs benefits while signed out LOA through next review date. A record review of the facility investigation revealed on 3/31/24 at approximately 8:30 PM, the Director of Nursing (DON) contacted the Administrator and stated the police had Resident #1 on (Formal Name of street in the community). The Administrator contacted the Interim DON, who was at the facility, to verify that Resident #1 was not in the facility. She confirmed that he was not. The facility driver was contacted and dispatched to pick up Resident #1 who remained under the supervision of the police officer until pick up. Resident #1 returned to the facility at 9:29 PM. Resident #1 was assessed by Interim DON with no injuries noted. An updated wander assessment was completed by the Administrator and Interim DON to reflect new behavior. The Administrator verified that the wander guard was working and placed the bracelet on the left wrist of Resident #1. Upon staff interviews and review of camera footage, the facility noted Resident #1 exiting the facility at 7:25 PM when an agency Licensed Practical Nurse (LPN) opened the door for him. When questioned by the Administrator, the LPN stated that she thought he was going to sit on the front porch. Resident #1 was admitted on [DATE] the facility with diagnoses including Epilepsy and Dependence on a wheelchair. In an interview with Licensed Practical Nurse #2 (LPN) at 8:35 AM on 4/3/24, she verified that in the past Resident #1 did go on Leave of Absence (LOA) outside the facility without supervision, but the facility staff no longer allowed him to go out unsupervised due to his confusion. LPN #2 was unsure when the facility stopped letting him go on leave of absence (LOA) by himself, but verified it was prior to 3/31/24. On 4/3/24 at 1:30 PM, during an interview with the Assistant Director of Nursing (ADON), she verified that Resident #1's most recent Brief Interview for Mental Status (BIMS) score on 2/22/24 was a five (5), indicating severe cognitive impairment and that he was not safe to go LOA by himself. During an interview with the Social Worker (SW) on 4/3/24 at 1:46 PM, she stated that once Resident #1's cognition declined, and his BIMS was less than 12 he was no longer safe to go LOA by himself . The SW verified that the resident's BIMS was five (5) on 2/22/24, indicating severe cognitive impairment. The SW verified Resident #1's care plan did not reflect that he could not go LOA by himself. She stated that based on Resident #1's care plan, staff could allow Resident #1 LOA by himself. She agreed that his care plan should have been updated to reflect that he was no longer safe to go LOA by himself when his BIMS score fell below 12 and verified that it was not updated until 4/1/24 after the resident left the building unsupervised. In an interview with Interim Director of Nursing (DON) on 4/4/24 at 9:45 AM, she agreed Resident #1's care plan should have been updated at the time he was determined to no longer be safe to go LOA unsupervised. Record review of the Admission Record for Resident #1 revealed that the facility admitted the resident on 11/8/21 with a diagnosis of Epilepsy. Removal Plan On 3/31/2024 at approximately 9:35 PM the interim Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns. Resident #1 had no negative skin issues or concerns. On 3/31/2024 at about 10:30 PM, the Interim DON oversaw verification of all residents in facility using census with only one resident out of the facility and currently in the hospital. The census in the facility was 140. On 3/31/2024 at approximately 10:30 PM, staff present in the facility during the time of Resident #1 exit received immediate in-service by the Interim DON and Administrator on the procedures with residents signing out to exit facility to include verification of BIMS (Brief Interview for Mental Status). On 3/31/2024 at approximately 1030 PM, the Interim DON and Administrator initiated servicing with all staff present on Abuse, Neglect, Resident Rights, Vulnerable Adult, and Wandering. Staff Development will continue In-Servicing. No staff will be allowed to return to work without completing. On 3/31/2024 at approximately 10:40 PM, Resident #1 wandering evaluation was reviewed by Interim Director of Nursing and indicated low risk for wandering. Resident #1 wandering evaluation was updated by the Interim DON and Administrator on 3/31/2024. On 3/31/2024 at approximately 10:40 PM, the wander guard bracelet was verified to work properly by checking function with door alarm by Administrator, and then placed on Resident #1's left wrist. On 3/31/2024, the facility camera was reviewed by the Administrator to determine the timeline of events leading up to Resident #1 exit of facility. On 3/31/24 at 10:45 PM, the Administrator interviewed staff present of Resident #1 leaving the facility unattended. The agency LPN who held the door open stated that she was not aware he could not leave the facility. On 3/31/2024 at approximately 11:05 PM, the Mississippi State Department of Health was notified of Resident #1 elopement. On 3/31/2024 at approximately 11:09 PM, the Nurse Practitioner (NP) was notified by the Administrator of Resident #1 elopement and return to facility. On 3/31/2024, licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs. On 4/01/2024 approximately 12:30 AM, the LPN #1 initiated facility-based incident reporting on Resident #1. On 4/01/2024 approximately 10:00 AM, the Corporate Clinical Specialist (CCS) initiated an audit of the wander risk evaluations on all 140 active residents. Results indicated twelve (12) residents requiring updates to the wander system. All updates were corrected on 4/1/2024. On 4/1/2024 at approximately 10:30 AM, the Social Services Director updated the wander and elopement binders to ensure all are reflective of results. On 4/01/2024 at approximately 11:00 AM, the Maintenance Supervisor checked all wander guards to verify all were in correct working order with no issues found. On 4/1/2024 at approximately 11:19 AM, the NP placed orders for Resident to obtain Urinalysis, Comprehensive Metabolic Panel, and Complete Blood Count. On 4/01/2024 at approximately 1:46 PM, the Administrator performed an elopement drill to review and educate day shift on policies and procedures on elopement. On 4/01/2024 at approximately 2:00 PM, Social Services completed a BIMS on Resident #1 which resulted in moderate cogitative impairment of a 9. On 4/1/2024 at approximately 2:00 PM, a Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/lnfection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction. On 4/01/2024 at approximately 3:11 PM, Resident # 1 was assessed by the NP no issues found and care plan was updated by interdisciplinary team to reflect changes in leave of absence status. On 4/01/2024 at approximately 11 P.M., the Registered Nurse Supervisor #1 performed an elopement drill to review and educate night shift on policies and procedures on elopement. On 4/2/2024 at about 11:30 PM, the Interim DON and Administrator Assistant performed an elopement Drill and educated staff on day shift. On 4/2/2024 at approximately 3:30 PM, the Administrator Assistant developed an orientation binder for all agency' staff onboard to be in-se Nice on facilities policies and procedures to include wandering, elopement, where to find if a resident is allowed to out leave of absence, and appointment guidelines. On 4/03/2024 at approximately 11:00 AM, NP reviewed results of labs ordered and placed an order for Levaquin 750 milligrams one by mouth at bedtime for 7 days related to Urinary Tract Infection to start on 4/3/2024 at 9:00 PM. Starting 4/3/2024, a current BIMS list will be in the leave of absence binder updated weekly or as needed by Social Services. All residents with BIMS under 12 will not be allowed to leave the facility without supervision. On 4/3/2024 at 5:50 PM., The final letter of investigation was sent to the Mississippi State Department of Health. On 4/3/2024 at 5:54 PM, the Attorney General was notified regarding the results of the Investigation. On 4/03/2024 at approximately 7:00 PM, the Administrator performed an elopement drill to review and educate evening shift on policies and procedures on elopement. On 4/4/2024 at approximately 8:30 AM, the Interim DON contacted Resident #2 general surgeon office to confirm phone for communication that is currently in their file and provide the facility contact information for any further communication. On 4/04/2024 at approximately 9:30 AM, Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility IJs. On 4/4/2024, an in-service was initiated by Staff Development Coordinator on leave of absence process and how to locate residents BIMS. No staff will be allowed to return to work without signing. On 4/4/2024 at approximately 11:00 AM, the Administrator held a one-to-one in-service with the Licensed Social Worker on Leave of Absences Care plans to include who can exit facility, supervision needed and process for a change in BIMS (Brief Interview for Mental Status). On 4/4/2024 at 12:44 PM, Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments. On 4/4/2024 at approximately 2:00 PM, Regional Case Mix conducted in-service with Minimum Data Set (MDS) to include implementation, Reviewing, Revising, and Resolving person-centered care plans. On 4/4/2024 at approximately 11:00 AM, An audit was initiated by Social Services Director on leave of absence care plans to ensure resident with impaired cognition receive adequate supervision. On 4/4/2024, the Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 4/04/2024 and the Immediate Jeopardy was removed. Validation: On 4/05/24, the SA validated through staff interviews, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): The SA verified through record review, that interim Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns on 3/31/24 at 9:35 PM. Resident #1 had no negative skin issues or concern. The SA verified through record review, the Interim DON oversaw verification of all residents in facility using census with only one resident out of the facility and currently in the hospital. The census in the facility was 140 on 3/31/24 at 10:30 PM. The SA verified through staff interview, sign-in sheets, and in-service reviews, on 3/31/2024 at approximately 10:30 PM, staff present in the facility during the time of Resident #1 exit received immediate in-service by the Interim DON and Administrator on the procedures with residents signing out to exit facility to include verification of BIMS (Brief Interview for Mental Status). The SA verified through staff interview, sign-in sheets, and in-service reviews, on 3/31/2024 at approximately 10:30 PM the Interim DON and Administrator initiated servicing with all staff present on Abuse, Neglect, Resident Rights, Vulnerable Adult, and Wandering. Staff Development will continue In-Servicing. No staff will be allowed to return to work without completing. The SA verified through staff interview and record review, on 3/31/2024 at approximately 10:30 PM Resident #1 wandering evaluation was reviewed by Interim Director of Nursing and indicated low risk for wandering. Resident #1 wandering evaluation was updated by the Interim DON and Administrator on 3/31/2024. The SA verified through staff interview and record review, the wander guard bracelet was verified to work properly by checking function with door alarm by Administrator, and then placed on Resident #1's left wrist on 3/31/24 at 10:40 PM. The SA verified through staff interview and record review, on 3/31/24 at 10:45 PM, the facility camera was reviewed by the Administrator to determine the timeline of events leading up to Resident #1 exit of facility. The SA verified through staff interview, staff interview and record review, on 3/31/24 at 10:45 PM the Administrator interviewed staff present of Resident #1 leaving the facility unattended. The agency LPN who held the door open stated that she was not aware he could not leave the facility. The SA verified through staff interview and record review, on 3/31/24 at 11:05 PM the SA was notified of Resident #1 elopement. The SA verified through record review, on 3/31/2024 at approximately 11:09 PM, the Nurse Practitioner (NP) was notified by the Administrator of Resident #1 elopement and return to facility. The SA verified through staff interview and record review, on 3/31/2024, licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs. The SA verified through record review, on 4/01/2024 approximately 12:30 AM, the LPN #1 initiated facility-based incident reporting on Resident #1. The SA verified through record review, on 4/01/2024 approximately 10:00 AM, the Corporate Clinical Specialist (CCS) initiated an audit of the wander risk evaluations on all 140 active residents. Results indicated twelve (12) residents requiring updates to the wander system. All updates were corrected on 4/1/24. The SA verified through staff interview and record review, on 4/1/2024 at approximately 10:30 AM, the Social Services Director updated the wander and elopement binders to ensure all are reflective of results. The SA validated through staff interview and record review that on 4/01/2024 at approximately 11:00 AM, the Maintenance Supervisor checked all wander guards to verify all were in correct working order with no issues found. The SA verified through record review, on 4/1/2024 at approximately 11:19 AM, the NP placed orders for Resident to obtain Urinalysis, Comprehensive Metabolic Panel, and Complete Blood Count. The SA verified through staff interview, record review, and sign-in sheets, on 4/01/2024 at approximately 1:46 PM, the Administrator performed an elopement drill to review and educate day shift on policies and procedures on elopement. The SA verified through record review, on 4/01/2024 at approximately 2:00 PM, Social Services completed a BIMS on Resident #1 which resulted in moderate cogitative impairment of a 9. The SA verified through staff interview, sign-in sheets, and record review, on 4/1/2024 at approximately 2:00 PM, a Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/lnfection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction. The SA verified through staff interview and record review, on 4/01/2024 at approximately 3:11 PM, Resident # 1 was assessed by the NP no issues found and care plan was updated by interdisciplinary team to reflect changes in leave of absence status. The SA verified through staff interview, and sign-in sheets, on 4/01/2024 at approximately 11 P.M., the Registered Nurse Supervisor #1 performed an elopement drill to review and educate night shift on policies and procedures on elopement. The SA verified through staff interview and sign-in sheets, on 4/2/2024 at about 11:30 PM, the Interim DON and Administrator Assistant performed an elopement Drill and educated staff on day shift. The SA verified through record review on 4/03/2024 at approximately 11:00 AM, NP reviewed results of labs ordered and placed an order for Levaquin 750 milligrams one by mouth at bedtime for 7 days related to Urinary Tract Infection to start on 4/3/2024 at 9:00 PM. The SA verified through staff interview and record review, starting 4/3/2024, a current BIMS list will be in the leave of absence binder updated weekly or as needed by Social Services. All residents with BIMS under 12 will not be allowed to leave the facility without supervision. The SA verified through record review, on 4/3/2024 at 5:50 PM, the final letter of investigation was sent to the SA. The SA verified through record review, on 4/3/2024 at 5:54 PM, the Attorney General was notified regarding the results of the investigation. The SA validated through interview and record, on 4/03/2024 at approximately 7:00 PM, the Administrator performed an elopement drill to review and educate evening shift on policies and procedures on elopement. The SA verified through staff interview, sign-in sheets, and in-service reviews, on 4/4/2024, an in-service was initiated by Staff Development Coordinator on leave of absence process and how to locate residents BIMS. No staff will be allowed to return to work without signing. The SA verified through record review on 4/4/2024 at approximately 11:00 AM, an audit was initiated by Social Services Director on leave of absence care plans to ensure resident with impaired cognition receive adequate supervision. The SA verified through staff interview, sign-in sheets, and in-service reviews and record review on 4/4/2024 at approximately 11:00 AM, the Administrator held a one-to-one in-service with the Licensed Social Worker on Leave of Absences Care plans to include who can exit facility, supervision needed and process for a change in BIMS (Brief Interview for Mental Status). The SA verified through record review on, 4/2/2024 at approximately 3:30 PM, the Administrator Assistant developed an orientation binder for all agency' staff onboard to be in-serviced on facilities policies and procedures to include wandering, elopement, where to find if a resident is allowed to out leave of absence, and appointment guidelines. The SA verified through resident interview and sign in sheets, on 4/04/2024 at approximately 9:30 AM, Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility received IJs. The SA verified through staff interview, sign-in sheets, and in-service reviews on 4/04/2024 at approximately 10:00 AM, the Staff Development initiated in-servicing with all licensed nurses, transportation, front desk receptionist on communication with appointments to include the process with signing resident in and out of facility, the daily transportation log along with the sign out binder. Inservice also includes adding a step to the appointment communication process with Admission Coordinator to review the communication tab within the electronic records to ensure all appointments are listed. No staff have been allowed to return to work without completing. The SA verified through staff interview and sign-in sheet, on 4/4/2024 at 12:44 PM, Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments. The SA verified through staff interview and record review, on 4/4/2024 at approximately 2:00 PM, Regional Case Mix conducted in-service with Minimum Data Set (MDS) to include implementation, Reviewing, Revising, and Resolving person-centered care plans. The SA verified through staff interview, sign-in sheets, and in-service reviews on 4/4/2024, the Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents. On 4/05/24, the SA validated that all corrective actions had been taken by the facility to remove the IJ on 4/04/24 and the IJ was removed on 4/05/24. Surveyor: [NAME], Shelbie 47158

Based on staff and resident interviews, record review and facility policy review, the facility failed to provide supervision to prevent the elopement of a resident who was severely cognitively impaired for one (1) of five (5) residents reviewed. Resident #1. The facility failed to provide supervision to prevent the elopement of Resident #1, who was severely cognitively impaired and left the facility unattended. This failure allowed Resident #1 to be away from the facility unnoticed and unsupervised on 3/31/24 from 7:25 PM until 8:41 PM, when the facility was alerted that the resident was seen in the community, approximately eight-tenths (0.8) of a mile from the facility. This was approximately 81 minutes after Resident #1 was last observed in the facility. The facility's failure to provide supervision resulted in Resident #1's elopement and has the likelihood to result in serious harm, serious injury, serious impairment, or death for Resident #1 and all other cognitively impaired residents who leave the facility unsupervised. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 3/31/24 when a severely cognitively impaired resident left the facility unsupervised. The facility Administrator was notified of the IJ by the SA on 4/3/24 at 5:31 PM and provided the IJ Template. The facility provided an acceptable Removal Plan on 4/4/24, in which the facility alleged all corrective actions were completed to remove the IJ. The SA validated the Removal Plan and determined the IJ was removed on 4/5/24, prior to exit, and the scope and severity for 42 CFR(s) 483.25(d)(1)(2) Free of Accidents Hazard/supervision/devices (F689) was lowered from a J to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of a statement, on facility letterhead, dated 4/4/24, and signed by the Administrator, revealed that the facility does not have a policy related to resident leave of absence. Review of the facility's policy titled, Wanderer Management, Monitoring System & Resident Elopement Protocol revealed, Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible . Record review of the Brief Interview for Mental Status (BIMS), dated 2/22/24 revealed Resident #1 had a score of five (5) indicating severe cognitive impairment. During an interview with Licensed Practical Nurse #2 (LPN) at 8:35 AM on 4/3/24, she stated that in the past Resident #1 did leave the building by himself, but they no longer let him do that due to his confusion. She could not remember when they stopped letting him go on leave of absence (LOA) by himself, but verified it was prior to 3/31/24. She stated she did not know how the facility communicated that a resident was not supposed to go LOA by themselves. In an interview with Resident #1 on 4/3/24 at 9:30 AM, he stated he remembered going outside on 3/31/24. He stated he just wanted to get some air. He denied having the exit code and stated he just went out the door. Resident #1 would not answer any further questions. In an interview with the Interim DON on 4/3/24 at 12:01 PM, she stated she arrived at the facility on 3/31/24 at 7:30 PM but did not see Resident #1 outside. She stated that around 8:30 PM the floor nurse asked her if she had seen Resident #1. She stated she went downstairs but the resident was not there. She stated that around 8:41 PM she received a call from the Administrator notifying her that the police had located the resident in the community. She stated that the resident was returned to the facility at 9:30 PM. She performed an assessment at that time and the resident had no injuries. She stated that the resident was wearing long jean pants, long sleeve pullover sweatshirt, tennis shoes and a cap. During a telephone interview with Police Officer #1 on 4/3/24 at 1:06 PM, he verified that on 3/31/24 he received a call from dispatch that a man in a wheelchair was seen in the middle of the street near (Proper Name of apartment complex). He said when he arrived the person was already gone. Officer #1 stated at that time he received a second call that a man in a wheelchair was seen at the intersection of (Proper Name of streets )where he located the resident. He stated the facility sent someone to pick the resident up. In an interview with the Administrator on 4/3/24 at 1:16 PM, she stated that she watched the surveillance camera footage for 3/31/24 and she saw that an agency nurse let Resident #1 outside at 7:25 PM. During an interview with LPN #1 on 4/3/24 at 1:24 PM, she verified that at 7:20 PM on 3/31/24 the resident was downstairs by the elevator, she asked him where he was going, and he stated nowhere so she went back upstairs. LPN # 1 stated around 8:30 PM she arrived at Resident #1's room, and he was not in the room. She notified the DON that she had not seen the resident since she was downstairs at 7:20 PM. She stated the DON went downstairs to look for the resident and at around 9:15 PM the DON told her that the resident had been found in the community by the police. During an interview with the Assistant Director of Nursing (ADON) on 4/3/24 at 1:30 PM, she verified that Resident #1's last BIMS score on 2/22/24 was a 5, indicating severe cognitive impairment and that he was not safe to go LOA by himself. She agreed that the facility did not have anything in place to ensure effective communication that the resident was not safe to go LOA by himself, but that they should have something in place. During an interview with the Social Worker (SW) on 4/3/24 at 1:46 PM, she stated that once Resident #1's cognition declined, and his BIMS was less than 12 he was no longer safe to go LOA by himself. She stated that residents must have a BIMS of 12 or higher to go LOA by themselves because of potential problems. She verified that Resident #1's BIMS on 2/22/24 was 5, indicating severe cognitive impairment and he was no longer safe to go outside the facility by himself. In an interview with Registered Nurse# 1 (RN) on 4/3/24 at 3:10 PM, she stated that due to Resident #1's increased confusion he was not safe to go LOA by himself. She stated that this information is communicated verbally during the report, and there is no written communication provided. In an interview with Certified Nursing Assistant (CNA) #1 on 4/3/24 at 3:15 PM, she stated that she does not know which residents can or cannot go LOA by themselves. During a telephone interview conducted with the Administrator on 4/3/24 at 3:27 PM, she stated she was notified Resident #1 was not in the facility on 3/31/24 at 8:30 PM, when the DON called informing her that he was seen by a witness in the community. She stated that she then contacted the facility and notified them of the resident's whereabouts and called the van driver to pick the resident up. During a telephone interview with the Van Driver on 4/3/24 at 3:46 PM, he verified the location in the community where he picked up Resident #1 on 3/31/24 at approximately 9:20 PM. During a telephone interview with LPN #3 on 4/5/24 at 11:00 AM, she verified on 3/31/24 Resident #1 was at the front door of the facility attempting to exit. She stated that she really did not know who the resident was. She stated that she thought he was just going to sit on the porch. LPN #3 stated that she was not aware that Resident #1 was not allowed to go out by himself. She stated there was no communication in place that informed her what residents could or could not leave the building unattended. Record review of Past Weather in (Name of City) dated 3/31/24 revealed that sunset was at 7:22 PM and it was 55 degrees Fahrenheit (F) from 7:30 PM to 9:30 PM with no precipitation. Record review of Google Maps revealed that the address where Resident #1 was located was eight-tenths (0.8) of a mile from the facility. Record review of the Admission Record for Resident #1 revealed that the facility admitted the resident on 11/8/21 with diagnoses including Epilepsy. A record review of the facility investigation revealed Resident #1 was admitted on [DATE] the Facility with diagnoses including Epilepsy and Dependence on a wheelchair. On 3/31/24 at approximately 8:30 PM, Director of Nursing (DON) contacted the Administrator and stated the police had Resident #1 on (Formal Name of street in the community). The Administrator contacted the Interim DON ,who was at the facility, to verify that Resident #1 was not in the facility. She confirmed that he was not. The facility driver was contacted and dispatched to pick up Resident #1 who remained under the supervision of the police officer until pick up. Resident #1 returned to the facility at 9:29 PM. Resident #1 was given a head-to-toe assessment by Interim DON with no injuries noted. An updated wander assessment was completed by Administrator and Interim DON to reflect new behavior. The Administrator verified that the wander guard was working and placed the bracelet on the left wrist of Resident #1. Upon staff interviews and review of camera footage, Resident #1 noted exiting the facility at 7:25 PM when the agency Licensed Practical Nurse (LPN) opened the door for him. When questioned by the Administrator she stated that she thought he was going to sit on the front porch. The Administrator educated LPN on the fact that residents are required to sign out even if they are sitting on the porch. Resident #1 is his own responsible party. The Medical Director and Nurse Practitioner were also notified. Prior to this incident Resident #1 was not deemed a wander risk due to no previous exit seeking behavior and a previous wander assessment completed on 2/1/24 placed him at low risk for wandering. Resident #1's care plan was reviewed and updated by the interdisciplinary team to include new wander behaviors. The Wander Binder was updated to reveal new behavior. In services began on 3/31/24 on Abuse and Neglect, Resident's Rights, MS (Mississippi) Vulnerable Adult Act, and Elopement. A binder was started and placed at each nurse's station for Orientation Procedure. An Ad hoc Quality Assurance (QA) meeting was held on 4/1/2024 with the Medical Director, Interdisciplinary team to discuss events along with plan of correction. Social Services to follow up as needed for any physical, mental, or psychosocial needs. The labs obtained revealed the resident has a Urinary Tract Infection (UTI) and his treatment has been started. The resident remains his own Responsible Party but due to his variations in health status, and for process improvement the staff was in serviced to ensure BIMS (Brief Interview for Mental Status) verification is obtained along with the resident signing out prior to exit from facility. In conclusion, abuse and/or neglect by the facility could not be substantiated. Observation based on the reported sightings of the resident on 3/31/24 there were three (3) possible routes Resident #1 could have taken when he left the facility. On 4/3/24 at 6:00 PM, the SA retraced the possible routes that Resident #1 could have taken revealed that all routes were dimly lit with ditches and large culverts on the sides of the roads, as well as railroad tracks on all three (3) routes. All routes were eight-tenths (0.8) of a mile from the facility. Record review of the Incident Report from local police department revealed On 3-31-24, I (Proper Name of officer) was dispatched at 8:12 PM to look for a subject in front of (Proper Name of apartment complex) in a wheelchair in the middle of the roadway. I arrived on the scene at 8:16 PM. Upon my arrival, I did not see anyone in a wheelchair in the roadway. I rode around the apartment complex and still didn't see a subject in a wheelchair. I went back in service at 8:20 PM. I received another call at 8:27 PM about a male subject in the roadway on (Proper name of Street) near (Proper Name of street). I arrived on the scene at 8:28 PM. I came into contact with (Proper Name of Witness) she was following the male subject in her car so no one would run over him. We came to a stop near (Proper Name of Street). I came into contact with the male subject (Proper name of Resident #1) who was in a wheelchair. I asked if he was ok. He advised that he was ok and that he was just going home. There was a lady who lived next to where we were she called (Proper name of Facility) and talked to the director. I advised that I was calling Emergency Medical Services (EMS) to transport (Proper Name of Resident #1) back to the facility. The director advised that they were going to send a van to pick up (Proper Name of Resident #1). Record review of a facility Behavior Note dated 3/31/2024 at 9:30 PM, revealed This nurse got off the elevator to go get supplies at 7:20 PM on another unit. This nurse passed the resident sitting in wheelchair downstairs in hallway by the social worker's office door and asked, Where are you going? Resident answered, No where. This nurse said OK and proceeded to go get supplies on Annex unit. This nurse then went back up to her unit on the 2nd floor and started the med pass. When this nurse reached the resident room around 8:30 PM the resident was not in his room. DON was on the unit and this nurse asked if she had seen the resident. This nurse stated that the resident was downstairs earlier and is usually back in bed by now. DON (Formal Name of DON) stated that she would go look for the resident. DON returned at 9:15 PM and notified this nurse that the resident had left the building and was located near the police station. DON stated facility transportation was on the way to pick up the resident. Resident returned to unit per wheelchair around 9:30 PM with DON. Resident was assisted into bed and a head-to-toe assessment was performed by DON and this nurse. When asked why he left the building resident stated, I was going to my cousin house across the street to get my truck. Confusion noted. Resident received a wander guard for elopement monitoring to left wrist and placed on q (every) 15 minute checks for elopement risk while in bed. Administrator present in building. Facility Removal Plan On 3/31/2024 at approximately 9:35 PM the interim Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns. Resident #1 had no negative skin issues or concerns. On 3/31/2024 at about 10:30 PM, the Interim DON oversaw verification of all residents in facility using census with only one resident out of the facility and currently in the hospital. The census in the facility was 140. On 3/31/2024 at approximately 10:30 PM, staff present in the facility during the time of Resident #1 exit received immediate in-service by the Interim DON and Administrator on the procedures with residents signing out to exit facility to include verification of BIMS (Brief Interview for Mental Status). On 3/31/2024 at approximately 1030 PM, the Interim DON and Administrator initiated servicing with all staff present on Abuse, Neglect, Resident Rights, Vulnerable Adult, and Wandering. Staff Development will continue In-Servicing. No staff will be allowed to return to work without completing. On 3/31/2024 at approximately 10:40 PM, Resident #1 wandering evaluation was reviewed by Interim Director of Nursing and indicated low risk for wandering. Resident #1 wandering evaluation was updated by the Interim DON and Administrator on 3/31/2024. On 3/31/2024 at approximately 10:40 PM, the wander guard bracelet was verified to work properly by checking function with door alarm by Administrator, and then placed on Resident #1's left wrist. On 3/31/2024, the facility camera was reviewed by the Administrator to determine the timeline of events leading up to Resident #1 exit of facility. On 3/31/24 at 10:45 PM, the Administrator interviewed staff present of Resident #1 leaving the facility unattended. The agency LPN who held the door open stated that she was not aware he could not leave the facility. On 3/31/2024 at approximately 11:05 PM, the Mississippi State Department of Health was notified of Resident #1 elopement. On 3/31/2024 at approximately 11:09 PM, the Nurse Practitioner (NP) was notified by the Administrator of Resident #1 elopement and return to facility. On 3/31/2024, licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs. On 4/01/2024 approximately 12:30 AM, the LPN #1 initiated facility-based incident reporting on Resident #1. On 4/01/2024 approximately 10:00 AM, the Corporate Clinical Specialist (CCS) initiated an audit of the wander risk evaluations on all 140 active residents. Results indicated twelve (12) residents requiring updates to the wander system. All updates were corrected on 4/1/2024. On 4/1/2024 at approximately 10:30 AM, the Social Services Director updated the wander and elopement binders to ensure all are reflective of results. On 4/01/2024 at approximately 11:00 AM, the Maintenance Supervisor checked all wander guards to verify all were in correct working order with no issues found. On 4/1/2024 at approximately 11:19 AM, the NP placed orders for Resident to obtain Urinalysis, Comprehensive Metabolic Panel, and Complete Blood Count. On 4/01/2024 at approximately 1:46 PM, the Administrator performed an elopement drill to review and educate day shift on policies and procedures on elopement. On 4/01/2024 at approximately 2:00 PM, Social Services completed a BIMS on Resident #1 which resulted in moderate cogitative impairment of a 9. On 4/1/2024 at approximately 2:00 PM, a Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/lnfection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction. On 4/01/2024 at approximately 3:11 PM, Resident # 1 was assessed by the NP no issues found and care plan was updated by interdisciplinary team to reflect changes in leave of absence status. On 4/01/2024 at approximately 11 P.M., the Registered Nurse Supervisor #1 performed an elopement drill to review and educate night shift on policies and procedures on elopement. On 4/2/2024 at about 11:30 PM, the Interim DON and Administrator Assistant performed an elopement Drill and educated staff on day shift. On 4/2/2024 at approximately 3:30 PM, the Administrator Assistant developed an orientation binder for all agency' staff onboard to be inserviced on facility's policies and procedures to include wandering, elopement, where to find if a resident is allowed to out leave of absence, and appointment guidelines. On 4/03/2024 at approximately 11:00 AM, NP reviewed results of labs ordered and placed an order for Levaquin 750 milligrams one by mouth at bedtime for 7 days related to Urinary Tract Infection to start on 4/3/2024 at 9:00 PM. Starting 4/3/2024, a current BIMS list will be in the leave of absence binder updated weekly or as needed by Social Services. All residents with BIMS under 12 will not be allowed to leave the facility without supervision. On 4/3/2024 at 5:50 PM., The final letter of investigation was sent to the Mississippi State Department of Health. On 4/3/2024 at 5:54 PM, the Attorney General was notified regarding the results of the Investigation. On 4/03/2024 at approximately 7:00 PM, the Administrator performed an elopement drill to review and educate evening shift on policies and procedures on elopement. On 4/4/2024 at approximately 8:30 AM, the Interim DON contacted Resident #2 general surgeon office to confirm phone for communication that is currently in their file and provide the facility contact information for any further communication. On 4/04/2024 at approximately 9:30 AM, Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility received Immediate Jeopardies. On 4/4/2024, an in-service was initiated by Staff Development Coordinator on leave of absence process and how to locate residents BIMS. No staff will be allowed to return to work without signing. On 4/4/2024 at approximately 11:00 AM, the Administrator held a one-to-one in-service with the Licensed Social Worker on Leave of Absences Care plans to include who can exit facility, supervision needed and process for a change in BIMS (Brief Interview for Mental Status). On 4/4/2024 at 12:44 PM, Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments. On 4/4/2024 at approximately 2:00 PM, Regional Case Mix conducted in-service with Minimum Data Set (MDS) to include implementation, Reviewing, Revising, and Resolving person-centered care plans. On 4/4/2024 at approximately 11:00 AM, An audit was initiated by Social Services Director on leave of absence care plans to ensure resident with impaired cognition receive adequate supervision. On 4/4/2024, the Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 4/04/2024 and the Immediate Jeopardy was removed 4/05/2024. Validation: On 4/05/24, the SA validated through staff interviews, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): Resident # 1 The SA verified through record review, that interim Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns on 3/31/24 at 9:35 PM. Resident #1 had no negative skin issues or concern. The SA verified through record review, the Interim DON oversaw verification of all residents in facility using census with only one resident out of the facility and currently in the hospital. The census in the facility was 140 on 3/31/24 at 10:30 PM. The SA verified through staff interview, sign-in sheets, and in-service reviews, on 3/31/2024 at approximately 10:30 PM, staff present in the facility during the time of Resident #1 exit received immediate in-service by the Interim DON and Administrator on the procedures with residents signing out to exit facility to include verification of BIMS (Brief Interview for Mental Status). The SA verified through staff interview, sign-in sheets, and in-service reviews, on 3/31/2024 at approximately 10:30 PM the Interim DON and Administrator initiated servicing with all staff present on Abuse, Neglect, Resident Rights, Vulnerable Adult, and Wandering. No staff have been allowed to return to work without completing. The SA verified through staff interview and record review, on 3/31/2024 Resident #1's wandering evaluation was reviewed by Interim Director of Nursing and indicated low risk for wandering. Resident #1 wandering evaluation was updated by the Interim DON and Administrator on 3/31/2024. The SA verified through staff interview and record review, the wander guard bracelet was verified to work properly by checking function with door alarm by Administrator, and then placed on Resident #1's left wrist. The SA verified through staff interview, staff interview and record review, on 3/31/24 at 10:45 PM the Administrator interviewed staff present of Resident #1 leaving the facility unattended. The agency LPN who held the door open stated that she was not aware he could not leave the facility. The SA verified through staff interview and record review, on 3/31/24 at 11:05 PM the SA was notified of Resident #1 elopement. The SA verified through record review, on 3/31/2024 at approximately 11:09 PM, the Nurse Practitioner (NP) was notified by the Administrator of Resident #1 elopement and return to facility. The SA verified through staff interview and record review, on 3/31/2024, licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs. The SA verified through record review, on 4/01/2024 approximately 12:30 AM, the LPN #1 initiated facility-based incident reporting on Resident #1. The SA verified through record review, on 4/01/2024 approximately 10:00 AM, the Corporate Clinical Specialist (CCS) initiated an audit of the wander risk evaluations on all 140 active residents. Results indicated twelve (12) residents requiring updates to the wander system. All updates were corrected on 4/1/24. The SA verified through staff interview and record review, on 4/1/2024 at approximately 10:30 AM, the Social Services Director updated the wander and elopement binders to ensure all are reflective of results. The SA validated through staff interview and record review that on 4/01/2024 at approximately 11:00 AM, the Maintenance Supervisor checked all wander guards to verify all were in correct working order with no issues found. The SA verified through record review, on 4/1/2024 at approximately 11:19 AM, the NP placed orders for Resident to obtain Urinalysis, Comprehensive Metabolic Panel, and Complete Blood Count. The SA verified through staff interview, record review, and sign-in sheets, on 4/01/2024 at approximately 1:46 PM, the Administrator performed an elopement drill to review and educate day shift on policies and procedures on elopement. The SA verified through record review, on 4/01/2024 at approximately 2:00 PM, Social Services completed a BIMS on Resident #1 which resulted in moderate cogitative impairment of a 9. The SA verified through staff interview, sign-in sheets, and record review, on 4/1/2024 at approximately 2:00 PM, a Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/lnfection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction. The SA verified through staff interview and record review, on 4/01/2024 at approximately 3:11 PM, Resident # 1 was assessed by the NP no issues found and care plan was updated by interdisciplinary team to reflect changes in leave of absence status. The SA verified through staff interview, and sign-in sheets, on 4/01/2024 at approximately 11 P.M., the Registered Nurse Supervisor #1 performed an elopement drill to review and educate night shift on policies and procedures on elopement. The SA verified through staff interview and sign-in sheets, on 4/2/2024 at about 11:30 PM, the Interim DON and Administrator Assistant performed an elopement Drill and educated staff on day shift. The SA verified through record review on 4/03/2024 at approximately 11:00 AM, NP reviewed results of labs ordered and placed an order for Levaquin 750 milligrams one by mouth at bedtime for 7 days related to Urinary Tract Infection to start on 4/3/2024 at 9:00 PM. The SA verified through staff interview and record review, starting 4/3/2024, a current BIMS list will be in the leave of absence binder updated weekly or as needed by Social Services. All residents with BIMS under 12 will not be allowed to leave the facility without supervision. The SA verified through record review, on 4/3/2024 at 5:50 PM, the final letter of investigation was sent to the SA. The SA verified through record review, on 4/3/2024 at 5:54 PM, the Attorney General was notified regarding the results of the investigation. The SA validated through interview and record, on 4/03/2024 at approximately 7:00 PM, the Administrator performed an elopement drill to review and educate evening shift on policies and procedures on elopement. The SA verified through staff interview, sign-in sheets, and in-service reviews, on 4/4/2024, an in-service was initiated by Staff Development Coordinator on leave of absence process and how to locate residents BIMS. No staff will be allowed to return to work without signing. The SA verified through record review on 4/4/2024 at approximately 11:00 AM, an audit was initiated by Social Services Director on leave of absence care plans to ensure resident with impaired cognition receive adequate supervision. The SA verified through staff interview, sign-in sheets, and in-service reviews and record review on 4/4/2024 at approximately 11:00 AM, the Administrator held a one-to-one in-service with the Licensed Social Worker on Leave of Absences Care plans to include who can exit facility, supervision needed and process for a change in BIMS (Brief Interview for Mental Status). The SA verified through record review on, 4/2/2024 at approximately 3:30 PM, the Administrator Assistant developed an orientation binder for all agency' staff onboard to be in-serviced on facilities policies and procedures to include wandering, elopement, where to find if a resident is allowed to out leave of absence, and appointment guidelines. The SA verified through resident interview and sign in sheets, on 4/04/2024 at approximately 9:30 AM, Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility received IJs. The SA verified through staff interview, sign-in sheets, and in-service reviews on 4/04/2024 at approximately 10:00 AM, the Staff Development initiated in-servicing with all licensed nurses, transportation, front desk receptionist on communication with appointments to include the process with signing resident in and out of facility, the daily transportation log along with the sign out binder. Inservice also includes adding a step to the appointment communication process with Admission Coordinator to review the communication tab within the electronic records to ensure all appointments are listed. No staff will be allowed to return to work without completing. The SA verified through staff interview and sign-in sheet, on 4/4/2024 at 12:44 PM, Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments. The SA verified through staff interview and record review, on 4/4/2024 at approximately 2:00 PM, Regional Case Mix conducted in-service with Minimum Data Set (MDS) to include implementation, Reviewing, Revising, and Resolving person-centered care plans. The SA verified through staff interview, sign-in sheets, and in-service reviews on 4/4/2024, the Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents. On 4/05/24, the SA validated that all corrective actions had been taken by the faci[TRUNCATED]

Based on dialysis center staff interviews, facility staff interviews, resident interview, record review, and facility policy review, the facility failed to ensure the right to be free from neglect when the facility failed to transport a dialysis resident to a scheduled surgical procedure to ligate (to tie up or close off an artery) an arteriovenous (AV) fistula scheduled on 03/21/24 resulting in the resident being admitted to the hospital on 03/22/24 with a bleeding aneurysm of the AV fistula requiring a blood transfusion with (4) four units of blood for one (1) of four (4) residents on dialysis reviewed. (Resident #2) The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 03/21/24, when the facility neglected to transport Resident #2 to his appointment for a scheduled surgical procedure. The facility's failure to transport this dialysis resident to the appointment placed this resident and other residents in a situation which was likely to cause serious injury, serious harm, serious impairment, or death. On 04/03/24 at 5:31 PM, the SA informed the Nursing Home Administrator (NHA) of the IJ and SQC and presented the IJ Template to the Administrator. The facility submitted a Removal Plan on 04/04/24, at 7:10 PM, in which the facility alleged all corrective actions to remove the IJ were completed on 4/04/2024 and the IJ removed as of 4/05/2024. The SA validated the Removal Plan on 04/05/2024 and determined the IJ was removed on 4/05/24, prior to exit; therefore, the scope and severity for Abuse and Neglect (F600) was lowered from a J to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled, Abuse Prohibition, revised 11/07/2023, revealed this protocol was intended to assist in the prevention of neglect. Each resident has the right to be free from neglect. Neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services that are necessary to a resident to avoid physical harm, mental anguish, or emotional distress. Review of a statement on facility letterhead dated 04/04/24 and signed by the Administrator revealed the facility has no policy related to appointments. Review summary of an anonymous complaint the State Agency (SA) received on 03/25/24, revealed Resident #2 is a dialysis patient who resides at the nursing home. Resident #2 needed a life sustaining surgery to prevent his dialysis access from rupturing causing an estimated (4) four-pint blood loss. The facility was made aware of the surgery date and time and reported they would take the resident to the surgery. Record review of the Hemodialysis communication form for Resident #2 dated 03/18/24, revealed, Follow-up includes: appointment on 03/19/24 at 12:00 PM to have catheter placement to femoral artery and surgery on Thursday 03/21/24 to have ligation of the access. Record review of an appointment card for Resident # 2 in the medical record, revealed date 03/21/24 Ligate Access. Time TBA (to be announced). Record review of nurse's notes by an agency Licensed Practical Nurse (LPN) #4 dated 03/18/24 at 3:45 PM, revealed Resident #2 arrived from dialysis, did not receive dialysis today due to condition of access site. Site is to be monitored. Resident has an appointment tomorrow (03/19/24) for a catheter placement. Record review of Nurses Notes for Resident #2, dated 03/22/24 at 6:25 AM, revealed the resident noted in wheelchair with active bleeding noted from right arm from old dialysis site. Staff applied pressure to site. An ambulance was called and arrived and transported the resident to hospital. Record review of the physician's notes from the hospital revealed Resident #2 was admitted to the hospital on 03/22/24 with principal diagnosis of an Aneurysm of Arteriovenous (AV) Dialysis Fistula requiring four (4) units of blood related to acute blood loss anemia secondary to the ruptured aneurysm of AV dialysis fistula. The note documented the resident's blood pressure was 72/43 due to acute blood loss. An interview with Resident #6 on 04/05/24 at 9:50 AM, revealed he is Resident #2's roommate and also goes to dialysis every Monday, Wednesday and Friday. He revealed he knew Resident #2 had an appointment for a procedure on March 19th (03/19/24) and also had to have surgery on his arm on the following Thursday. He stated, I know Resident #2 went to the appointment on Tuesday the 19th, but not sure why he did not go on the following Thursday. Resident #6 also revealed on the morning his roommate went to the hospital, the staff had gotten him up for dialysis and after a little while he looked down at the floor where his roommate was sitting and saw blood dripping on the floor and there was a lot of it and confirmed he called for help and the staff worked on Resident #2 until the ambulance came. Review of section C of the Minimum Data Set (MDS) for Resident #6 with an Assessment Reference Date (ARD) of 01/09/24 revealed the Brief Interview for Mental Status (BIMS) score was a 15 indicating the resident was cognitively intact. An interview with agency LPN #4 on 04/03/24 at 11:00 AM, revealed she was assigned to Resident #2 on 03/18/24, she stated she remembered when he returned from dialysis that he had two appointment cards and paperwork for the appointments on March 19th (03/19/24) and one for March 21st (03/21/24). She revealed she works for a staffing agency and was unaware of the scheduling process, but she gave the information regarding the appointments to the charge nurse on duty and she filled out the appointment forms. An interview with Registered Nurse (RN) #3 on 04/03/24 at 3:00 PM, revealed on the evening of 03/18/24 around 5:30 PM the agency LPN #4 handed her the appointment cards and paperwork sent from dialysis for Resident #2. She revealed she filled out an appointment sheet for 03/19/24 at 12:00 PM and also filled out a form for 03/21/24 asking the Appointment Scheduler to get the time of the appointment clarified because there was no time listed on the card. She confirmed she did not put a physician's order for the 03/21/24 in the computer because it had to be clarified. She stated she placed the forms and appointment cards in the appointment folder and passed the information to the oncoming nurse to follow-up. She also stated she also copied the appointment cards and placed them in the medical records box. She stated when she returned to work on the 03/19/24, Resident #2 was out of the building for his first appointment scheduled, so she knew that the Appointment Scheduler got the appointment forms. RN #3 confirmed she did not personally follow-up to ensure the appointment time was clarified and scheduled for 03/21/24 for Resident #2 but she checked the appointment folder, and the form was not there. She also stated the dialysis clinic was closed at the time she was given the appointment information for Resident # 2, or she would have gotten the clarification for the order. Review of the March 2024 Order Summary Report for Resident #2 revealed there was no physicians order for the surgical procedure scheduled for 03/21/24. An interview with the Admission Coordinator/ Appointment Scheduler on 04/03/24 at 11:15 AM, revealed she scheduled the transportation for Resident #2 on 3/19/24 because she was notified by the dialysis clinic of the appointment at 12:00 PM on 03/19/24, but stated she was not notified of any appointment on 3/21/24 to repair the right arm. Review of the appointment calendar for 03/21/24 with the Admission Coordinator/ Appointment Scheduler revealed there were no appointments scheduled for Resident #2 for 03/21/24. She also revealed she did not have any of the appointment forms turned in for March, only the calendar logs that she wrote down for the schedule. She stated that she shreds the appointment forms at the end of each month. She also revealed that Resident #2's niece called her 03/19/24 asking her about Resident #2's surgery for his arm and she informed the niece that she was unaware of any surgery scheduled. The Admission Coordinator/ Appointment Scheduler was asked if she followed up with dialysis clinic regarding the niece's inquiry about his surgery to his right arm and she stated she informed the niece to let her know if she finds out anything. A phone interview with the dialysis clinic Office Coordinator/LPN #1 on 04/03/24 at 12:15 PM, revealed she sent the dialysis communication form and the two appointment cards back to the facility. She also revealed she called the facility on 03/18/24 in the evening and spoke with the Appointment Scheduler and gave specific instructions and times for both of the appointments on 03/19/24 at 12:00 PM and also for 03/21/24 at 11:30 AM. She revealed she informed the the Appointment Scheduler of the importance of Resident #2 not missing either of the appointments. She revealed she was on the speaker phone and had a witness to the phone call, the Administrative Secretary #2, and the dialysis RN #3. She revealed it is customary for the clinic to call the facilities to ensure they received the paperwork sent back to the facility with the residents. A phone interview with Administrative Secretary #2 at dialysis, on 04/03/24 at 12:20 PM, confirmed she was on the call with Office Coordinator/LPN #1 as a witness to the instructions given to the facility. She confirmed Appointment Scheduler was the staff on the phone at the nursing facility and she was informed of the appointments and times for the appointments 03/19/24 and 03/21/24 and specific instructions for the procedures. Review of the dialysis nurses note dated 03/18/24 by the dialysis Office Coordinator/LPN #1 at 1:43 PM, revealed Resident #2 came to clinic today blood noted on sleeve of shirt. Access was looked at several open areas noted, and small amount of blood noted. Access is pulsatile (pulse detected). The decision was made not to use dialysis access d/t (due to) risk of possible rupture. Informed the surgeon that a significant change in the appearance and size of access from previous visit. An appointment was already made for 03/19/24 at 12:00 PM for catheter placement. Surgery scheduled Thursday 03/21/24 for ligation surgery. The resident's Nephrologist was made aware of condition of access and stated to inform staff and nursing home to call 911 and apply pressure if he bleeds. The Appointment Scheduler at the facility was informed that literature and appointments were sent by the patient. She stated she will let the unit manager be made aware. I repeated several times how important it is for patient to keep the appointments. Record review of dialysis nurses note dated 03/18/24 at 2:51 PM by the dialysis RN #3 revealed, Asked Secretary to call nursing home and make sure they have arranged for Resident #2 to go to catheter appointment on 03/19/24 at 11:30 at hospital and again at 11:30 AM on 03/21/24 for his appointment with surgeon. I was standing next to the secretary when she made the call and heard her speaking with the Appointment Scheduler, who confirmed that she knew about both appointments and was making sure Resident #2 was on their schedule to be transported. An interview with RN #2 on 04/03/24 at 1:00 PM, revealed on 03/18/24 she was notified by the Appointment Scheduler that Resident #2 was scheduled to have a surgical procedure to the fistula site and have a catheter inserted to the groin site. She revealed she was informed by the Appointment Scheduler about the concerns from dialysis of potential risk for hemorrhage from the right arm fistula site and that the clinic was sending a tourniquet to apply to arm if bleeding occurs. She revealed she was unaware why Resident #2 did not go to the procedure on the 03/21/24. During an interview with the Administrator on 04/04/24 at 6:45 PM, she revealed the root cause of Resident #2 missing his scheduled appointment on 03/21/24 was related to the failure of staff to follow-up on a scheduled time for the procedure. Review of the Admission Record the facility admitted Resident #2 to the facility on [DATE] with diagnoses of End-Stage Renal Disease and Dependence on renal dialysis. Review of the MDS for Resident #2 with an ARD of 03/22/24, revealed Entry/Discharge: Discharge -return anticipated. Removal Plan On 04/04/2024 at approximately 8:30 AM, the Interim DON contacted Resident #2 general surgeon office to confirm phone for communication that is currently in their file and provide the facility contact information for any further communication. On 04/04/2024 at approximately 9:30 AM, Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility received Immediate Jeopardies. On 04/04/2024 at approximately 10:00 AM, the Staff Development initiated in-servicing with all licensed nurses, transportation, front desk receptionist on communication with appointments to include the process with signing resident in and out of facility, the daily transportation log along with the sign out binder. Inservice also includes adding a step to the appointment communication process with Admission Coordinator to review the communication tab within the electronic records to ensure all appointments are listed. No staff will be allowed to return to work without completing. On 04/04/2024 at approximately 11:25 AM, the Administrator held a one-to-one in-service with Admission Coordinator on the appointment scheduling process to include communication, scheduling and following up on appointments. On 04/04/2024 at approximately 12:30 PM, the Admission Coordinator conducted an audit of current dialysis patients to review for appointments by contacting the dialysis center and verifying any outside appointment to ensure facility followed up correctly. There are currently twelve (12) dialysis patients. All appointments were followed up. On 04/04/2024 at 12:44 PM, Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments. On 04/04/2024, the Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 04/04/2024 and the Immediate Jeopardy was removed 04/05/2024. State Agency Validation: On 04/05/24, the SA validated through staff interviews, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): Resident #2 The SA verified through staff interview and record review, on 04/04/2024 at approximately 8:30 AM, the Interim DON contacted Resident #2 general surgeon office to confirm phone for communication that is currently in their file and provide the facility contact information for any further communication. The SA verified through record review, sign-in sheets, and in-service reviews on 04/04/2024 at approximately 11:25 AM, the Administrator held a one-to-one in-service with Admission Coordinator on the appointment scheduling process to include communication, scheduling and following up on appointments. The SA verified through record review on 04/04/2024 at approximately 12:30 PM, the Admission Coordinator conducted an audit of current dialysis patients to review for appointments by contacting the dialysis center and verifying any outside appointment to ensure facility followed up correctly. There are currently twelve (12) dialysis patients. All appointments were followed up. The SA verified through record review on, 04/02/2024 at approximately 3:30 PM, the Administrator Assistant developed an orientation binder for all agency' staff onboard to be in-serviced on facilities policies and procedures to include wandering, elopement, where to find if a resident is allowed to out leave of absence, and appointment guidelines. The SA verified through resident interview and sign in sheets, on 04/04/2024 at approximately 9:30 AM, Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility had Immediate Jeopardies. The SA verified through staff interview, sign-in sheets, and in-service reviews on 04/04/2024 at approximately 10:00 AM, the Staff Development initiated in-servicing with all licensed nurses, transportation, front desk receptionist on communication with appointments to include the process with signing resident in and out of facility, the daily transportation log along with the sign out binder. Inservice also includes adding a step to the appointment communication process with Admission Coordinator to review the communication tab within the electronic records to ensure all appointments are listed. No staff will be allowed to return to work without completing. The SA verified through staff interview and sign-in sheet, on 04/04/2024 at 12:44 PM, Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments. The SA verified through staff interview and record review, on 04/04/2024 at approximately 2:00 PM, Regional Case Mix conducted in-service with Minimum Data Set (MDS) to include implementation, Reviewing, Revising, and Resolving person-centered care plans. The SA verified through staff interview, sign-in sheets, and in-service reviews on 04/04/2024, the Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents. On 04/05/24, the SA validated that all corrective actions had been taken by the facility to remove the IJ on 04/04/24 and the IJ was removed on 04/05/24.

Based on staff interviews, record review, staff schedule and facility policy review the facility: 1) failed to protect the residents right to be free from neglect as evidenced by failure to ensure nursing staff provided supervision and nursing services to 25 residents of 146 residents who resided in the facility when a nurse failed to report for duty for the 11:00 PM to 7:00 AM shift on 1/27/24, which resulted in 14 residents not receiving medications. (Resident #1, Resident # 2, Resident # 3, Resident # 4 Resident #5, Resident # 6, Resident # 7, Resident # 8, Resident #9, Resident #10, Resident # 11, Resident # 12, Resident # 13, and Resident #15), four residents with significant medication errors (Resident #1, Resident # 2, Resident # 3, Resident # 5) and 2) failed to ensure a resident was free from verbal abuse when a Certified Nurse Assistant (CNA) cursed a resident for one (1) of eight (8) residents reviewed for abuse, Resident #27. The facility's failure to ensure sufficient licensed staff on 1/27/24-1/28/24 from 11:00 PM through 7:00 AM to administer medications, provide monitoring and supervision resulted in the deprivation of goods and services by staff of services necessary to attain or maintain physical, mental, and psychosocial well-being, and had the likelihood to cause residents residing on the Annex A hall unit of the facility serious injury, serious harm, serious impairment, or possible death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 2/02/24, which began on 1/27/24, when the facility's failure to ensure a licensed nurse was present to provide necessary nursing services. On 2/02/24 at 12:20 PM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the facility with the IJ Templates. The facility submitted an acceptable Removal Plan on 2/02/24 at 9:52 pm, in which the facility alleged all corrective actions to remove the IJ and SQC were completed on 2/02/24 and the IJ was removed as of 2/03/24. The SA validated the Removal Plan on 2/03/24 and determined the IJ and SQC was removed on 2/03/24, prior to exit. Therefore, the scope and severity for CFR 483.12(a)(1) Abuse and Neglect (F 600), was lowered from a J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. CROSS REFERENCE F725, F760 Findings include: Review of the facility policy titled, Abuse Prohibition Policy, revised 11/7/23, revealed: Intent: .Each resident has a right to be free from abuse, mistreatment, neglect, .Policy: The facility will prohibit neglect, mental or physical abuse .of resident .Neglect - failure of the facility, it's employees or service providers to provide goods and services to the resident, necessary to avoid physical harm, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, good or services that a resident(s) requires but the facility fails to provide them to the resident . Review of the facility policy titled, Staffing, Sufficient and Competent Nursing, reviewed 3/2023, revealed: Policy Statement: Our facility provides nursing and related care and services for all residents .Factors considered in determining appropriate staffing ratios .include an evaluation of the diseases, conditions, physical and cognitive limitations of the resident population, and acuity. Minimum staffing requirements imposed by the state .are not necessarily considered a determination of sufficient and competent staffing. An interview with Licensed Practical Nurse (LPN) #1 on 2/1/24 at 10:50 AM, she revealed on 1/27/24, she notified the Staff Development Coordinator (SDC), that her relief did not show up at for the 7:00 PM-7:00 AM shift and the SDC stated she would notify the Director of Nursing (DON) and the Administrator and call around to find coverage. She stated that the SDC asked her if she would stay and administer the 9:00 PM medications. LPN #1 confirmed she worked until 11:00 PM when LPN #2 came over to count the Annex A medication cart, revealing she counted the cart and left the facility. LPN #1 then revealed when she returned to work on 1/28/24 at 7:00 AM, there was not a nurse assigned to the Annex A medication cart and she noticed the 6:00 AM medications had not been signed off as administered. She stated, I was told by one of the other nurses, not sure which one, that all the administrative nurses were aware that none of the 6:00 AM medications had been administered. LPN #1 then confirmed, potential concerns of there being no nurse to staff the Annex A Hall is the residents missed their medications, is the residents plan of care was not followed and that placed residents at risk to have adverse consequences such as Hypo-Hyperglycemia, unrelieved pain, seizures, and potential changes in their status that may not be identified. LPN #1 also revealed the facility consists of the 100 A and B Hall, 200 A and B Hall, and the Annex A and B Hall with each area having two medication carts and a nurse is supposed to be scheduled for each hall. During a phone interview with LPN #2 on 1/31/24 at 1:00 PM, she confirmed she counted the medication cart with LPN #1 on 1/27/24 at 11:00 PM so LPN #1 could go home. She revealed she was assigned to the 100 Hall and only counted the narcotics for the Annex A cart until someone came in. She confirmed she did not administer the 6:00 AM medications or monitor the residents on Annex A hall because she was assigned to the 100 Hall and was unable to take care of residents and administer medications for two halls. LPN #2 then confirmed she did not notify anyone that there was not a nurse for the Annex A cart or that the 6:00 AM medications were not administered because she thought LPN #1 informed all the administrative staff before she left at 11:00 PM. During a phone interview with LPN #3 on 1/31/24 at 2:30 PM, confirmed she worked on 1/27/24 from 7:00 PM-7:00 AM but she was unaware that the Annex A cart did not have a nurse assigned to it stating, I saw LPN #1 count the medication cart with another nurse. LPN # 3 then revealed she is an Agency nurse and does not know the staff very well and confirmed she did not monitor any residents on the Annex A hall and did not know they did not get their morning medications. An interview with the Assistant Director of Nursing (ADON) on 2/1/24 at 4:00 PM, he stated that the Registered Nurses (RN) take a call rotation and come in and work the medication cart if someone called in and coverage could not be found. An interview with the Administrator on 2/2/24 at 10:00 AM, she stated that she was not aware until around 6:45 AM on 1/28/24, that there was no nurse for Annex Hall Cart A from 11:00 PM until 7:00 AM on 1/27/24, and that the residents did not receive their 6:00 AM medications for 1/28/24. She then revealed that the SDC was the nurse on call for 1/27/24. She stated that the residents on Annex A hall were assessed by the RN supervisors on 1/28/24. She then stated she did not identify that the omission of some of the medications constituted significant medication errors. An interview with the ADON on 2/2/24 at 10:05 AM, he revealed that he was not aware that there was no nurse for Annex Hall Cart A from 11:00 PM until 7:00 AM on 1/27/24, and that the residents did not receive their 6:00 AM medications. He then stated he did not identify that the omission of insulin, anticonvulsants, blood thinners, and scheduled pain medications constituted as significant medication errors. The ADON stated that failure to administer insulin, anticonvulsants, blood thinners and scheduled pain medications could lead to hyperglycemia, seizures, and unrelieved pain. An interview on 2/2/24 at 10:20 AM, with the SDC, she stated that on 1/27/24 at 7:49 PM she received a text from LPN #1 notifying her that the night nurse had called in. The SDC stated she texted the Administrator, DON, and ADON at 7:55 PM. She then stated that initially she only received a response from the Administrator who told her that she would post the opening on the agency site and list it as premium. The SDC stated that premium means that it was a priority, and they were offering more pay for the shift to be covered. She stated that she then sent a text out to nurses to attempt to get the shift covered, but no one was available, so she notified the Administrator, DON, and ADON. She stated that DON responded and asked her to have LPN #1 administer the 9:00 PM medications. The SDC stated that no one accepted the shift from the agency website. She confirmed she never received a response from the ADON. During a further interview with the SDC she verified that she was the RN on call for 1/27/24, but that she is on light duty and cannot push a medication cart. She stated that she was only on call as a supervisor to attempt to find coverage for call ins. SDC further stated that she did not ask LPN #2 to count the cart with LPN #1 and she found out at 8:15 AM on 1/28/24 that the residents on the Annex A cart did not receive their 6:00 AM medications. In an interview with the RN Charge Nurse #1 on 2/2/24 at 10:30 AM, she stated she was notified by the SDC at 9:10 AM on 1/28/24 that there had been no nurse coverage for the Annex A residents for the 11:00 PM-7:00 AM shift and that the residents had not received 6:00 AM medications or accu-checks and to notify the provider and responsible party, assess the residents, and obtain vital signs. A phone interview with the DON on 2/2/24 at 10:45 AM, she stated that she received a phone call at 8:00 PM on 1/27/24 from the Respiratory Therapist (RT) #1 notifying her that the 7:00 PM to 7:00 AM nurse for the Annex A cart had called in. She stated that at that time she noticed that she had received a text at 7:58 PM from the SDC notifying her of the same thing. The DON stated that she asked the SDC if she had reached out to all the nurses that normally worked and the SDC told her that she had but no one could pick up the shift. She stated the SDC also informed her that LPN #1 had given the 9:00 PM medications for those residents. The DON then stated that she had fallen asleep and last talked to the SDC at 10:00 PM. The DON further stated that at 10:55 PM she reached out to the SDC asking what the plan for that cart was. She stated that the SDC told her that no one had responded to the shift posted on the agency website and that LPN #1 had left. The DON stated she reached back out to the SDC at 1:27 AM but there was still no nurse. The DON stated that at some point the ADON had informed her that he was out town and could not cover the shift. The DON stated that the agency nurse who was working the other cart on the Annex Hall told her that she had come to the desk and made rounds on the residents but did not administer the 6:00 AM medications. The DON stated that usually if there is no nurse for a certain cart then the nurses who are on duty will administer the medications. The DON stated that when she found out the residents had not received their medications, she informed the SDC to instruct the RN supervisor to assess the residents, notify the nurse practitioner and the resident representative. The DON stated that she knew the SDC was the nurse on call and if the on-call nurse cannot find coverage then they are to come in and work the cart. The DON stated that she was aware of the SDCs medical restrictions but did not think about the SDCs limitations when she received the call. A record review of the Daily Staffing Sheet revealed that there were five (5) nurses working from 11:00 PM to 7:00 AM on 1/27/24 with only one nurse assigned on the Annex Hall. A record review of the staff timecards for 1/27/24 through 1/28/24 revealed that there were five (5) Nurses working from 11:00 PM to 7:00 AM on 1/27/24. Resident #1 Review of the physician order for Resident # 1 revealed an order dated 10/12/23 for Apixaban Oral Tablet 5 mg (milligram) give one tablet via peg-tube (percutaneous endoscopic gastrostomy) two times daily related to Cerebral Infarction. Review of the January 2024 Medication Administration Record for Resident #1 revealed Apixaban Oral Tablet 5 mg (milligram) give one tablet via peg-tube two times daily at 6:00 AM and 2:00 PM, not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #1 to the facility on [DATE] with a diagnosis of Respiratory Failure, Hemiplegia, and Cerebral Infarction. Resident #2 Review of the physician's order for Resident # 2, revealed an order dated 5/19/23 for Novolin R (regular) injection solution 100 unit/ml (milliliter) (Insulin Regular Human): Inject as per sliding scale: if 60-80= OJ (orange juice) if semiconscious give some instant glucose. If unconscious give D5W (dextrose 5% in water)/AMP (ampule) IV or glucagon 1(one) mg IM/SQ (intramuscularly/subcutaneous). 81-200=0 units; 201-250=2 units; 251-300= 4 units; 301-350=6 units; 351-400 = 8 units; 400 + higher =10 units. Notify MD (medical doctor) for BS (blood sugar) (less than) < 60 & (greater than) > 401, subcutaneously before meals and bedtime. Review of a physician's order for Resident #2 dated 6/06/23 revealed Levothyroxine Sodium oral tablet 88 mcg (micrograms): give one tablet by mouth one time daily related to Hypothyroidism. Review of the January 2024 Medication Administration Record for Resident #2 revealed the blood glucose testing was not done to determine the need for the Novolin R: injection solution 100 unit/ml: Inject as per sliding scale before meals and bedtime scheduled at 6:00 AM and Levothyroxine Sodium oral tablet 88 mcg give one tablet by mouth one time daily at 6:00 AM, was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #2 to the facility on [DATE] with a diagnosis Diabetes Mellitus (DM). Resident # 3 Record review of a physician orders for Resident # 3 revealed an order dated 6/25/20 for Hydroxychloroquine Sulfate Tablet 200 mg: Give one tablet by mouth two times daily .Lacosamide tablet 100 mg: give one tablet by mouth two times daily related to seizures .Keppra tablet 500 mg: give one tablet by mouth two times daily related to seizures .Celecoxib Capsule 200 mg: give one capsule by mouth two times daily related to Rheumatoid Arthritis. Record review of a physician orders for Resident # 3 revealed an order dated 7/30/20 for Gabapentin capsule 100 mg: give one capsule by mouth three times daily related to seizures .Pantoprazole Sodium tablet delayed release: give one tablet by mouth two times daily for indigestion related to Gastro-Esophageal Reflux Disease (GERD). Record review of the January 2024 Medication Administration Record for Resident #3 revealed Hydroxychloroquine Sulfate Tablet 200 mg at 6:00 AM Lacosamide tablet 100 mg at 6:00 AM Keppra tablet 500 mg: give one tablet by mouth two times daily at 6:00 AM, Celecoxib Capsule 200 mg 6:00 AM, Gabapentin capsule 100 mg 6:00 AM, and Pantoprazole Sodium at 6:00 AM, to not be signed off as administered on 1/28/24 at 6:00 AM. Record review of the Face Sheet revealed that the facility admitted Resident #3 to the facility on [DATE] with diagnoses of Epilepsy, Rheumatoid Arthritis, and Gastro-Esophageal Reflux Disease. Resident #4 Record review of a physician orders for Resident # 3 revealed orders dated 7/13/23, revealed Norco Oral tablet 7.5-325 mg (Hydrocodone Acetaminophen): give one tablet enterally every eight hours related to pain; and an order dated 9/22/23, revealed Nexium oral packet 20 mg: give one packet via G-Tube (gastrostomy tube) one time a day related to Gastro-Esophageal Reflux Disease. Record review of the January 2024 Medication Administratioon Record for Resident #4 revealed, Norco oral tablet 7.5-325 mg enterally every eight hours at 6:00 AM and Nexium Oral packet 20 mg at 6:30 AM, to not be signed as administered on 1/28/24 at 6:00 AM and 6:30 AM. Record review of the Face Sheet revealed that the facility admitted Resident #4 to the facility on [DATE] with diagnoses of Anxiety and Gastro-Esophageal Reflux Disease. Resident #5 Record review of a physician orders for Resident # 5 revealed an order dated 7/13/23, revealed, Multivitamin-Minerals tablet: give one tablet by mouth one time a day related to Vitamin D Deficiency, an order dated 6/14/23, revealed, Euthyrox (Levothyroxine)oral tablet 88 mcg (micrograms) give one tablet by mouth one time a day related to Hypothyroidism; an order dated 9/11/23, revealed, Insulin Glargine Solution 100 units/ml: inject 8 units subcutaneously in the morning related to Type 2 (two) Diabetes; and an order dated 1/23/24, revealed, Furosemide 40 mg tablet: take one tablet by mouth twice daily before meals related to Hypertensive Heart Disease. Record review of the January 2024 Medication Administration Record for Resident # 5 revealed, Multivitamin-Minerals at 6:00 AM, Euthyrox oral tablet 88 mcg (micrograms) at 6:00 AM, Insulin Glargine Solution 100 units/ml: inject 8 units subcutaneously in the morning at 6:00 AM, and Furosemide 40 mg tablet at 6:00 AM were not signed off as administered on 1/28/24. Record review of the Admission Record revealed that the facility admitted Resident #5 to the facility on [DATE] with diagnoses of Type 2 (two) Diabetes, Hypertensive Heart Disease, and Vitamin Deficiency. Resident #6 Review of the physician order for Resident # 6 revealed an order dated 12/26/23 for Folic Acid oral tablet one mg: give one tablet via peg-tube in the morning related to Vitamin Deficiency; and an order dated 12/27/23 for Atorvastatin Calcium oral tablet 10 mg: give one tablet vis peg-tube in the morning related to Hyperlipidemia. Record review of the January 2024 Medication Administration Record for Resident #6, revealed Folic Acid oral tablet at 6:30 AM, Atorvastatin Calcium oral tablet 10 mg at 6:00 AM, were not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Face Sheet revealed that the facility admitted Resident # 6 to the facility on [DATE] with diagnoses of Persistent Vegetative State and Vitamin Deficiency. Resident #7 Record review of the physician's orders for Resident # 7 revealed an order with a start date of 10/8/20 revealed, Diazepam tablet 5 mg give one tablet by mouth three times a day related to anxiety disorder; an order dated 4/4/21 revealed, Novolin R injection solution 100 unit/ml (Insulin Regular Human): Inject as per sliding scale: if 60-80= OJ (orange juice) if semiconscious give some instant glucose. If unconscious give D5W AMP IV or glucagon 1(one) mg IM/SQ . 81-200=0 units; 201-250=2 units; 251-300= 4 units; 301-350=6 units; 351-400 = 8 units; 400 + higher =10 units. Notify MD for BS < 60 & > 401, subcutaneously before meals and bedtime related to Type Two Diabetes Mellitus, Seroquel tablet 100 mg: give one tablet by mouth three times a day related to Schizophrenia; and an order dated 11/9/23, revealed, Systane Complete Ophthalmic solution: instill one drop in both eyes two times a day related to Type Two Diabetes Mellitus. Review of the January 2024 Medication Administration Record for Resident # 7, revealed Diazepam tablet 5 mg give one tablet by mouth three times a day at 6:00 AM, the blood glucose testing to determine if Novolin R injection solution 100 unit/ml (Insulin Regular Human): Inject as per sliding scale: was needed was not conducted, Seroquel tablet 100 mg at 6:00 AM, Systane Complete Ophthalmic solution at 6:00 AM, were not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident # 7 to the facility on [DATE] with diagnoses of Type Two Diabetes Mellitus, Restlessness and Agitation, and Schizophrenia. Resident # 8 Record review of the physician's orders for Resident # 8 revealed an order dated 1/9/24 revealed, Novolin R injection solution 100 unit/ml (Insulin Regular Human): Inject as per sliding scale: if 60-80= OJ (orange juice) if semiconscious give some instant glucose. If unconscious give D5W AMP IV or glucagon 1(one) mg IM/SQ . 81-200=0 units; 201-250=2 units; 251-300= 4 units; 301-350=6 units; 351-400 = 8 units; 400 + higher =10 units. Notify MD for BS < 60 & > 401, subcutaneously before meals and bedtime related to Type Two Diabetes Mellitus. Vitamin C tablet 1000 mg: give one tablet via peg-tube one time a day related to Vitamin Deficiency. Record review of the January 2024 Medication Administration Record for Resident # 8 revealed the blood glucose testing to determine if Novolin R injection solution 100 unit/ml (Insulin Regular Human): Inject as per sliding scale was needed was not conducted, was not signed off as administered on 1/28/24 at 6:00 AM. Vitamin C tablet 1000 mg: give one tablet via peg-tube one time a day was not signed off as administered at 6:00 AM on 1/28/24. Record review of the Admission Record revealed that the facility admitted Resident #8 to the facility on [DATE] with diagnoses of Type 2 (two) Diabetes, Urinary Tract Infection, and Vitamin deficiency. Record review of the quarterly MDS Section C with an ARD of 11/07/23, revealed that Resident #8 had a BIMS score of 3 which indicated that she was severely cognitively impaired. Resident # 9 Record review of the physician's orders for Resident # 9 revealed orders dated 4/14/21 for Protonix tablet delayed Release 40 mg: give one tablet by mouth one time a day related to Gastro-Esophageal Reflux Disease .Dantrolene Sodium Capsule 50 mg: give one capsule by mouth three times a day related to contracture .Baclofen tablet 20 mg: give one tablet by mouth three times a day related to contracture of muscle. Record review of the January 2024 Medication Administration Record for Resident # 9 revealed Protonix tablet delayed Release 40 mg at 6:00 AM, Dantrolene Sodium Capsule 50 mg: give one capsule by mouth three times a day at 6:00 AM, Baclofen tablet 20 mg at 6:00 AM, to not be signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident # 9 to the facility on [DATE] with diagnoses of Contracture of muscle, right upper arm, Muscle Spasms, and Gastro-Esophageal Reflux Disease. Resident #10 Record review of the physician's orders for Resident # 10 revealed orders dated 9/15/21 for Protonix tablet delayed Release 40 mg: give one tablet by mouth one time a day related to Gastrointestinal (GI) bleed. Record review of the January 2024 Medication Administration Record for Resident # 10 revealed Protonix tablet delayed Release 40 mg at 6:00 AM, not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Face Sheet revealed that the facility admitted Resident #10 to the facility on [DATE] with a diagnosis of Gastrointestinal Hemorrhage. Resident #11 Record review of the physician's orders for Resident # 11 revealed orders dated 4/27/21 for Sucralfate tablet one gram: give one tablet via peg-tube four times a day for Gastro-Esophageal Reflux Disease. Record review of the January 2024 Medication Admministration Record for Resident # 11 revealed, Sucralfate tablet one gram at 6;30 AM, was not signed off as administered on 1/28/24 at 6:30 AM. Record review of the Admission Record revealed that the facility admitted Resident #11 to the facility on [DATE] with diagnoses of Persistent Vegetative State and Gastro-Esophageal Reflux Disease. Resident #12 Record review of the physician's orders for Resident # 12 revealed orders dated 11/29/23 for Lansoprazole tablet delayed release disintegrating 30 mg: give one tablet via peg-tube one time a day for Gastro-Esophageal Reflux Disease. Record review of the January 2024 Medication Administration Record for Resident # 12 revealed, Lansoprazole tablet at 6:00 AM, was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #12 to the facility on [DATE] with a diagnosis of Gastro-Esophageal Reflux Disease. Resident #13 Record review of the physician's orders for Resident # 13 revealed orders dated 12/5/23 for Protonix tablet delayed release 40 mg: give one time a day for Gastro-Esophageal Reflux Disease .Buspirone tablet 5 mg: give one tablet by three times a day related to anxiety disorder started 12/5/23 and revised 2/1/24. Record review of the January 2024 Medication Administration Record for Resident # 13 revealed, Protonix tablet delayed release 40 mg at 6:00 AM, Buspirone tablet 5 mg at 6:00 AM, were not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #13 to the facility on [DATE] with diagnoses of Gastro-Esophageal Reflux Disease and Anxiety. Resident #15 Record review of the physician's orders for Resident # 15 revealed orders dated 11/30/23 for Hydralazine 100 mg tablet: give one tablet by mouth three times a day for Hypertension; and an order dated 1/25/24 for Tylenol eight-hour Arthritis pain tablet extended release 650 mg: give 2 tablets by mouth two times a day related to Poly osteoarthritis. Record review of the January 2024 Medication record for Resident #15 revealed, Hydralazine 100 mg tablet at 6:00 AM, Tylenol eight-hour Arthritis pain tablet extended release 650 mg at 6:00 AM, were not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #15 to the facility on [DATE] with diagnoses of Poly osteoarthritis and Hypertension. REMOVAL PLAN The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: On 2/2/2024 at 12:20 P.M. State Agency (SA) notified facility Administrator of Immediate Jeopardy (IJ). State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. Facility respectfully submits this removal plan. Brief Summary of Events On 1/27/2024 the facility did not have a licensed practical nurse from 11:00pm to 7:00 am on Annex cart A. During this time fourteen (14) of twenty-five (25) residents were identified as not receiving the 6 am medication dose. On 1/28/2024 an investigation was initiated by the Director of Nursing. Licensed Practical Nurse #1 assigned to Annex Cart B stated that she rounded on the twenty-five (25) residents that resided on Annex Cart A but did not administer the 6 am medications. As a result of this investigation medication error reports were initiated and orders were received from the Nurse Practitioner to omit the 6 am dose and continue the regular dosing schedule and monitor the fourteen (14) residents for any adverse effects. Corrective Actions 1. On 01/28/2024 at approximately 9:00 A.M. The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 am medications. fourteen (14) residents were identified as missing one or more medications at 6 am on 1/28/24. 2. On 1/28/2024 at 9:00 A.M., the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00pm to 7:00 am. 3. On 01/28/2024 at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications. No adverse events were found. 4. On 1/28/2024 at approximately 11:35 A.M. the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. 5. On 1/28/2024 at approximately 1:00 P.M. the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. 6. On 1/29/2024 at approximately 9:30 A.M. the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. 7. On 1/29/2024 at approximately 10:30 A.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 held Ad hoc Quality Assurance Performance Improvement Meeting to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 8. On 02/02/2024 at approximately 3:30 P.M. Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. 9. On 02/02/2024 at approximately 4:00 P.M. Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision. No adverse events found. 10. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. 11. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff will be allowed to return to work without completing. 12. On 2/2/2024 at 5:15 P.M. Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision. No adverse effects found. 13. On 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 14. On 2/2/2024 at 5:30 P.M. the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. 15. On 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects due to the lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 16. [TRUNCATED]

Based on care plan review, record review, facility policy review, and staff interview, the facility failed to implement a comprehensive care plan related to medication administration for 14 of 25 residents reviewed for care plans. The facility's failure to implement care plans, placed the residents at risk, and in a situation that was likely to cause serious injury, harm, impairment, or death. On 2/2/24, the State Agency (SA) identified an Immediate Jeopardy (IJ) which began on 1/27/2024, with the facility's failure to provide a licensed nurse to implement comprehensive care plans resulted in 14 residents not receiving medications per physician's orders. On 2/02/24 at 12:20 PM, the SA informed the Nursing Home Administrator (NHA) of the IJ and provided the Administrator with the IJ Templates. The facility submitted a credible Removal Plan on 2/2/24 at 9:52 PM, in which the facility alleged all corrective actions to remove the IJ were completed on 2/2/24 and the IJ removed as of 2/03/24. The SA validated the Removal Plan on 2/03/24 and determined the IJ was removed prior to exit. Therefore, the scope and severity for CFR483.21(b)(1) - Develop/Implement Comprehensive Care Plan (F656) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of facility policy titled Care Plans, Comprehensive Person-Centered, reviewed 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 . An interview with Licensed Practical Nurse (LPN) #1 on 2/1/24 at 10:50 AM, she confirmed that concerns from there being no nurse to staff the Annex A Hall is the residents missed their medications, the residents plan of care was not followed and that placed residents at risk to have adverse consequences such as Hypo-Hyperglycemia, unrelieved pain, seizures, and potential changes in their status that may not be identified. An interview with the RN Charge Nurse #1 on 2/2/24 at 10:30 AM, she revealed resident's plan of care was not followed when their medications and accu-checks were missed, resulting in the need to assess the resident for possible adverse outcomes. Resident #1 A review a care plan for Resident # 1 titled, The resident is on anticoagulant therapy (Apixaban) r/t (related to), last revised 11/27/2023, revealed Interventions/Task: Administer Anticoagulant medications as ordered by the physician . Review of the January 2024 Medication Administration Record for Resident #1 revealed Apixaban Oral Tablet 5 mg (milligram) give one tablet via peg-tube (percutaneous gastrostomy) was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #1 to the facility on [DATE] with a diagnosis of Respiratory Failure, Hemiplegia, and Cerebral Infarction. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 1/11/24, revealed that Resident # 1 had a Brief Interview of Mental Status (BIMS) score of 6 which indicated that he was severely cognitively impaired. Resident #2 A review of a care plan for Resident # 2 titled, The resident has a diagnosis of Diabetes Mellitus . Interventions: Administer medications as ordered by the physician . A review of the care plan for Resident # 2 titled, The resident has Hypothyroidism and is at risk for complications, revealed Interventions: Give thyroid replacement as ordered . Review of the January 2024 Medication record for Resident #2 revealed the blood glucose testing to determine if Novolin R: injection solution 100 unit/ml: Inject as per sliding scale before meals and bedtime scheduled at 6:00 AM, and Levothyroxine Sodium oral tablet 88 mcg (micrograms) give one tablet by mouth one time daily at 6:00 AM, was not signed off as conducted/administered on 1/28/24 at 6:00 AM. Record review of the Face Sheet revealed that the facility admitted Resident #2 to the facility on [DATE] with a diagnosis Diabetes Mellitus (DM). Record review of the Quarterly MDS Section C with an Assessment Reference Date ARD of 11/16/23, revealed that Resident # 2 had a BIMS score of 6 which indicated that she was severely cognitively impaired. Resident #3 A review of a care plan for Resident# 3 titled, The resident has a seizure disorder, revealed, Interventions: Gabapentin Capsule 100 mg .Keppra .Lacosamide as ordered. A review of a care plan for Resident # 3 titled, The resident has Rheumatoid Arthritis, revealed, Interventions: Give analgesics as ordered. A review of a care plan for Resident # 3 titled, The resident has diagnosis of GERD, Interventions: Give medications as ordered. Review of the January 2024 Medication Administration Record for Resident #3 revealed Hydroxychloroquine Sulfate Tablet 200 mg, Lacosamide tablet 100 mg, Keppra tablet 500 mg, Celecoxib Capsule 200 mg, Gabapentin capsule 100 mg, and Pantoprazole Sodium tablet was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #3 to the facility on [DATE] with diagnoses of Epilepsy, Rheumatoid Arthritis, and Gastro-Esophageal Reflux Disease. Record review of the Quarterly MDS Section C with an ARD of 12/15/23, revealed that Resident # 3 had a Brief Interview of BIMS score of 15 which indicated that he was cognitively intact. Resident #4 A review of a care plan for Resident #4 titled, The resident is at risk for pain related to Joint pain, Chronic Respiratory Failure, left sided Hemiplegia, Diabetes Mellitus, revealed, Interventions: Give analgesics as ordered. A review of a care plan for Resident # 4 titled, The resident has diagnosis of GERD, revealed, Interventions: Give medications as ordered. Review of the January 2024 Medication Administration Record for Resident #4 revealed, Norco oral tablet 7.5-325 mg, Nexium Oral packet 20 mg was not signed as administered on 1/28/24 at 6:00 AM and 6:30 AM. Record review of the Admission Record revealed that the facility admitted Resident #4 to the facility on [DATE] with diagnoses of Anxiety and Gastro-Esophageal Reflux Disease. Record review of the Quarterly MDS Section C with an ARD of 12/18/23, revealed that Resident # 4 had a BIMS score of 12 which indicated that she was moderately cognitively impaired. Resident #5 A review of a care plan for Resident #5 titled, The resident has a diagnosis of HTN (hypertension) with Heart failure . Interventions: Give cardiac medications as ordered . A review of a care plan for Resident # 5 titled, The resident has diagnosis of Diabetes Mellitus .Interventions: Diabetic medications as ordered by doctor . A review of a care plan for Resident # 5 titled, The resident has Hypothyroidism . Interventions: Euthyrox as ordered . A review of a care plan for Resident # 5 titled, The resident is at risk for nutritional problems related to vitamin deficiency, DM, morbid obesity, protein calorie malnutrition, history of wanting to lose weight . Interventions: Administer medications as ordered . Review of the January 2024 Medication Administration Record for Resident # 5 revealed, Multivitamin-Minerals, Euthyrox oral tablet 88 mcg (micrograms), Insulin Glargine Solution 100 units/ml: inject 8 units, Furosemide 40 mg tablet was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #5 to the facility on [DATE] with diagnoses of Type 2 (two) Diabetes, Hypertensive Heart Disease, and Vitamin Deficiency. Record review of the MDS Section C with an ARD of 11/27/23, revealed that Resident # 5 had a BIMS score of 15 which indicated that she was cognitively intact. Resident #6 A review of a care plan for Resident # 6 titled, The resident has the potential nutritional problem related to Vitamin Deficiency .Administer medications as ordered . A review of a care plan for Resident # 6 titled, The resident has impaired circulation .Interventions: Administer statin medication .' Review of the January 2024 Medication Administration Record for Resident #6, revealed, Folic Acid oral tablet give one tablet via peg-tube two times daily at 6:30 AM and Atorvastatin Calcium oral tablet 10 mg was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident # 6 to the facility on [DATE] with diagnoses of Persistent Vegetative State and Vitamin Deficiency. Resident #7 A review of a care plan for Resident # 7 titled, The resident uses psychotropic medications Seroquel related to schizoaffective disorder, revealed Interventions: Administer psychotropic (Seroquel) as ordered by physician. A review of a care plan for Resident # 7 titled, The resident uses anti-anxiety medications Ativan and Diazepam related to anxiety disorder, revealed Intervention: Administer medications as ordered by physician. A review of a care plan for Resident # 7 titled, The resident has diagnosis of Diabetes Mellitus revealed, Interventions: Diabetic medications as ordered by doctor. Review of the January 2024 Medication Administration Record for Resident # 7, revealed Diazepam tablet 5 mg at 6:00 AM , the blood glucose test to determine if Novolin R injection solution 100 unit/ml (Insulin Regular Human): Inject as per sliding scale was needed was not conducted, Seroquel tablet 100 mg, and Systane Complete Ophthalmic solution was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident # 7 to the facility on [DATE] with diagnoses of Type Two Diabetes Mellitus, Restlessness and Agitation, and Schizophrenia. Record review of the Quarterly MDS Section C with an ARD of 11/27/23, revealed that Resident # 5 had a BIMS score of 10 which indicated that he was moderately cognitively impaired. Resident # 8 A review of a care plan for Resident # 8 titled, The resident has Vitamin Deficiency . Interventions: Give medications as ordered . A review of a care plan for Resident # 8 titled, The resident has diagnosis of Diabetes Mellitus, revealed, Interventions: Insulin Lispro Solution 100 unit/ml inject as per sliding scale as ordered. Review of the January 2024 Medication record for Resident # 8 revealed the blood glucose test to determine if Novolin R injection solution 100 unit/ml (Insulin Regular Human): Inject as per sliding scale, Vitamin C 1000 mg at 6:00 AM, was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Face Sheet revealed that the facility admitted Resident #8 to the facility on [DATE] with diagnoses of Type 2 (two) Diabetes, Urinary Tract Infection, and Vitamin deficiency. Record review of the quarterly MDS Section C with an ARD of 11/07/23, revealed that Resident #8 had a BIMS score of 3 which indicated that she was severely cognitively impaired. Resident # 9 A review of a care plan for Resident # 9 titled, The resident has chronic pain related to Cerebral Palsy, headaches and muscle spasms, contractures of right and left hand .Interventions: Give medications as per orders . A review of a care plan for Resident # 9 titled, The resident has GERD .Interventions: Give medications as ordered . Review of the January 2024 Medication Administration Record for Resident # 9 revealed, for Protonix tablet delayed Release 40 mg. Dantrolene Sodium Capsule 50 mg, and Baclofen tablet 20 mg was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident # 9 to the facility on [DATE] with diagnoses of Contracture of muscle, right upper arm, Muscle Spasms, and Gastro-Esophageal Reflux Disease. Record review of the MDS Section C with an ARD of 12/19/23, revealed that Resident #9 had a BIMS score of 9 which indicated that he was moderately cognitively impaired. Resident #10 A review of a care plan for Resident # 10 titled, The resident has alteration in hematological status related to history of GI bleed . Interventions: Give medications as ordered . Review of the January 2024 Medication Administration Record for Resident # 10 revealed, for Protonix tablet delayed Release 40 mg was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Face Sheet revealed that the facility admitted Resident #10 to the facility on [DATE] with a diagnosis of Gastrointestinal Hemorrhage. Record review of the MDS Section C with an ARD of 11/29/23, revealed that Resident #10 had a BIMS score of 15 which indicated that she was cognitively intact. Resident #11 A review of a care plan for Resident # 11 titled, The resident has GERD (Gastro-Esophageal Reflux Disease) .Interventions: Sucralfate as ordered . Review of the January 2024 Medication Administration Record for Resident # 11 revealed, Sucralfate tablet one gram: give one tablet via peg-tube four times a day at 6;30 AM was not signed off as administered on 1/28/24 at 6:30 AM. Record review of the Admission Record revealed that the facility admitted Resident #11 to the facility on [DATE] with diagnoses of Persistent Vegetative State and GERD. Resident #12 A review of a care plan for Resident # 12 titled, The resident has GERD .Interventions: Lansoprazole as ordered . Review of the January 2024 Medication Administration Record for Resident # 12 revealed, Lansoprazole tablet at 6:00 AM, was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #12 to the facility on [DATE] with a diagnosis of Gastro-Esophageal Reflux Disease. Record review of the MDS Section C with an ARD of 12/20/23, revealed that Resident #12 had a Staff Assessment for Mental Status coded as severely cognitively impaired. Resident #13 A review of a care plan for Resident # 13 titled, The resident has potential nutritional problem related GERD . Interventions: Administer medications as ordered . A review of a care plan for Resident # 13 titled, The resident uses anti-anxiety medications (Buspar) related to anxiety disorder .Interventions: Administer Anti-Anxiety medications as ordered . Review of the January 2024 Medication Administration Record for Resident # 13 revealed, Protonix tablet at 6:00 AM .Buspirone tablet 5 mg at 6:00 AM, was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #13 to the facility on [DATE] with diagnoses of Gastro-Esophageal Reflux Disease and Anxiety. Record review of the MDS Section C with an ARD of 12/15/23, revealed that Resident #13 had a BIMS score of 14 which indicated that she was cognitively intact. Resident #15 A review of a care plan for Resident # 15 titled, The resident has a diagnosis of Hypertension .Interventions: Administer medications as ordered . A review of a care plan for Resident # 15 titled, The resident is at risk for pain related to GOUT End stage Renal Disease, DM . Interventions: Administer analgesics as ordered . Review of the January 2024 Medication Administration Record for Resident #15 revealed, Hydralazine 100 mg tablet at 6:00 AM, Tylenol eight-hour Arthritis pain tablet extended release 650 mg at 6:00 AM, was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #15 to the facility on [DATE] with diagnoses of Poly osteoarthritis and Hypertension. Record review of the MDS Section C with an ARD of 12/14/23, revealed that Resident #15 had a BIMS score of 11 which indicated that she was moderately cognitively impaired. REMOVAL PLAN The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Corrective Actions 1. On 01/28/2024 at approximately 9:00 A.M. The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 am medications. fourteen (14) residents were identified as missing one or more medications at 6 am on 1/28/24. 2. On 1/28/2024 at 9:00 A.M., the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00pm to 7:00 am. 3. On 01/28/2024 at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications. No adverse events were found. 4. On 1/28/2024 at approximately 11:35 A.M. the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. 5. On 1/28/2024 at approximately 1:00 P.M. the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. 6. On 1/29/2024 at approximately 9:30 A.M. the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. 7. On 1/29/2024 at approximately 10:30 A.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 held Ad hoc Quality Assurance Performance Improvement Meeting to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 8. On 02/02/2024 at approximately 3:30 P.M. Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. 9. On 02/02/2024 at approximately 4:00 P.M. Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision. No adverse events found. 10. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. 11. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff will be allowed to return to work without completing. 12. On 2/2/2024 at 5:15 P.M. Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision. No adverse effects found. 13. On 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 14. On 2/2/2024 at 5:30 P.M. the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. 15. On 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects due to the lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 16. On 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. 17. Beginning 02/02/2024 at approximately 6:00 P.M. the Interim Director of Nursing began Competency skills check offs on licensed nurses regarding the five rights of medication administration. 18. On 2/2/2024 at 6:30 P.M. the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. 19. On 2/2/2024 at 6:30 P.M. the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. 20. On 02/02/2024 at 7:00 P.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 21. On 2/2/2024, in-services were initiated, and no staff will be able to work until receiving in-service. 22. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 02/02/2024 and the Immediate Jeopardy was removed 02/03/2024. Validation On 2/3/24, the SA surveyor validated through staff interview, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): The SA verified through record reviews, and staff interviews that on 01/28/2024, The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 AM medications. fourteen (14) residents were identified as missing one or more medications at 6 AM on 1/28/24. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00 PM to 7:00 AM. The SA verified through record reviews, and staff interviews that on 01/28/2024, at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications and that adverse events were found. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. The SA verified through record reviews, and staff interviews that on 1/29/2024 the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. The SA verified through record reviews, and staff interviews that on 1/29/2024 a Quality Assurance Performance Improvement meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, staff, and resident interviews that on 02/02/2024, a Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision with no adverse events found. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff was allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision with no adverse effects found. The SA verified through record reviews, and staff interviews that on 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects. The SA verified through record reviews, and staff interviews that on 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. The SA verified through record reviews, and staff interviews that on beginning 02/02/2024. The Interim Director of Nursing began competency skills check offs on licensed nurses regarding the five rights of medication administration. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. The SA verified through record reviews, and staff interviews that on 02/02/2024 a Quality Assurance Performance Improvement Meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 to address the notification of Immediate Jeopardy and to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, and staff interviews that on, in-services were initiated, and staff on duty has received the in-services. The SA validated on 2/3/24, that all corrective actions had been taken by the facility to remove the IJ during the survey on 2/2/24 and the IJ was removed on 2/3/24.

Based on facility policy review, record review, resident and staff interviews, the facility failed to provide: 1. sufficient qualified nursing staff to provide nursing related services to assure resident safety, as evidenced by failure to ensure a licensed nurse was present to administer medications, and monitoring for 25 of 52 residents on the Annex Hall from 11:35 PM on 1/27/24 to 7:00 AM on 1/28/24. and 2. failed to ensure sufficient staff to provide care and services for two (2) of 22 residents reviewed. The Licensed Practical Nurse (LPN) who was scheduled to report at 7:00 PM on 1/27/24 did not arrive for her shift at the facility. Licensed Practical Nurse (LPN) #1 had worked since 7:00 AM and left the facility at 11:35 PM without on-site licensed nurse relief present. At this time, LPN # 2 counted the narcotics on the medication cart for Annex A hall and took the keys to the cart but did not accept responsibility for the twenty (25) residents on the Annex A hall of the facility. The Administrator, Director of Nursing (DON), and Staff Development Coordinator (SDC) were aware that the scheduled LPN did not show up for her shift. Staff and agency nurses did not respond to the call for replacement. No licensed nurse reported to duty on the Annex A hall of the facility between 11:35 PM and 7:00 AM. The facility failed to follow its stated practice for replacing staff in case of call-ins or no call, no shows. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Staff Development Coordinator (SDC) were aware of the staffing problem. The On-Call SDC failed to report to duty related to limitations. The facility's failure to provide a licensed nurse to administer medications, and monitoring for 8 (eight) hours had the likelihood to cause all residents on Annex Cart A serious harm, serious injury, serious impairment, or possible death. The State Agency (SA) identified an Immediate Jeopardy (IJ) on 2/02/24, which began on 1/27/24, when the facility's failure to ensure sufficient licensed nurse was present to provide necessary nursing services. On 2/02/24 at 12:20 PM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the facility with the IJ Templates. The facility submitted an acceptable Removal Plan on 2/02/24 at 9:52 PM which the facility alleged all corrective actions to remove the IJ and SQC were completed on 2/02/24 and the IJ was removed as of 2/03/24. The SA validated the Removal Plan on 2/03/24 and determined the IJ was removed on 2/03/24, prior to exit. Therefore, the scope and severity for 42 CFR 483.35(a) Sufficient Staffing was lowered from a J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Cross Reference F600, F690 and F760 Record review of the facility policy titled, Staffing, Sufficient and Competent Nursing, reviewed 3/2023, revealed, Policy Statement: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans .Minimum staffing requirements imposed by the state .are not necessarily considered a determination of sufficient and competent staffing. A record review of the Daily Staffing Sheet revealed that there were five (5) nurses working from 11:00 PM to 7:00 AM on 1/27/24 with only one nurse assigned on the Annex Hall. A record review of the staff timecards for 1/27/24 through 1/28/24 revealed that there were five (5) Nurses working from 11:00 PM to 7:00 AM on 1/27/24. During an interview with Licensed Practical Nurse (LPN) #1 on 2/1/24 at 10:50 AM, she revealed on 1/27/24, she notified the Staff Development Coordinator (SDC), that she did not have relief for the 7:00 PM-7:00 AM shift because the scheduled nurse did not show up. The SDC stated she would notify the Director of Nursing (DON) and the Administrator and call around to find coverage. LPN #1 stated that the SDC asked her if she would stay and administer the 9:00 PM medications. LPN #1 confirmed she worked until 11:00 PM and then LPN #2 came over to count the Annex A medication cart. She stated she counted the cart with LPN #2 and left the facility. LPN #1 then revealed when she returned to work on 1/28/24 at 7:00 AM there was not a nurse assigned to the Annex A medication cart and she noticed the 6:00 AM medications had not been signed off as administered and stated I was told by one of the other nurses, not sure which one, that all the administrative nurses were aware that none of the 6:00 AM medications had been administered. LPN #1 stated that , potential concerns of there being no nurse to staff the Annex A Hall is the residents missed their medications, is the residents plan of care was not followed and that placed residents at risk to have adverse consequences such as Hypo-Hyperglycemia, unrelieved pain, seizures, and potential changes in their status that may not be identified. LPN #1 also revealed the facility consists of the 100 A and B Hall, 200 A and B Hall, and the Annex A Hall and Annex B Hall with each area having two medication carts and a nurse is supposed to be scheduled for each hall. A phone interview with LPN #2 on 1/31/24 at 1:00 PM, confirmed she counted the medication cart with LPN #1 on 1/27/24 at 11:00 PM. She stated she was assigned to the 100 Hall and only counted the narcotics for the Annex A cart until someone came in. LPN #2 confirmed she did not notify anyone that there was not a nurse for the Annex A cart. She stated she thought LPN #1 informed all the administrative staff before she left at 11:00 PM that there was no nurse for that cart. A telephone interview with LPN #3 on 1/31/24 at 2:30 PM, confirmed she worked the Annex B Hall on 1/27/24 from 7:00 PM-7:00 AM but she was unaware that the Annex A cart did not have a nurse assigned to it. She stated, I saw LPN #1 count the medication cart with another nurse. LPN # 3 then stated that she is an agency nurse and does not know the staff very well and confirmed she did not monitor any residents on the Annex A hall and did not know they did not get their morning medications. During an interview with the Assistant Director of Nursing (ADON) on 2/1/24 at 4:00 PM, he stated that the Registered Nurses (RN) take a call rotation and come in and work the medication cart if someone called in and coverage could not be found. During an interview with the Administrator on 2/2/24 at 10:00 AM, she stated that she was not aware that there was no nurse on the Annex A hall from 11:00 PM until 7:00 AM on 1/27/24 until around 7:00 AM on 1/28/24, and that the residents did not receive their 6:00 AM medications for 1/28/24. She then revealed that the SDC was the nurse on call for 1/27/24. During an interview with the ADON on 2/2/24 at 10:05 AM, he revealed that he was not aware that there was no nurse on the Annex Hall from 11:00 PM until 7:00 AM on 1/27/24, and that the residents did not receive their 6:00 AM medications. During an interview on 2/2/24 at 10:20 AM, with the SDC, she stated that on 1/27/24 at 7:49 PM she received a text from LPN #1 notifying her that the night nurse had called in. The SDC stated she texted the Administrator, DON, and ADON at 7:55 PM. The SDC stated that initially she only received a response from the Administrator who told her that she would post the opening on the agency site. She stated that she then sent a text out to nurses to attempt to get the shift covered, but no one was available, so she notified the Administrator, DON, and ADON. The SDC stated that no one accepted the shift from the agency website. She confirmed she never received a response from the ADON. During a further interview with the SDC she verified that she was the RN on call for 1/27/24, but that she is on light duty and cannot push a medication cart. She stated that she was only on call as a supervisor to attempt to find coverage for call ins. SDC further stated that she did not ask LPN #2 to count the cart with LPN #1 and she found out at 8:15 AM on 1/28/24 that the residents on the Annex A cart did not receive their 6:00 AM medications. During an interview with the RN Charge Nurse #1 on 2/2/24 at 10:30 AM, she stated she was notified by the SDC at 9:10 AM on 1/28/24 that there had been no nurse coverage for the Annex A residents for the 11:00 PM-7:00 AM shift and that the residents had not received 6:00 AM medications or accu-checks and to notify the provider and responsible party, assess the residents, and obtain vital signs. During a telephone interview with the DON on 2/2/24 at 10:45 AM, she stated that she received a phone call at 8:00 PM on 1/27/24 from Respiratory Therapist #1 (RT) notifying her that the 7:00 PM to 7:00 AM nurse for Annex A hall had called in. She stated that at that time she noticed that she had received a text at 7:58 PM from the SDC notifying her of the same thing. The DON stated that she asked the SDC if she had reached out to all the nurses that normally worked and the SDC told her that she had but no one could pick up the shift. The DON then stated that she had fallen asleep and last talked to the SDC at 10:00 PM. The DON further stated that at 10:55 PM she reached out to the SDC asking what the plan for that cart was. She stated that the SDC told her that no one had responded to the shift posted on the agency website and that LPN #1 had left. The DON stated that at 1:27 AM she reached back out to the SCD around but there was still no nurse. The DON stated that at some point the ADON had informed her that he was out town and could not cover the shift. The DON stated that the agency nurse who was working the other cart on the Annex Hall told her that she had come to the desk and made rounds on the residents but did not administer the 6:00 AM medications. The DON stated that usually if there is no nurse for a certain cart then the nurses who are on duty will administer the medications. The DON stated that when she found out the residents had not received their medications, she informed the SDC to instruct the RN supervisor to assess the residents, notify the nurse practitioner and the responsible party. The DON stated that she knew the SDC was the nurse on call and if the on-call nurse cannot find coverage then they are to come in and work the cart. The DON stated that she was aware of the SDCs medical restrictions but did not think about the SDCs limitations when she received the call. Resident #1 During an interview with Resident #1 on 1/31/24 at 9:30 AM, revealed they frequently must wait long periods of time for someone to provide incontinent care. Resident #1 stated It is worse on the night shift because they do not have enough staff. Resident #1 reported that he has sat in his bowel movement (BM) for an entire shift. During an interview with Anonymous Resident # 2 on 1/31/24 at 11:15 AM revealed the staff does not come in to check or change them at all on the night shift. During a phone interview with Anonymous Staff #1 on 1/31/24 at 5:45 PM, stated that there are not enough staff members to take care of the residents on the Annex and they are neglected. Staff #1 also stated that most of the residents are dependent, and it takes two staff members to care for them and some residents do not get changed all night. A phone interview with Anonymous Staff #2 on 1/31/24 at 7:14 PM, stated that the Annex does not have enough staff to take care of residents and the nurses do not help. They also stated that residents stay wet for extended periods of time. During an observation and interview on 2/1/24 at 12:35 AM, upon entering the Annex Hall observed two nurses sitting behind the Annex nursing desk. Two Certified Nurse assistants (CNAs) were standing in front of the desk and one CNA was walking towards the desk. An interview with Licensed Practical Nurse (LPN) #5 revealed she was working on the 11 PM to 7 AM assignment for the CNAs. She stated We were waiting for staff to arrive, we had four CNAs scheduled, one was a no call no show, the other did not arrive until 12:00 AM. An observation of Resident #1 with CNA #1 on 2/1/24 at 12:58 AM, revealed the room had a strong urine odor. Resident #1 was observed lying on his right side covered with a sheet and was observed to be wet with urine from the mid chest area to the bottom of the sheet. CNA #1 pulled back the top sheet from Resident #1 and the bottom sheet was soaked with urine extending down the bottom of the mattress and mid back area with a brown ring at edge of both sides of the bed. CNA #1 confirmed the resident was soaked and laying on sheets with old dried urine noted at the edges of the sheets. Record review of the Admission Record revealed that the facility admitted Resident #1 to the facility on [DATE] with diagnoses that included Respiratory Failure, Hemiplegia, and Cerebral Infarction. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 1/11/24, revealed Resident # 1 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated that she was severely cognitively impaired. Section H revealed Resident #1 was always incontinent of bowel and bladder. Resident #8 On 2/1/24 at 12:45 AM, during an observation and interview of the Annex Hall , a voice was heard coming from room Resident #8's room. Resident #8 was saying what took you so long, I'm soaked, I'm soaked wet. An interview with CNA # 1 reported as he exited Resident #8's room that Resident #8 was upset because she was soaking wet. He verbalized he just got his assignment at 12:40 AM and had not made previous rounds, only answered call lights because he did not know which patients he would be assigned. He then stated, this happens all the time we rarely have enough help and the residents on this hall are bed bound total care residents requiring heavy physical assistance of more than one staff member. An observation of the incontinent brief that was removed from Resident #8 by CNA #1 during perineal care was observed to be extremely saturated with dark yellow urine with a strong urine odor. There was a large bulking noted to the absorbent layer to the diaper lining with saturation noted from the top of the front to the top of the back of the brief. CNA #1 confirmed the brief removed from Resident #8 was very saturated with urine and heavy. Record review of the Admission Record revealed the facility admitted Resident #8 to the facility on [DATE] with diagnoses that included Type 2 (two) Diabetes and Vitamin deficiency. Record review of the Quarterly Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 11/07/23, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated that she was severely cognitively impaired. Section H with an ARD of 1/05/24 revealed she was always incontinent of bowel and bladder. In an interview with the Administrator on 2/2/24 at 10:20 AM, revealed on 1/31/24 on the 11 PM-7 PM shift the nurse should have made the assignment for the CNAs at the beginning of the shift to begin rounds and then adjust the assignments as the other staff came in. She confirmed if the sheets were wet then the resident had probably not been changed since previous shift. In an interview with the Assistant Director of Nursing (ADON) on 2/2/24 at 10:25 AM, he revealed concerns from not changing resident and leaving them wet is skin concerns such as moisture associated skin damage and urinary tract infections. The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: On 2/2/2024 at 12:20 P.M. State Agency (SA) notified facility Administrator of Immediate Jeopardy (IJ). State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. Facility respectfully submits this removal plan. Brief Summary of Events On 1/27/2024 the facility did not have a licensed practical nurse from 11:00pm to 7:00am on Annex cart A. During this time fourteen (14) of twenty-five (25) residents were identified as not receiving the 6 am medication dose. On 1/28/2024 an investigation was initiated by the Director of Nursing. Licensed Practical Nurse #1 assigned to Annex Cart B stated that she rounded on the twenty-five (25) residents that resided on Annex Cart A but did not administer the 6 am medications. As a result of this investigation medication error reports were initiated and orders were received from the Nurse Practitioner to omit the 6 am dose and continue the regular dosing schedule and monitor the fourteen (14) residents for any adverse effects. Corrective Actions 1. On 01/28/2024 at approximately 9:00 AM the Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 AM medications. fourteen (14) residents were identified as missing one or more medications at 6 AM on 1/28/24. 2. On 1/28/2024 at 9:00 AM, the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00 PM to 7:00 AM. 3. On 01/28/2024 at approximately 10:42 AM Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications. No adverse events were found. 4. On 1/28/2024 at approximately 11:35 AM the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. 5. On 1/28/2024 at approximately 1:00 PM the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. 6. On 1/29/2024 at approximately 9:30 AM the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 AM. 7. On 1/29/2024 at approximately 10:30 AM Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 held Ad hoc Quality Assurance Performance Improvement Meeting to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 8. On 02/02/2024 at approximately 3:30 PM Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 PM to 7:00 AM on Annex Cart A resulting in missed medications. 9. On 02/02/2024 at approximately 4:00 PM Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision. No adverse events found. 10. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. 11. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff will be allowed to return to work without completing. 12. On 2/2/2024 at 5:15 P.M. Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision. No adverse effects found. 13. On 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 14. On 2/2/2024 at 5:30 P.M. the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. 15. On 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects due to the lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 16. On 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. 17. Beginning 02/02/2024 at approximately 6:00 P.M. the Interim Director of Nursing began Competency skills check offs on licensed nurses regarding the five rights of medication administration. 18. On 2/2/2024 at 6:30 P.M. the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. 19. On 2/2/2024 at 6:30 P.M. the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. 20. On 02/02/2024 at 7:00 P.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 21. On 2/2/2024, in-services were initiated, and no staff will be able to work until receiving in-service. 22. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 02/02/2024 and the Immediate Jeopardy was removed 02/03/2024. Validation On 2/3/24, the SA surveyor validated through staff interview, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): The SA verified through record reviews, and staff interviews that on 01/28/2024, The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 AM medications. fourteen (14) residents were identified as missing one or more medications at 6 AM on 1/28/24. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00 PM to 7:00 AM. The SA verified through record reviews, and staff interviews that on 01/28/2024, at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications and that adverse events were found. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. The SA verified through record reviews, and staff interviews that on 1/29/2024 the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. The SA verified through record reviews, and staff interviews that on 1/29/2024 a Quality Assurance Performance Improvement meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, staff, and resident interviews that on 02/02/2024, a Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision with no adverse events found. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff was allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision with no adverse effects found. The SA verified through record reviews, and staff interviews that on 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects. The SA verified through record reviews, and staff interviews that on 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. The SA verified through record reviews, and staff interviews that on beginning 02/02/2024. The Interim Director of Nursing began competency skills check offs on licensed nurses regarding the five rights of medication administration. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. The SA verified through record reviews, and staff interviews that on 02/02/2024 a Quality Assurance Performance Improvement Meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 to address the notification of Immediate Jeopardy and to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, and staff interviews that on, in-services were initiated, and staff on duty had received the in-services. The SA validated on 2/3/24, that all corrective actions had been taken by the facility to remove the IJ during the survey on 2/2/24 and the IJ was removed on 2/3/24.

Based on facility policy review, record review, staff interviews, and resident interviews the facility administration failed to use its resources effectively and efficiently to ensure licensed staff was available to provide care for twenty-five (25) of (53) residents on the Annex Unit with for eight (8) hours on 1/27/24 from 11:00 PM through 7:00 AM on 1/28/24. The Licensed Practical Nurse (LPN) who was scheduled to report at 7:00 PM on 1/27/24 did not arrive for her shift at the facility. LPN #1 had worked since 7:00 AM and left the facility at 11:35 PM on 1/27/24. LPN # 2 counted the narcotic cart for Annex A hall and took the keys to the cart but did not accept responsibility for the twenty (25) residents on the Annex A hall of the facility. The Administrator, Director of Nursing (DON), and Staff Development Coordinator (SDC) were aware that the scheduled LPN did not report for her shift. Staff and agency nurses did not respond to the call for replacement. No licensed nurse reported to duty on the Annex A hall of the facility between 11:35 PM and 7:00 AM. The facility failed to follow its stated practice for replacing staff in case of call-ins or no call, no shows. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Staff Development Coordinator (SDC) were aware of the staffing problem. The On-Call SDC failed to report to duty related to limitations. The facility' s failure to provide administrative oversight and supervision to ensure sufficient nursing staff to provide supervision, care and services placed residents on the South Unit at risk, and in a situation likely to cause serious injury, serious impairment, serious harm, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) on 2/02/24, which began on 1/27/24, when the facility failed to ensure sufficient licensed nurse was present to provide necessary nursing services. On 2/02/24 at 12:20 PM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and provided the facility with the IJ Templates. The facility submitted an acceptable Removal Plan on 2/02/24 at 9:52 pm, in which the facility alleged all corrective actions to remove the IJ and SQC were completed on 2/02/24 and the IJ was removed as of 2/03/24. The SA validated the Removal Plan on 2/03/24 and determined the IJ was removed on 2/03/24, prior to exit. Therefore, the scope and severity for CFR 483.12(a)(1) Abuse and Neglect (F 600), was lowered from a J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled, Staffing, Sufficient and Competent Nursing, reviewed 3/2023, revealed, Policy Statement: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans .Minimum staffing requirements imposed by the state .are not necessarily considered a determination of sufficient and competent staffing. A record review of the Job Description: Facility Administrator, dated March 2017, revealed Basic Function: Responsible for the overall management .of the facility .Supervisory Responsibilities: The Administrator supervises the Director of Nursing .Essential Functions and Responsibilities: Operations .Ensures that the quality and appropriateness of resident care meets or exceeds company and industry standards and ensures compliance with state and federal legal, regulatory, accreditation and reimbursement guidelines. Record review of facility Daily Staffing Sheet revealed no licensed staff was on duty for the Annex A hall of the facility from 11:35 PM on 1/27/24 through 7:00 AM on 1/28/24. During an interview with the ADON on 2/1/24 at 4:00 PM, he stated that it is the facilities practice that the Registered Nurses (RN) take a call rotation and come in and work the medication cart if someone called in and coverage could not be found. In an interview with the Administrator on 2/2/24 at 10:00 AM, she stated that she was not aware that there was no nurse for Annex Cart A from 11:00 PM until 7:00 AM on 1/28/24. In an interview on 2/2/24 at 10:20 AM, with the Staff Development Coordinator she stated that on 1/27/24 at 7:49 PM she received a text from Licensed Practical Nurse #1(LPN) notifying her that the night nurse had called in. The SDC stated she text the Administrator, DON, and ADON at 7:55 PM. She stated that she then sent a text out to nurses to attempt to get the shift covered, but no one was available. The SCD stated that she notified the Administrator, DON, and ADON that there was no coverage. The SDC stated that no one accepted the shift from the agency website. During a further interview with the SDC she verified that she was the RN on call for 1/27/24, but that she is on light duty and cannot push a medication cart. She stated that she was only on call as a supervisor to attempt to find coverage for call ins. In a telephone interview with the DON on 2/2/24 at 10:45 AM, she stated that she received a phone call at 8:00 PM on 1/27/24, notifying her that the 7:00 AM to 7:00 PM nurse for the Annex had called in. The DON stated that she asked the SCD if she had reached out to all of the nurses that normally worked and the SCD told her that she had but no one could pick up the shift. The DON further stated that she had fallen asleep and reached back out at 10:55 PM to the SCD asking what the plan for that cart was. She stated that the SCD told her that no one had responded to the shift posted on the agency website and that LPN #1 left. The DON stated she reached back out to the SCD around 1:27 AM but there was still no nurse. The DON stated that at some point the ADON had informed her that he was out town and could not cover the shift. The DON stated that she was also out of town and could not cover the shift. The DON stated that she knew the SDC was the nurse on call and if the on-call nurse cannot find coverage then they are to come in and work the cart. The DON stated that she was aware of the SDC's medical restrictions but did not think about the SDC's limitations when she was notified there was no nurse for the Annex A hall. She stated that she did not think about needing someone to cover for her or the ADON due to them being out of town, or the SDC related to her medical restrictions. The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Brief Summary of Events On 1/27/2024 the facility did not have a licensed practical nurse from 11:00 PM to 7:00 AM on Annex cart A. During this time fourteen (14) of twenty-five (25) residents were identified as not receiving the 6:00 AM medication dose. On 1/28/2024 an investigation was initiated by the Director of Nursing. Licensed Practical Nurse #1 assigned to Annex Cart B stated that she rounded on the twenty-five (25) residents that resided on Annex Cart A but did not administer the 6 AM medications. As a result of this investigation medication error reports were initiated and orders were received from the Nurse Practitioner to omit the 6 AM dose and continue the regular dosing schedule and monitor the fourteen (14) residents for any adverse effects. Corrective Actions 1. On 01/28/2024 at approximately 9:00 A.M. The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 am medications. fourteen (14) residents were identified as missing one or more medications at 6 am on 1/28/24. 2. On 1/28/2024 at 9:00 A.M., the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00pm to 7:00 am. 3. On 01/28/2024 at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications. No adverse events were found. 4. On 1/28/2024 at approximately 11:35 A.M. the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. 5. On 1/28/2024 at approximately 1:00 P.M. the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. 6. On 1/29/2024 at approximately 9:30 A.M. the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. 7. On 1/29/2024 at approximately 10:30 A.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 held Ad hoc Quality Assurance Performance Improvement Meeting to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 8. On 02/02/2024 at approximately 3:30 P.M. Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. 9. On 02/02/2024 at approximately 4:00 P.M. Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision. No adverse events found. 10. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. 11. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff will be allowed to return to work without completing. 12. On 2/2/2024 at 5:15 P.M. Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision. No adverse effects found. 13. On 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 14. On 2/2/2024 at 5:30 P.M. the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. 15. On 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects due to the lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 16. On 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. 17. Beginning 02/02/2024 at approximately 6:00 P.M. the Interim Director of Nursing began Competency skills check offs on licensed nurses regarding the five rights of medication administration. 18. On 2/2/2024 at 6:30 P.M. the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. 19. On 2/2/2024 at 6:30 P.M. the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. 20. On 02/02/2024 at 7:00 P.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 21. On 2/2/2024, in-services were initiated, and no staff will be able to work until receiving in-service. 22. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 02/02/2024 and the Immediate Jeopardy was removed 02/03/2024. Validation On 2/3/24, the SA surveyor validated through staff interview, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): The SA verified through record reviews, and staff interviews that on 01/28/2024, The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 AM medications. fourteen (14) residents were identified as missing one or more medications at 6 AM on 1/28/24. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00 PM to 7:00 AM. The SA verified through record reviews, and staff interviews that on 01/28/2024, at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications and that adverse events were found. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. The SA verified through record reviews, and staff interviews that on 1/29/2024 the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. The SA verified through record reviews, and staff interviews that on 1/29/2024 a Quality Assurance Performance Improvement meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, staff, and resident interviews that on 02/02/2024, a Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision with no adverse events found. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff was allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision with no adverse effects found. The SA verified through record reviews, and staff interviews that on 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects. The SA verified through record reviews, and staff interviews that on 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. The SA verified through record reviews, and staff interviews that on beginning 02/02/2024. The Interim Director of Nursing began competency skills check offs on licensed nurses regarding the five rights of medication administration. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. The SA verified through record reviews, and staff interviews that on 02/02/2024 a Quality Assurance Performance Improvement Meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 to address the notification of Immediate Jeopardy and to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, and staff interviews that on, in-services were initiated, and staff on duty has received the in-services. The SA validated on 2/3/24, that all corrective actions had been taken by the facility to remove the IJ during the survey on 2/2/24 and the IJ was removed on 2/3/24.

Based on record review, staff interview, and facility policy review the facility failed to report to the State Survey Agency that there was no licensed nurse available for 25 residents of 146 residents residing in the facility on the 11:00 to 7:00 shift on 1/27/24. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 1/27/24 when a licensed nurse failed to report for duty and the facility failed to find a replacement. Fourteen residents did not receive their 6:00 AM medications on the 11 PM to 7:00 AM shift on 1/27/24, related to no licensed nurse assigned to the Annex A medication cart. Twenty-five residents did not receive monitoring or supervision. The facility's failure to report the negligent practice, placed the residents at risk, and in a situation which was likely to cause serious injury, serious harm, serious impairment, or death. On 2/2/24 at 12:20 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the IJ Templates. The facility submitted a credible Removal Plan on 2/2/24, in which the facility alleged all corrective actions to remove the IJ were completed on 2/2/24 and the IJ removed as 2/3/24. The SA validated the Removal Plan on 2/3/24 and determined the IJ was removed prior to exit. Therefore, the scope and severity for CFR(s)483.12(c)(1) - Reporting of Alleged Violations (F609) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Cross Reference F600, F725, F760 Review of the facility policy titled, Abuse Prohibition Policy, revised 11/7/23, revealed: .Neglect - failure of the facility, it's employees or service providers to provide goods and services to the resident, necessary to avoid physical harm, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, good or services that a resident(s) requires but the facility fails to provide them to the resident .Reporting, 2. The facility will report all allegations and substantiated occurrences of abuse, neglect, or misappropriation of resident property to the state agency and all other agencies as required by law . Interview on 2/2/24 at 10:20 AM, with the Staff Development Coordinator (SDC), she stated that on 1/27/24 at 7:49 PM, she received a text from Licensed Practical Nurse #1 (LPN) notifying her that the night nurse had called in. The SDC stated she texted the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) at 7:55 PM. She stated that she then sent a text out to nurses to attempt to get the shift covered, but no one was available, so she notified the Administrator, DON, and ADON. The SDC stated that no one accepted the shift from the agency website. She confirmed she never received a response from the ADON. She verified that she was the Registered Nurse (RN) on call for 1/27/24, but that she is on light duty and cannot push a medication cart. She stated that she was only on call as a supervisor to attempt to find coverage for call ins. SDC further stated she found out at 8:15 AM on 1/28/24 that the residents on the Annex A cart did not receive their 6:00 AM medications. Interview via telephone with the DON on 2/2/24 at 10:45 AM, she stated that she received a phone call at 8:00 PM on 1/27/24 from Respiratory Therapist #1 (RT) notifying her that the 7:00 PM to 7:00 AM nurse for the Annex A hall had called in. The DON stated that she asked the SDC if she had reached out to all the nurses that normally worked and the SDC told her that she had, but no one could pick up the shift. The DON further stated that at 10:55 PM she reached out to the SDC asking what the plan for that cart was. She stated that the SDC told her that no one had responded to the shift posted on the agency website and that LPN #1 had left. The DON stated she reached back out to the SCD around 1:27 AM but there was still no nurse. The DON stated that the agency nurse who was working the other cart on the Annex Hall told her that she had come to the desk and made rounds on the residents but did not administer the 6:00 AM medications. The DON stated that she knew the SDC was the nurse on call and if the on-call nurse cannot find coverage then they are to come in and work the cart. The DON stated that she was aware of the SDCs medical restrictions but did not think about the SDCs limitations when she received the call. The DON stated that when she found out the residents had not received their medications, she informed the SDC to instruct the Registered Nurse Supervisor (RNS) to assess the residents, notify the nurse practitioner and the responsible party. Interview with the Administrator on 2/2/24 at 10:00 AM, she stated that she was notified around 7:00 AM on 1/28/24 that there was no nurse for the Annex cart A and that some of the residents did not receive their medications scheduled for 6:00 AM. She stated that she did not report the incident to the State Agency. A record review of the Job Description: Facility Administrator, dated March 2017, revealed .Essential Functions and Responsibilities .Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal and other regulatory guidelines .Report incident reports to proper company and agency authorities in accordance with regulatory guidelines. The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Brief Summary of Events On 1/27/2024 the facility did not have a licensed practical nurse from 11:00pm to 7:00 am on Annex cart A. During this time fourteen (14) of twenty-five (25) residents were identified as not receiving the 6 am medication dose. On 1/28/2024 an investigation was initiated by the Director of Nursing. Licensed Practical Nurse #1 assigned to Annex Cart B stated that she rounded on the twenty-five (25) residents that resided on Annex Cart A but did not administer the 6 am medications. As a result of this investigation medication error reports were initiated and orders were received from the Nurse Practitioner to omit the 6 am dose and continue the regular dosing schedule and monitor the fourteen (14) residents for any adverse effects. Corrective Actions 1. On 01/28/2024 at approximately 9:00 A.M. The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 am medications. fourteen (14) residents were identified as missing one or more medications at 6 am on 1/28/24. 2. On 1/28/2024 at 9:00 A.M., the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00pm to 7:00 am. 3. On 01/28/2024 at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications. No adverse events were found. 4. On 1/28/2024 at approximately 11:35 A.M. the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. 5. On 1/28/2024 at approximately 1:00 P.M. the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. 6. On 1/29/2024 at approximately 9:30 A.M. the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. 7. On 1/29/2024 at approximately 10:30 A.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 held Ad hoc Quality Assurance Performance Improvement Meeting to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 8. On 02/02/2024 at approximately 3:30 P.M. Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. 9. On 02/02/2024 at approximately 4:00 P.M. Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision. No adverse events found. 10. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. 11. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff will be allowed to return to work without completing. 12. On 2/2/2024 at 5:15 P.M. Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision. No adverse effects found. 13. On 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 14. On 2/2/2024 at 5:30 P.M. the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. 15. On 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects due to the lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 16. On 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. 17. Beginning 02/02/2024 at approximately 6:00 P.M. the Interim Director of Nursing began Competency skills check offs on licensed nurses regarding the five rights of medication administration. 18. On 2/2/2024 at 6:30 P.M. the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. 19. On 2/2/2024 at 6:30 P.M. the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. 20. On 02/02/2024 at 7:00 P.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 21. On 2/2/2024, in-services were initiated, and no staff will be able to work until receiving in-service. 22. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 02/02/2024 and the Immediate Jeopardy was removed 02/03/2024. On 2/3/24, the SA surveyor validated through staff interview, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): The SA verified through record reviews, and staff interviews that on 01/28/2024, The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 AM medications. fourteen (14) residents were identified as missing one or more medications at 6 AM on 1/28/24. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00 PM to 7:00 AM. The SA verified through record reviews, and staff interviews that on 01/28/2024, at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications and that adverse events were found. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. The SA verified through record reviews, and staff interviews that on 1/29/2024 the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. The SA verified through record reviews, and staff interviews that on 1/29/2024 a Quality Assurance Performance Improvement meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, staff, and resident interviews that on 02/02/2024, a Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision with no adverse events found. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff was allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision with no adverse effects found. The SA verified through record reviews, and staff interviews that on 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects. The SA verified through record reviews, and staff interviews that on 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. The SA verified through record reviews, and staff interviews that on beginning 02/02/2024. The Interim Director of Nursing began competency skills check offs on licensed nurses regarding the five rights of medication administration. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. The SA verified through record reviews, and staff interviews that on 02/02/2024 a Quality Assurance Performance Improvement Meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 to address the notification of Immediate Jeopardy and to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, and staff interviews that on, in-services were initiated, and staff on duty has received the in-services. The SA validated on 2/3/24, that all corrective actions had been taken by the facility to remove the IJ during the survey on 2/2/24 and the IJ was removed on 2/3/24.

Based on staff interviews, resident interviews, facility policy review, and record review the facility failed to ensure significant medications were administered to prevent discomfort or complications for four (4) of 14 residents reviewed with medication errors. This resulted in significant medication errors for Resident #1, Resident #3, Resident #4, and Resident #5. The facility did not have licensed nurse coverage for twenty-five (25) residents on the Annex A Hall of the facility for eight (8) hours from 11:00 PM through 7:00 AM on 1/27/24. Resident #1 Resident #3, Resident #4, and Resident #5 had scheduled medications to be administered at 6:00 AM. The significant medications which were missed included anti-coagulants, anti-seizure, anti-diabetic (insulin), diuretic, and pain management medications. This placed the residents at risk and in a situation which was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 2/02/24, which began on 1/27/24, when the facility's failure to ensure sufficient licensed nurse was present to provide necessary nursing services. On 2/02/24 at 12:20 PM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the facility with the IJ Templates. The facility submitted an acceptable Removal Plan on 2/02/24 at 9:52 PM, in which the facility alleged all corrective actions to remove the IJ and SQC were completed on 2/02/24 and the IJ was removed as of 2/03/24. The SA validated the Removal Plan on 2/03/24 and determined the IJ and SQC was removed on 2/03/24, prior to exit. Therefore, the scope and severity for CFR 483.45(f)(2) (F760)- Residents are free from any significant medication errors, was lowered from an J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled, Administering Medications, revised April 2019, revealed, Medications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation: 3.) Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions .4.) Medications are administered in accordance with prescriber's orders, including any required timeframe.5.) Medication administration times are determined by the resident need and benefit, not staff convenience. Review of the facility policy titled, Adverse Consequences and Medication Errors, revised February 2023, revealed, Medication Errors: 1.) A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer guidelines, or accepted professional standards and principles of professionals providing services.5.) In the event of a significant medication-related error. Take action, to protect the resident's safety and welfare .6.) Promptly notify the provider of any significant error. Record review of the facility schedule/time sheets for 1/27/24 revealed the facility did not have licensed nurse coverage for twenty-five (25) residents on the Annex A Hall of the facility for eight (8) hours from 11:00 PM through 7:00 AM. On 1/31/24 at 1:00 PM, during a phone interview with Licensed Practical Nurse (LPN) #2, she confirmed she counted the medication cart with LPN #1 on 1/27/24 at 11:00 PM so LPN #1 could go home. She revealed she was assigned to the 100 Hall and only counted the narcotics for the Annex A cart until someone came in. She confirmed she did not administer the 6:00 AM medications or monitor the residents on Annex A hall because she was assigned to the 100 Hall and was unable to take care of residents and administer medications for two halls. On 1/31/24 at 2:30 PM, a phone interview with LPN #3 revealed she worked on 1/27/24 from 7:00 PM-7:00 AM but she was unaware that the Annex A cart did not have a nurse assigned to it and confirmed she did not monitor any residents on the Annex A hall and did not know they did not get their morning medications. On 2/1/24 at 10:50 AM, an interview with LPN #1, she revealed when she returned to work on 1/28/24 at 7:00 AM there was not a nurse assigned to the Annex A medication cart and she noticed the 6:00 AM medications had not been signed off as administered. On 2/2/24 at 10:00 AM, in an interview with the Administrator, she stated that she was not aware that there was no nurse for on the Annex A hall from 11:00 PM until 7:00 AM on 1/27/24, and that the residents did not receive their 6:00 AM medications for 1/28/24 until around 7:00 AM. She stated that the residents on Annex A hall were assessed by the RN supervisors on 1/28/24. On 2/2/24 at 10:05 AM, an interview with the Assistant Director of Nursing (ADON) revealed that failure to administer insulin, anticonvulsants, blood thinners and scheduled pain medications could lead to hyperglycemia, seizures, and unrelieved pain. On 2/2/24 at 10:20 AM, during an interview with the Staff Development Coordinator (SDC), she found out at 8:15 AM on 1/28/24 that Residents #1, #3, #4 and #5 did not receive their 6:00 AM medications. Resident #1 Review of the physician order for Resident # 1 revealed an order dated 10/12/23 for Apixaban Oral Tablet 5 mg (milligram) give one tablet by via peg-tube (percutaneous endoscopic gastrostomy) two times daily related to Cerebral Infarction. Review of the January 2024 Medication Administration Record for Resident #1 revealed Apixaban Oral Tablet 5 mg (milligram) was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #1 to the facility on [DATE] with diagnoses including Respiratory Failure, Hemiplegia, and Cerebral Infarction. Resident # 3 Review of a physician orders for Resident # 3 revealed an order dated 6/25/20 revealed Lacosamide tablet 100 mg: give one tablet by mouth two times daily related to seizures and.Keppra tablet 500 mg: give one tablet by mouth two times daily related to seizures. Review of the January 2024 Medication Administration Record for Resident #3 revealed. Lacosamide tablet 100 mg and Keppra tablet 500 mg was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #3 to the facility on [DATE] with diagnoses including Epilepsy. Resident #4 Review of a physician orders for Resident # 3 revealed an order dated 7/13/23, revealed Norco Oral tablet 7.5-325 mg (Hydrocodone Acetaminophen): give one tablet enterally every eight hours related to pain. Review of the January 2024 Medication Administration Record for Resident #4 revealed, Norco oral tablet 7.5-325 mg was not signed as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #4 to the facility on [DATE] with diagnoses including Anxiety and Pain in unspecified joint. Resident #5 Record review of physician orders for Resident # 5 revealed an order dated 9/11/23, revealed, Insulin Glargine Solution 100 units/ml: inject 8 units subcutaneously in the morning related to Type 2 (two) Diabetes. Record review of physician orders for Resident # 5 revealed an order dated 1/23/24, revealed, Furosemide 40 mg tablet: take one tablet by mouth twice daily before meals related to Hypertensive Heart Disease. Review of the January 2024 Medication Administration Record for Resident # 5 revealed, Insulin Glargine Solution 100 units/ml: inject 8 units subcutaneously and Furosemide 40 mg tablet, was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #5 to the facility on [DATE] with diagnoses including Type 2 Diabetes and Hypertensive Heart Disease. REMOVAL PLAN On 2/2/2024 at 12:20 P.M. State Agency (SA) notified facility Administrator of Immediate Jeopardy (IJ). State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. Facility respectfully submits this removal plan. Brief Summary of Events On 1/27/2024 the facility did not have a licensed practical nurse from 11:00pm to 7:00 am on Annex cart A. During this time fourteen (14) of twenty-five (25) residents were identified as not receiving the 6 am medication dose. On 1/28/2024 an investigation was initiated by the Director of Nursing. Licensed Practical Nurse #1 assigned to Annex Cart B stated that she rounded on the twenty-five (25) residents that resided on Annex Cart A but did not administer the 6 am medications. As a result of this investigation medication error reports were initiated and orders were received from the Nurse Practitioner to omit the 6 am dose and continue the regular dosing schedule and monitor the fourteen (14) residents for any adverse effects. Corrective Actions 1. On 01/28/2024 at approximately 9:00 A.M. The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 am medications. fourteen (14) residents were identified as missing one or more medications at 6 am on 1/28/24. 2. On 1/28/2024 at 9:00 A.M., the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00pm to 7:00 am. 3. On 01/28/2024 at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications. No adverse events were found. 4. On 1/28/2024 at approximately 11:35 A.M. the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. 5. On 1/28/2024 at approximately 1:00 P.M. the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. 6. On 1/29/2024 at approximately 9:30 A.M. the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 AM. 7. On 1/29/2024 at approximately 10:30 A.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 held Ad hoc Quality Assurance Performance Improvement Meeting to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 8. On 02/02/2024 at approximately 3:30 P.M. Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. 9. On 02/02/2024 at approximately 4:00 P.M. Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision. No adverse events found. 10. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. 11. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff will be allowed to return to work without completing. 12. On 2/2/2024 at 5:15 P.M. Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision. No adverse effects found. 13. On 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 14. On 2/2/2024 at 5:30 P.M. the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. 15. On 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects due to the lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 16. On 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. 17. Beginning 02/02/2024 at approximately 6:00 P.M. the Interim Director of Nursing began Competency skills check offs on licensed nurses regarding the five rights of medication administration. 18. On 2/2/2024 at 6:30 P.M. the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. 19. On 2/2/2024 at 6:30 P.M. the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. 20. On 02/02/2024 at 7:00 P.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 21. On 2/2/2024, in-services were initiated, and no staff will be able to work until receiving in-service. 22. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 02/02/2024 and the Immediate Jeopardy was removed 02/03/2024. The facility submitted an acceptable Removal Plan for the IJ on 2/2/24 at 9:52 PM. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ on 2/02/24: Validation On 2/3/24, the SA surveyor validated through staff interview, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): The SA verified through record reviews, and staff interviews that on 01/28/2024, The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 AM medications. fourteen (14) residents were identified as missing one or more medications at 6 AM on 1/28/24. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00 PM to 7:00 AM. The SA verified through record reviews, and staff interviews that on 01/28/2024, at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications and that adverse events were found. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. The SA verified through record reviews, and staff interviews that on 1/29/2024 the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. The SA verified through record reviews, and staff interviews that on 1/29/2024 a Quality Assurance Performance Improvement meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, staff, and resident interviews that on 02/02/2024, a Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision with no adverse events found. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff was allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision with no adverse effects found. The SA verified through record reviews, and staff interviews that on 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects. The SA verified through record reviews, and staff interviews that on 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. The SA verified through record reviews, and staff interviews that on beginning 02/02/2024. The Interim Director of Nursing began competency skills check offs on licensed nurses regarding the five rights of medication administration. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. The SA verified through record reviews, and staff interviews that on 02/02/2024 a Quality Assurance Performance Improvement Meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 to address the notification of Immediate Jeopardy and to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, and staff interviews that on, in-services were initiated, and staff on duty has received the in-services. The SA validated on 2/3/24, that all corrective actions had been taken by the facility to remove the IJ during the survey on 2/2/24 and the IJ was removed on 2/3/24.

Based on observations, record reviews, staff interviews, resident interviews, and policy and procedure reviews, the facility failed to provide supervision for Resident #1 when he lit his bed linens on fire with a cigarette lighter, threw the burning bed linen out into the hallway, and caused a facility fire on 07/26/2021. Resident #1 was one (1) of seven (7) residents reviewed for supervision to prevent the potential for accidents/hazards. The facility's failed to adequetely assess and develop a plan of care to reflect Resident #1's psychosocial well being and failed to supervise Resident #1 during his admission adjustment to the facility. The facility's failure to prevent the potential for accidents and hazards resulted in Resident #1 setting his bed linens on fire and throwing them out in to the hallway causing a fire that set off the fire alarms and caused the Fire Department to be dispatched to the facility in the early morning hours of 1:30 A.M. on 07/26/2021. This placed this resident and other residents at risk, in a situation that was likely to cause serious harm, injury, impairment or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 07/26/2021, when the facility's failure to provide supervision of Resident #1 as he obtained a cigarette lighter in his room and lit his bed linen on fire and threw the burning bed linens out in to the hallway of the facility. On 08/10/2021 at 4:02 PM, the State Agency (SA) notified the facility Administrator of the IJ and SQC and the facility was presented with the IJ template. The facility submitted a credible Removal Plan on 08/12/2021 at 5:29 P.M., in which the facility alleged all corrective actions to remove the IJ were completed on 08/11/2021 and the IJ removed as of 08/12/2021. The SA validated the Removal Plan on 08/14/2021 and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CFR(s): 483.25(d)(1)(2)-Accidents/Supervision (F689) was lowered from L level scope and severity to a F while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings: Record review of the facility policy and procedure titled: Fire Plan Appendix I: Fire page 150 (undated) was provided as the facility's policy and procedure for Fire Prevention. The Fire Policy revealed, Fire is a rapid oxidation process that releases energy in varying intensities in the form of heat and often light, generally creates and releases toxic vapors. Fire does not have to be in immediate proximity to be fatal. The reduced oxygen and production of smoke and fumes can release breathable air, creating an anaerobic environment that leads to asphyxiation. Not all fires create visible smoke. Inside a building where airflow is restricted, the risk of dying from oxygen starvation is greatly increased. If a fire is located at one end of the building, resident on the fire end will be evacuated to the other end of the building. If the fire is uncontrollable, all residents be evacuated outside through doors at either end of the hallway. Second floor residents will be brought downstairs at either end of the hallway and then evacuated out the side doors. After fire is discovered, nurse on that station is responsible for calling 911 and pulling fire alarm. If the fire is small and contained, fire extinguishers may be used. When evacuating room, staff must check all rooms for fire and remove all residents from rooms. When room is clear close all doors, including bathroom doors. The facility policy and procedure titled, Policy for Resident Incident and Visitor Accident Report, revised 7/23/18 and reviewed 10/08/2020 revealed, The facility will conduct an investigation of all incidents involving residents of the facility .The investigation will be conducted by designated personnel and reported to the Administrator/designee . Procedure: Reporting of Resident Incidents and Visitor Accidents: Any employee witnessing or having knowledge of an incident or accident involving a resident or visitor must immediately report such occurrence to his/her supervisor . Regardless of how minor an incident/accident appears to be, it must be reported to the Department Supervisor, Administrator, or DON/designee. As soon as possible after becoming aware of an incident/accident, the Witness Form must be completed by any person witnessing the incident or any person thought to have witnessed the incident. An Incident Report must be completed by the person reporting the incident or the supervisor on the shift that the incident occurred. The Investigation must be initiated by the Department Supervisor or Charge Nurse and completed by the Administrator or DON/designee . Observation on 08/10/2021 at 6:15 AM, of Resident #1's room revealed that the floor in front of his doorway in the hall had an area of moderate size to be discolored with brown marks that would not rub off when surveyor rubbed the brown marks with her shoes. RN#4 stated that she was not sure of what the brown discoloration was on the floor in front of Resident #1's room. At that time a staff member identifying herself as Physical Therapy (PT) staff interrupted and said those brown marks are from (Proper Name of Resident 1) throwing his burning bed linens out in to the hall. Those brown marks were not there prior to the fire. PT denied witnessing the fire. PT stated that the other staff had informed her about the fire and had shown her the brown marks to be where Res #1's burning bed linens were thrown. Observation on 08/10/2021 at 6:30 AM, revealed that the Annex unit on the first floor of the facility housed numerous bedfast, oxygen dependent, and [CONDITION(S)] residents. The facility tour of the second floor of the facility revealed several bedfast residents and residents with oxygen. Interview on 8/10/2021 at 6:54 AM,. with the Director of Nursing (DON) revealed that she had no knowledge of a fire at the facility in July 2021. The DON stated that she had been off some in July 2021 and possibly there had been a fire that she was not informed had occurred. The DON stated that she would go check her records to see if a fire was reported without her knowledge. Interview 8/10/2021 at 7:20 AM, with the Activities Director (AD) revealed that she had been the AD for three (3) years. The AD stated that she had no knowledge of a fire being discussed in the facility stand-up meeting and the AD had not been questioned or interviewed by anyone about a second fire at the facility. She stated that she is responsible for keeping all the lighters, cigarettes, cigars, and smoking materials, for the residents at the facility that use them. The AD stated that since the fire at the facility in March 2021 she locks the smoking materials up in her office through the week and day hours and on weekends and after hours the nurses lock up the smoking materials. Residents are not allowed to have lighters, matches, and/or smoking materials in their possession. Facility staff have to be outside in the smoking area with the residents during smoke breaks. AD stated that she had not attended any In-Services concerning the fire of July 2021. AD stated that there are 17 smokers in the facility and all 17 were evaluated for smoking safety. The AD stated that Res #1 is not a smoker. She stated that Res #1 was the resident that started a fire up on the second floor a couple of weeks prior. She stated that she participated in a sweep of the residents rooms to look for lighters, matches, smoking materials, and harmful items. If items were found they were to be taken to the nursing station. Interview and Observation on 08/10/2021 at 7:35 AM with Certified Nursing Assistant (CNA#4) revealed that she had worked at the facility for [AGE] years. CNA #4 stated that she worked the 6:30 AM -2:30 PM first (1st) shift at the facility on the second floor. CNA #4 confirmed that the brown discolored scorched marks on the floor were not there until Res. #1 set the fire. CNA #4 stated that Res #1 would be able to tell surveyors about what had occurred and that he was very interviewable. CNA #4 had no knowledge of Res #1 having been placed on close observation or on regular rounds checks. CNA #4 has not been interviewed or questioned concerning Res #4's mental or physical health after the fire he set on 07/26/2021. Interview and observation on 08/10/2021 at 7:38 AM, with Resident #1 stated that he was having one of those bad days. He stated: I really don't know what happened. He said that he really believed that he was on too much medicine and that being over medicated caused him to set the fire. Res #1 stated that he had a lighter that he had brought to the facility in his bag upon admission. Res #1 stated that he had been admitted to the facility about a month when he set the fire. Res #1 stated that he use to smoke but I don't smoke anymore and confirmed that he set the fire with his lighter that he had in his room. Res #1 stated that he felt bad most of the time and was in a lot of pain. Res #1 stated that he really did not know what he set on fire or where he got it from but I threw it out into the hallway. He stated that the fire department did come to the unit for the fire and that the fire alarm was sounded when he threw the fire out into the hallway. Res #1 stated that he knew now that he was not suppose to have a lighter in his possession. Res #1 stated that the fire had burned the floor tiles in front of his bedroom. He denied any injury from the fire and stated, I was ok, I did not get hurt. During the interview, he had rapid disconnected speech. At times, when he was talking, he appeared to loose his concentration. At times, during the interview, Res #1 was difficult to understand. He rambled and mumbled in a soft rapid low voice. Res #1 stated that he had not visited with a doctor since the fire and had not left the facility. He stated, I don't know what made me do it. It was one of those bad days. I started hollering 'fire' and the staff came and got it out. Interviews on 08/10/2021 at 7:57 AM, with the facility Administrator (ADM) and the facility Director of Nursing (DON) revealed the DON stated that she had received a text message that there was a possible paper fire that the nurse had put out with a blanket. The ADM stated that the facility was not required to report small fires with no injuries and there was no abuse involved. The ADM stated the small fire did not cause any damage and was not reported. The ADM stated that there had not been an investigation completed because there was nothing to investigate, the nurse had put the fire out prior to the fire department's arrival and it was very small. The ADM stated that the fire department was called but they did not have to do anything because the small fire was out when the fire department got to the facility. The ADM and DON stated that they were not sure of the exact date of the second fire but that it was 2-3 weeks prior to 08/10/2021. The ADM stated: We will have to look at the text messages in our phones to get the date of the fire. The DON and ADM did not give any details or names involved with the second floor facility fire. ADM stated that the resident involved in the fire in July 2021 was not a smoker and that he was a new admission and should not have had a lighter. Interviews on 08/10/2021 at 9:06 AM, with the Director of Social Services (DSS) and the Assistant Director of Social Services (ADSS) revealed the ADSS stated that she was made aware of a fire being set by Res #1 on 07/26/2021. The second floor first shift LPN#5 had called her on the morning after the fire and had asked her and the DSS to come to second floor to talk to Res #1 because he had set a fire on the night shift in the early morning hours and had been in possession of a cigarette lighter. The ADSS and the DSS stated that they were not sure of the date of when the fire was set by Res #1 but they thought it happened on July 26, 2021 at about 2:00 AM. Both stated that when they got to Resident #1's room they noticed that the floor outside his room was scarred as if it had been burned. They both went inside of Res #1's room and he told them that he was sitting in a car waiting on a friend to come out of the store and decided to light a cigarette. Res #1 said he noticed the fire and threw it in the hall. Res #1 stated that he threw the blanket in the hall, and yelled, fire and got back in the bed. Res #1 stated that he thought his medications were causing him to act out. The ADSS stated that Res #1 asked for a medication decrease and that she did not know for sure but thought that he had a medication decrease 48 hours prior to the fire on 07/26/2021. Both stated that Res #1 was homeless prior to his admission to the local hospital, for end stage cancer. Both stated that they have had monthly fire drills at the facility but there have been no in-services on fire prevention/safety since the fire on 07/26/2021 that was set by Res #1. They stated that they had never had a facility in-service on how to operate a fire extinguisher. The second floor LPN#5 and LPN#2 had told Social Services that Res #1 had told them that he set the fire because he was cold. Res #1 did not have a room mate on 07/26/2021. The facility did conduct a room audit of 100% of all resident rooms in the facility on Thursday (7/29/2021) after the fire. Both stated that they did not up date and/or revise Res #1's Plan of Care after the fire on 07/26/2021. The DSS and ADSS have no knowledge of any assessments/evaluations that were done for Res #1 immediately following the fire on 07/26/2021. Both were not aware of any investigations that were conducted after the fire of 07/26/2021. Interview on 08/10/2021 at 10:49 A.M. with the SSD and ADSS revealed that they were told by the ADM on 07/26/2021 not to document the incident of the fire set by Res #1 in the computer or in the Medical Record of Res #1. The ADM told them to make a written statement and to give it only to her to keep in her office in a Hot File. They stated that they are totally an electronic charting system and there were no paper charts in the facility. The hand written statements that they made were given to the ADM to keep in her office. They stated that they do inventory lists for new admissions and that if Res #1 had a lighter in his possession upon admission that it should have been obtained and placed in a box at the nursing station for the resident upon discharge. They have no documentation that Res #1 had a lighter and they stated that Res #1 was not assessed as a smoker. Observations on 08/10/2021 at 12:15 PM, of the number of rooms and the number of residents for A wing of second floor contained 13 rooms and 20 residents. The second floor of B wing had 14 rooms and 27 residents. The observation revealed that Resident #1's was located on the A wing of second floor. Interview on 08/10/201 at 2:15 PM, LPN#7 stated that she was working the first shift on the B Wing 7:00 AM - 7:00 PM on the second floor the morning of 07/26/2021. LPN#5 was working the A wing of the second floor. A wing was the wing that housed Res #1. LPN#7 stated that when she got to work the night shift nurse LPN#2, was still at work and she relayed to the day shift what had happened with Res #1 setting a fire on the night shift during the early morning hours. LPN#7 stated that no one from the facility came to the unit to conduct an investigation of the events. LPN #7 stated that Res #1 was not acting like he usually did and he seemed different. LPN#5 called the social worker and asked her to come up and talk to Res #1. LPN#7 stated that she had no knowledge of a facility investigation. Interview on 08/10/2021 at 2:22 PM, with LPN#5 stated that on 7/26/2021 she called the social worker, and asked her to come up and interview Res #1. She stated that he was not acting like he normally acted. LPN#5 thought he was pacing and walking about his room and appeared anxious. LPN#5 thought that Res #1 needed to be assessed. LPN#5 stated that Res #1 was on a lot of medication. LPN#5 had no knowledge of a facility investigation and she had not documented anything in the medical records of Res #1. LPN#5 did not have any conversation with the facility ADM or DON concerning Res #1. LPN#5 had no knowledge of Res #1 having been placed on rounds checks through the night and day and had no knowledge of Res #1 having been placed on close observation after the fire on 07/26/2021. Interview on 08/10/2021 at 3:15 PM, with the city Fire Chief revealed that the report was signed by another fireman that had attended to the fire at the facility on 07/26/2021. Fire Chief stated that the fire alarm did sound and the fire department did come to the facility early in the morning just after midnight at approximately 1:39 AM on 07/26/2021. The alarm was sounding when they arrived at the facility and the fire had been put out by a nurse on the second floor of the facility. The Fire Chief stated that there were no injuries reported. Record review of the State Fire Marshall form signed 07/26/2021 confirmed that the 911 call was dispatched through the 911 services. The 911 dispatch report was obtained and reviewed. The report documented the fire alarm dispatched the Fire Department at 1:31 AM and the Fire Department arrived at 1:39 AM. The fire was controlled at 1:53 AM and the unit was cleared at 1:53 AM. No other details were documented on the fire department report or the 911 dispatch report. Record review of the CAD Detail revealed an incoming 911 call was received at 1:31 AM on 7/26/2021 from the facility. Interviews on 08/10/2021 at 3:45 PM with LPN #7 and RN #2 revealed that the 24 hour report that was kept at the nursing station on second floor contained no reports of the fire set by Res #1 on 07/26/2021. No assessments or change in conditions documented in the 24 hour report for Res #1 on 07/26/2021. Both nurses stated that all changes in conditions, changes in mental status, changes in medications, and incidents/accidents were to be documented in the 24 hour report and maintained at the nursing station. Both nurses confirmed that the fire set by Res #1 should have been an event that was documented in the 24 hour report at the nursing station. Both nurses confirmed that there was no documentation on 07/25/2021, 07/26/2021, and 07/27/2021 contained in the 24 hour report concerning Res #1 and the fire he set on the second floor. Record review of the 24 hour reports were obtained and reviewed and there was no fire documented on the 24 hour report for 7/25/2021-7/27/2021. The mental and physical condition of Res #1 was not documented in the 24 hour reports. Interview on 08/10/2021 at 3:51 PM with the ADM and the DON confirmed that they had not investigated the fire set by Res #1 on 07/26/2021 and they had not reported the fire set by Res #1 to any State agencies. The ADM stated that she received a text message from the facility at approximately 2:00 AM on 07/26/2021 that Res #1 had set a small fire with a piece of paper. The ADM did not conduct an investigation and did not report the fire. ADM confirmed that she had not obtained any statements from Res #1 and had not updated and/or revised his plan of care or behavioral health assessments. ADM stated that it was her thoughts that Res #1 set the fire because he was use to setting fires due to his being homeless and living on the streets. ADM stated that the staff were verbally informed that a fire had occurred on 07/26/2021. ADM stated that she realized now that she had made a mistake by not reporting the fire of 07/26/2021 set by Res #1. ADM stated that they did not conduct a thorough investigation of the fire on 07/26/2021 and that they did not place Res #1 on close observation after the fire on 07/26/2021. ADM stated that resident #1 was not a smoker and they were not able to predict that a non-smoker would have a cigarette lighter. Interview on 08/11/2021 at 10:25 AM the Maintenance Director/Supervisor (Main. Super.) revealed that he had been called by someone at the facility in the early morning hours of 07/26/2021, at approximately 3:00 AM. The Maintenance Supervisor (Main. Super) was unsure of the date of the fire and was unsure of the time he was contacted. He also stated that he did not know the name of the person that called him about the fire in the facility. He stated that he did not complete any reports concerning the fire and did not document his being contacted by the facility. He stated that he was asleep in his bed when he got the call and does not remember the details. Main. Super. stated that he was unable to go back to sleep because he was worried that the fire alarm may need re-setting so he got out of his bed and drove to the facility at approximately 3:00 AM to check on the fire alarm. Main. Super. stated that when he got to the facility he went to the fire alarm to check it and to make sure it was functioning properly. The fire alarm had been re-set prior to his arriving at the facility, but he does not know who re-set the fire alarm. He stated that he went to the second floor of the facility to see where the fire had been set and to look around the facility. He stated that there was a pile of what looked like a burned blanket or sheets in the floor out in the hallway in front of Res. #1's room. The Main. Super. stated that he really was not able to make out what the burned items were and he did not touch them. He stated that he did not ask any questions of anyone and he did not dispose of the burned items that were in the floor. Main. Super. stated that he was not asked by anyone to document his findings after coming to the facility, and he was not asked to investigate the fire or its cause. Main. Super. stated that he does not have any knowledge of how the fire was started and/or who started the fire. The Main. Super. stated that he has no idea how the fire was put out, or who put out the fire. The Main. Super. stated that he conducts the monthly facility fire drills and he has had the local fire department to come to the facility a couple of times per year to instruct the staff on the use of a fire extinguisher. He stated that only a fire extinguisher is to be used in putting out a fire at the facility. Main. Super. stated that he had no knowledge of any fire prevention In-Services and/or fire extinguisher use In-Services having been conducted in the facility following the fire in July 2021. Main. Super. stated that he checked all of the facility fire extinguishers in the building and none of them had been used in putting out the fire. The Main. Super. had no knowledge of an investigation by the facility following the fire in July 2021. Main. Super. stated that all the information that was given to him was that the fire department did arrive at the facility as a result of the fire alarm sounding. Main. Super. stated that the sprinkler system had not been engaged. Main. Super. stated that he had no contact with the City Fire Department following the fire and the Fire Department had left the facility prior to his arrival. The Main. Super. confirmed that the brown discolored marks on the floor in front of Res. #1's room was caused by the fire and were not present prior to the fire. Interview on 08/11/2021 at 11:21 AM with the two (2) Social Workers, Social Services Direstor (SSD) and the Assistant Social Services Director (ASSD) revealed that they had not updated the care plan of Res #1 following the fire of 07/26/2021. SSD stated that she had not developed a care plan to address the behavioral and mental health needs of Res #1. SSD stated that neither of the Social Workers had documented their conversations and/or observations of Res #1. SSD stated that the Progress Notes for Res #1 have not been updated following the fire on 07/26/2021. SSD had no knowledge of a facility investigation that was conducted following the fire on 07/26/2021. SSD and ASSD both stated that Res #1 told them that he was in a car with another guy when he lit a cigarette and started the fire. Res #1 was delusional on 07/26/2021 and was unable to give a sound reason for starting the fire on 07/26/2021. SSD stated that there are no care plans addressing Res #1's delusional thoughts following the fire on 07/26/2021. SSD stated that Res #1 told them that he thought his medications needed adjusting. The SSD stated that there is no documentation available in Res #1's medical records to address his mental health and no care plan to address Res #1's medication adjustments. During interviews on 08/11/2021 at 2:47 PM with the three (3) second shift Certified Nursing Assistants (CNA#6, CNA #8, CNA #9) who were assigned to the second floor, all three (3) CNA's confirmed that the brown discolored marks in the floor outside of Res. #1's room was caused by the fire set by Res #1 on 07/26/2021. Observation on 08/11/2021 at 2:50 P.M. surveyor measured the brown discolored area in the hallway on the floor in front of Res. #1's room. The measurements were 31 inches long by 16 inches wide. Interview on 08/12/2021 at 12:40 PM with LPN#2, the night shift nurse who was working on the A Wing 7/26/2021 when Resident #1 set the fire on the second floor. This was the first time that she had worked with Res #1 and did not know much about him. LPN#2 stated that she was at the nursing station with the other nurse (LPN#1) when they heard CNA#1 holler FIRE and they all ran down the A wing of second floor where they saw, CNA #1, trying to put out the fire burning in the floor outside of Res. #1's room. CNA #1 had a chair pad or a brief slapping at the fire which was applying more oxygen to the fire. LPN #1 told CNA #1 to stop fanning the fire and to let her take control. LPN #2 stated that the flames from the fire were approximately as high as a resident's bed would be in its lowest position. LPN #1 obtained a blanket from the nearby linen cart and threw it on top of the burning bed linens and LPN#1 danced on top of the blanket with her feet smothering the flames which put out the fire. LPN #1 told CNA #1 to never fan a fire. It all happened so fast none of us had time to grab a fire extinguisher. LPN#1 took control and put out the fire. The fire alarm did go off and the fire doors closed. The first floor LPN#3 arrived soon after the fire was out with her fire extinguisher from first floor. LPN #3 did not have to use the fire extinguisher. LPN #3 called the DON and the ADM and then came and told LPN#2 not to document the fire in the computer and not to document the fire on the 24 hour report like was usually done. LPN #3 went to Res #1's room and he gave her a cigarette lighter from his pocket and they got his permission to search his room for more lighters and LPN #3 found a second lighter in Res #1's bag. LPN#2 confirmed that they did not remove any residents from the building and they did not assess any residents after the fire. LPN #2 stated that they did not place Res #1 on a suicide watch nor did they place Res #1 on any safety rounds checks after he set the fire on 07/26/2021. LPN#2 stated that most all the residents on second floor slept through the entire fire and the fire alarm. The city fire department did arrive on the unit after LPN#1 had put the fire out and then they left. The fire department did not clean up the burned linens and they did not ask LPN#2 any questions. LPN #2 stated that she had no idea how the fire alarm was reset or who re-set the fire alarm. LPN#2 stated that Res #1 told them that he just woke up and could not believe he had set the fire. Res #1 did not verbalize why he set the fire. He told the nurses that he was sitting in a car with some friends and decided to light a cigarette when he saw the fire. LPN #2 stated that Res #1 was quite and rather calm after the fire. LPN#2 asked Res #1 if he was hurt and he said no. LPN#2 stated that LPN #1 cleaned up the burned debris and threw it away. LPN #2 stated that no body audits of any residents were documented following the fire on 07/26/2021. LPN #2 stated that the ADM nor the DON had spoken to her about the fire and no investigation had been conducted to her knowledge. LPN#2 stated that LPN #3 had told her to write a brief statement on a piece of plain paper and put it in an envelope and leave it at the nursing station for the DON to pick up the next morning. LPN #2 stated that she had not been spoken to about the fire since it happened on 07/26/2021 at 1:30 AM. LPN #2 stated that she was told by other staff on second floor that Res #1 was not acting like he usually acted and they had thought he was not himself., but because she had not worked with Res #1 prior to 07/26/2021 she had nothing to compare his actions too. LPN #2 stated that she stayed over until the morning shift and verbally reported what had happened with the fire to the morning staff, and she called the social worker to come up and talk to Res #1 because she thought he may need to have a talk with some staff that knew him better. The LPN#2 did not up date or revise Res #1's plan of care following the fire of 07/26/2021. Observation on 08/12/2021 at 2:26 PM with the Maintenance Supervisor/Director, using his personal measuring tape, he measured the brown discolored scorched marks on the floor in front of room #210 on second floor. The Maint. Super. stated that the measurements were 29 inches long and 18 inches wide. Maint. Super. confirmed that the brown discolored marks were caused by the fire on 07/26/2021. Interview on 08/12/2021 at 4:18 PM with the psychiatric Nurse Practitioner (PNP), he confirmed that the facility had not notified him to assess Res #1 following the fire on 07/26/2021. He reported that he had no knowledge of the fire until 08/10/2021 after the surveyor entered the building to conduct an investigation. He stated that he would have usually been contacted after an event like setting a fire, but had not been contacted. PNP stated that he happened to be in the facility on 08/10/2021 when a staff member approached him and asked him to talk to Res #1 because he had set a fire on 07/26/2021 and the State was in the facility to investigate. PNP stated that he had not seen Res #1 since his admission assessment. Interview on 08/12/2021 at 8:30 PM, with LPN#1, revealed that she had been the one that put the fire out on the unit. LPN#1 stated that she was sitting at the nursing station on second floor at about 1:30 AM on 07/26/2021, when they heard someone yell out FIRE and they took off running. LPN#1 stated that CNA #1 was fanning the fire with a diaper and the flames were rising up about three (3) feet high and that CNA #1 was making the fire worse by fanning it. LPN#1 told CNA #1 to stop fanning the fire and slapping the diaper at the fire and she asked her to step back and let her put it out. LPN #1 grabbed a blanket off the linen cart that was close by and folded it in half and dropped it on top of the fire and smothered it out. She told CNA #1 to never fan at a fire that it makes it worse. LPN #1 stated that she was assigned to work B wing and that LPN #2 was assigned to work A wing of second floor. The fire was on the A wing in front of Res #1's room. LPN #1 stated that the fire alarm did sound and the fire doors did close but the sprinkler system did not activate. LPN #1 stated that there was a fair amount of smoke but not terrible. LPN #1 stated that the fire department came to the unit dressed in full fire gear. The Fire Department asked: who put out this fire and played the hero? LPN #1 stated that the fire department took a statement from her and took her phone number and told her that she had saved lives. LPN #1 stated that LPN #2 had talked to LPN #3 and was told by the ADM not to document the fire and to not put anything in the computer or in the 24 hour report book that the fire had occurred. LPN #1 stated that she had worked at the facility for years prior and had worked at State hospital for [AGE] years prior and that fires had to be well documented and statements taken from all involved, she had never be [TRUNCATED]

Based on record reviews, staff interviews, resident interviews, and policy and procedure reviews, the facility failed to develop and implement and/or revise a Comprehensive Plan of Care for one (1) of seven (7) residents reviewed for care plans. Resident #1 was not care planned for behaviors, delusions, and/or hallucinations following a fire that he set when he set bed linens on fire and threw them into the hallway outside his room. The facility's failed to adequately assess and develop a plan of care to reflect Resident #1's psychosocial well-being and failed to supervise Resident #1 during his admission adjustment to the facility. The facility's failure to prevent the potential for accidents and hazards resulted in Resident #1 setting his bed linens on fire and throwing them out into the hallway causing a fire that set off the fire alarms and caused the Fire Department to be dispatched to the facility in the early morning hours of 1:30 AM on 07/26/2021. This placed this resident and other residents at risk, in a situation that was likely to cause serious harm, injury, impairment or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 07/26/2021 when the facility's failure to provide supervision of Resident #1 as he obtained a cigarette lighter in his room and lit his bed linen on fire and threw the burning bed linens out into the hallway of the facility. On 08/11/2021 at 5:30 PM, the State Agency (SA) notified the facility Administrator of the IJ and SQC and the facility was presented with the IJ template. The facility submitted a credible Removal Plan on 08/12/2021 at 5:29 PM in which the facility alleged all corrective actions to remove the IJ were completed on 08/11/2021 and the IJ removed as of 08/12/2021. The SA validated the Removal Plan on 08/14/2021 and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CRF 483.21(b)(1) Comprehensive Care Plans (F656) was lowered from a J level scope and severity to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Finding include: Record review of the facility policy Care Plans, Comprehensive Person-Centered dated 2001 Revised December 2016 revealed A comprehensive, person - centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation .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 . d. Describe any specialized services to be provided as a result of PASARR recommendations; e. Include the resident's stated goals upon admission and desired outcomes; f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire . 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan . 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Record review of the facility policy Behavioral Health Services dated 7/22/2018 revealed, Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This involves an interdisciplinary approach to care, with qualified staff who demonstrate the competencies and skills necessary to provide appropriate services to the resident. Individualized approaches to care (including direct care and activities) are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities . Record review of Res #1's Admission Record revealed that he had been admitted to the facility on [DATE] with admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1 ' s Baseline Care Plan v1.1 dated 6/29/21 revealed A. Health Conditions/Special Treatments .B.2. Cognitive status-Cognitively intact .H. Safety Risk5. Does the resident smoke-b. Yes-Unsupervised. Progress note dated 7/9/21 at 11:19 AM revealed copy of baseline care plan and orders given to Resident. The entry was signed by RN #6/Minimum Data Set (MDS) Coordinator. Interview on 08/10/2021 at 7:38 AM, with Resident #1 (Res #1) revealed Res #1 stated that he was having one of those bad days. He stated, I really don't know what happened. Res #1 stated that he really believed that he was on too much medicine and that being over medicated caused him to set the fire. Res #1 stated that he had a lighter that he had brought to the facility in his bag upon admission. Res #1 stated that he had been admitted to the facility about a month when he set the fire. Res #1 stated that he used to smoke but I don't smoke anymore. Res #1 confirmed that he set the fire with his lighter that he had in his room. Res #1 stated that he felt bad most of the time and was in a lot of pain. Res #1 stated that he really did not know what he set on fire or where he got it from but I threw it out into the hallway. Res #1 stated that the fire department did come to the unit for the fire. Res #1 stated that the fire alarm was sounded when he threw the fire out in to the hallway. Res #1 stated that he knew now that he was not supposed to have a lighter in his possession. Res #1 stated that the fire had burned the floor tiles in front of his bedroom. Res #1 denied any injury from the fire. I was ok, I did not get hurt. Res #1 stated that he had not visited with a doctor since the fire and had not left the facility. Res #1 stated, I didn't get hurt. I don't know what made me do it. It was one of those bad days. I started hollering ' fire' and the staff came and got it out. Interview on 08/10/2021 at 9:06 AM, with the two (2) facility Social Services (SS) staff the Director of SS (DSS) and Assistant Director of SS (ADSS) stated that she was made aware of a fire being set by Res #1 on 07/26/2021. Both the SS's confirmed that they did not update and/or revise Res #1's Plan of Care after the fire on 07/26/2021. The SS's have no knowledge of any assessments/evaluations that were done for Resident #1 immediately following the fire on 07/26/2021. Interview on 08/11/2021 at 11:21 AM, with the two (2) Social Workers (SSD) and (ASSD) revealed that they had not updated the care plan of Resident #1 following the fire. SSD stated that she had not completed a care plan to address the behavioral and mental health needs of Res #1. SSD stated that she had not made referrals for services such as hospice, behavioral and mental health assessments, and services. SSD stated that neither of the Social Workers had documented their conversations and/or observations of Resident #1. SSD stated that the progress notes for Resident #1 have not been updated following the fire. Interview on 08/12/2021 at 12:40 PM, with LPN#2, night shift nurse on second floor confirmed that she was a witness to the fire set by Res #1 on 07/26/2021. LPN#2 stated that she was working the night of the fire and it was her first night back to the facility since Res #1 had been admitted to the facility. This was the first time that she had worked with Res #1 and did not know much about him. LPN#2 did not update or revise Res #1's plan of care following the fire of 07/26/2021. Record review of Res #1's medical records revealed there were no mental health assessments conducted for Res #1 following the fire of 07/26/2021. The record review revealed that the psychiatric nurse practitioner had not re-assessed Res #1 and there were no care plans to address Res #1's fire starting on 07/26/2021, and no care plans were observed in the medical records for behavioral health and mental health services discussed with Res #1. The Social Worker conducted a Brief Interview of Mental Status (BIMS) on 07/26/2021 and lowered his BIMS score one (1) point, from BIMS of 13, to BIMS of 12 which indicated mild cognitive impairment. No mood changes noted with the BIMS score. The record review revealed no revision in the care plan of Res #1. There was no documentation in the medical records of Res #1 that documented the reason why the Social Worker Director (SSD) had completed the BIMS for Res #1 on 07/26/2021. Record review of the Progress Notes for Res #1 since his admission of 06/29/2021 contained no information of his mental or behavioral assessments and/or monitoring of behaviors. REMOVAL PLAN The facility submitted a Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Brief Summary of Events On 7//26/21 at approximately 1:30 am Licensed Practical Nurse LPN#1 reported witnessing a small fire and heard fire alarm sounding simultaneously. Fire was located in middle of second floor A wing hall outside of Resident #1's room (210). Fire was located in center hall not encountering outside walls. LPN (Licensed Practical Nurse) #1 immediately extinguished fire by smothering with a blanket. LPN #! inspected area surrounding previous fire for any further active fires with none found. LP #2 contacted local fire department. LPN #1 and LPN #3 were going room to room with in location of the incident and reported Resident #1 was up sitting on edge of the bed upon entering the room. LPN #1 questioned Resident #1 on awareness of fire starting. Resident #1 reported he lit the fire because he was cold but when he started to get hot, he threw it out the room. Resident #1 was immediately assessed by LPN #1 for any injury with no injuries found. Resident#1 reported he was in possession of a lighter. Lighter was removed by LPN #1. After room search completed, a second lighter was removed by LPN #3. Resident #1 denied any pain. Resident #1 refused to answer on where he obtained the lighter from. Resident #1 reported he had lighter to keep him warm. No other Residents were in surrounding incident. Resident #1 had no roommate. Corrective Actions 1- On 07/26/21 at approximately 1:30 A.M. LPN #2 called 91 1 while facility alarm was sounding. Sprinkler systems were not activated as fire induced levels did not reach needed levels to activate. 2 -On 7/26/21 at approximately 1:33 A.M. Resident #1 was assessed by LPN #1 and found to have no injuries. The facility has no outside legal representative for Resident #1. Resident #1 is his own Responsible Party. 3- On 7/26/21 at 1:39 A.M. Yazoo City File Department arrived on scene. 4.- On 7/26/21 at 1:43 A-M. LPN#2 contacted Administrator and Director of Nursing via text message. 5.- On 7/26/21 at 1:50 A. M. Administrator contacted facility. 6.- On 7/26/21 at I A.M. Yazoo City Fire Department cleared the scene and departed the facility. 7.- On 7/26/21 beginning at approximately 8:30 A.M. Director of Nursing, RN Supervisor #1, RN Supervisor #2, Assistant Director of Nursing (ADON), Medical Records, and Activity Director began resident room checks of the entire facility to ensure all lighters were removed. Room checks were completed and no lighters were found. 8.- On 7/26/21 beginning at approximately 10:30 A.M. Staff Development Coordinator (SDC) 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 and Flammable materials and storage. 9.- On 7/28/21 at 12:30 P.M., the Medical Director, Administrator, Director Assistant Director of Nursing, Social Services, Nurse Practitioner, Activity Director Business Office Manager, Wound Care Nurse and Medical Records held Quality Assurance Performance Improvement Committee meeting where the file was discussed and Resident Safety. 10.- On 8/10/21 at approximately 12:30 P.M. Psychiatric Nurse Practitioner #1 assessed Resident #1 fi)r psychosocial, emotional, and mental distress along with a review of all of Resident #1 current medications. Psychiatric Nurse Practitioner #1 recommended a medication addition to assist with anxiousness- Resident #1 declined medication 11.- On 8/10/21 at 4:02 P.M. State Agency (SA) notified facility Administrator, Director Nursing and Assistant Director of Nursing of Immediate Jeopardy (IJ) with substandard quality of care. State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. 12.- On 8/10/21 at approximately 5:15 P.M. Director of Nursing, RN Supervisor #1, RN Supervisor #2, RN Supervisor #3, Assistant Director of Nursing (ADON), Medical Records, Business Office Manager, Assistant Business Office Manager, Admission Coordinator, Maintenance Director, and Activity Director began resident room cheeks to ensure that all lighters were removed. Room checks were completed, and no lighters were found. Room checks completed at approximately 6:00 P.M. on 8/10/21 of all rooms in the building. 13.- On 8/10/21 at 7:09 P.M. facility Administrator initiated automated phone reporting system alert to resident families and staff of combustible safety storage, including facility storage of lighters, asking families not to purchase flammable materials including new policy implementation of combustible safety to use in conjunction with the current fire prevention policy. This combustible safety policy was created by the Quality Assurance Performance Improvement committee and approved by the facility medical director. The system automatically sends alerts and contacts families and staff listed in resident's records and payroll system. 14.- On 8/10/21 beginning at 8:15 P.M. Staff Development Coordinator initiated education on Combustible Safety storage and fire prevention with staff and residents to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, Business Office staff, Therapy staff, Dietary staff, and administrative staff on new Combustible Safety Policy. No staff will be allowed to work without completing. 15.- On 8/10/21 at 9:00 P.M. Mississippi State Department of Health notified of event and pending Life Safety notification. 16.- On 8/1 1/21 at 10:30 A.M Mississippi State Department of Life Safety notified of fire with unusual incident report submitted. 17.- On 8/11/21 at 10:45 A.M. Medical Director, Administrator, Director of Nursing, RN Superviseor and RN Supervisor #4, LPN #4 held Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further occurrence including new policy on Combustible Safety Storage. Policy includes no flammable materials in Resident's possession regardless of smoking status. 18.- On 8/11/21 at 9:30 A.M. Resident Council Meeting Held with Activity Director, Activity Assistant, Admission Coordinator, Resident Council President, and 13 total residents were present to discuss the new policy on Combustible Safety to include facility storage of flammable materials regardless of smoking status. 19.- On 8/11/21 at 5:30 P.M. Mississippi State Department of Health added 3 additional Immediate Jeopardy's (IJ). 20.- On 08/11/21 at 6:00 P.M. Resident had a Smoking evaluation completed by Director of Nursing (DON) and deemed currently as non-smoker. This is second smoking evaluation completed on Resident since admission which was on 6/29/21. 21.- On 8/11/2021 at 6:45 P.M. Social Services Director (SSD) developed a plan of care based on Resident #1 hallucinations occurring on 7/26/21. Adjustments to be made to the plan of care in event of further behaviors on an as needed basis. 22.- On 08/11/2021 at 7:15 P.M. Psychosocial interviews were completed by Administrator #2 and Area Director of Business Development (ADBD)on eight (8) Residents with BIMS (Brief Interview Mental Status) of 13 or higher in the seven (7) surrounding rooms to Resident to assess for psychosocial, emotional. or mental distress surrounding fire event with no emotional concerns noted. 23.- On 8/11/2021 at 7:19 P.M. a body audit was completed on Resident #1 by the MDS (Minimum Data Set) Coordinator to assess for any injuries with no negative findings. 24.- On 08/1 1/2021 at 7:30 P-M. the Administrator and Director of Nursing received education on proper Abuse and Neglect Reporting and investigation guidelines following State and Federal Regulations by Senior Administrator from a sister facility. 25.- On 08/11/2021 at 8:40 P.M. Medical Director. Administrator, Director of Nursing, Corporate Clinical Specialist (CCS) and Area Director of Business Development (ADBD )held an Ad-Hoc Quality Assurance Performance Improvement Meeting to include notification of additional Immediate Jeopardy (IJ) tags F610, F656 and F742 with no further recommendations. 26.- On 8/11/2021 at approximately 9:30 P.M. in-services were initiated to include Care Plans with a focus on behaviors and investigations of unusual occurrences. No staff members will be able to work until they are in-serviced. 27.- Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 08/11/21, and the Immediate Jeopardy was removed 08/12/21. On Saturday August 14, 2021 the State Agency (SA) validated the facility's Removal Plan for the Immediate Jeopardy (IJ). Validations of the facility's Removal Plan was conducted through staff interview, observations, policy and procedure review, and record reviews. The SA's validations on 08/14/2021 revealed that the facility took the following actions to remove the IJ: 1-The SA validated through interview with LPN#3 on 08/14/2021 at 10:54 AM that on 07/26/21 at approximately 1:30 AM the facility fire alarm was sounding and the facility sprinkler systems were not activated as fire induced levels did not reach needed levels to activate the sprinkler system. LPN#3 validated that she called the Maintenance Director on 07/26/2021 at approximately 2:00 AM to obtain instructions as to how to reset the fire alarm after the fire had been extinguished by the facility staff. 2 -The SA validated through interview on 08/14/2021 at 10:54 AM with LPN#3, that she and LPN#1 had verbally assessed resident #1 on 7/26/21 at approximately 1:33 AM Resident #1 was verbally assessed by LPN #1 and found to have no injuries. The facility has no outside legal representative for Resident #1. Resident #1 is his own Responsible Party. 3- On 08/14/2021 at 9:00 AM the SA validated through record review of the City Fire Department's written report, that on 7/26/21 at 1:39 AM the City File Department arrived on the scene at the facility and the facility ' s fire alarm was sounding. Record review of the written City Fire Report validated that the fire was extinguished prior to their arrival at the facility. 4.- The SA validated through interview on 08/14/2021 at 10:54 AM with LPN#3 that on 7/26/21 at approximately 1:43 AM. LPN#3 had contacted the Administrator and Director of Nursing via text message that there had been a fire at the facility on 07/26/2021. 5.-The SA validated through interview on 08/14/2021 at 10:54 AM with LPN#3 that on 7/26/21 at 1:50 AM the Administrator contacted LPN#3 concerning the fire. 6.- The SA validated on 08/14/2021 through record review of the City Fire Department's Report that on 7/26/21 at 1:53 AM the City Fire Department cleared the scene and departed the facility. The SA also validated through interview on 08/14/2021 at 10:54 AM with LPN#3 that the City Fire Department came to the facility on [DATE] at approximately 1:30 AM and left the facility at approximately 1:53 AM on 07/26/2021. 7.- The SA validated on 08/14/2021 through record review that on 7/26/21 beginning at approximately 8:30 AM Director of Nursing, RN Supervisor #1, RN Supervisor #2, Assistant Director of Nursing (ADON), Medical Records, and Activity Director began resident room checks of the entire facility to ensure all lighters were removed. Room checks were completed and no lighters were found. 8.-The SA validated on 08/14/2021 through record review of the In-Services sign-in/attendance sheets, that on 7/26/21 beginning at approximately 10:30 AM Staff Development Coordinator (SDC) 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 and Flammable materials and storage. 9.- The SA validated through interview, and record review of the QA Meeting ' s sign-in/attendance sheet dated 07/28/2021, and with the facility Administrator (ADM) interview on 08/14/2021 at 10:00 AM that on 7/28/21 at 12:30 PM, the Medical Director, Administrator, Director Assistant Director of Nursing, Social Services, Nurse Practitioner, Activity Director Business Office Manager, Wound Care Nurse and Medical Records held Quality Assurance Performance Improvement Committee meeting where the file was discussed and Resident Safety. 10.-On 08/14/2021 the SA validated through record review that on 8/10/21 at approximately 12:30 PM the facility's Psychiatric Nurse Practitioner assessed Resident #1 for psychosocial, emotional, and mental distress along with a review of all of Resident #1 current medications. Psychiatric Nurse Practitioner recommended a medication addition to assist with anxiousness- Resident #1 declined medication. 11.-The SA validated on 08/14/2021 through record review that the IJ Templates were provided to the facility on [DATE] at 4:02 PM the SA validated through record review, that the notification of the IJ was provided to the facility Administrator, Director Nursing and Assistant Director of Nursing. The validation on 08/14/2021 by record review documented that the Immediate Jeopardy (IJ) with Substandard Quality of Care was provided in writing, to the facility, per the submission of the IJ Templates dated 08/10/2021 at 4:02 PM. 12.-On 08/14/2021 the SA validated through record review that on 8/10/21 at approximately 5:15 PM Director of Nursing, RN Supervisor #1, RN Supervisor #2, RN Supervisor #3, Assistant Director of Nursing (ADON), Medical Records, Business Office Manager, Assistant Business Office Manager, Admission Coordinator, Maintenance Director, and Activity Director began resident room cheeks to ensure that all lighters were removed. Room checks were completed, and no lighters were found. Room checks completed at approximately 6:00 PM on 8/10/21 of all rooms in the building. 13.-The SA validated on 08/14/2021 at 10:00 A.M. through interview with the facility ADM that on 8/10/21 at 7:09 PM the facility Administrator initiated automated phone reporting system alert to resident families and staff of combustible safety storage, including facility storage of lighters, asking families not to purchase flammable materials including new policy implementation of combustible safety to use in conjunction with the current fire prevention policy. This combustible safety policy was created by the Quality Assurance Performance Improvement committee and approved by the facility medical director. The system automatically sends alerts and contacts families and staff listed in resident's records and payroll system. 14.- On 08/14/2021 the SA validated through a record review, the In-Service sign-in/attendance sheets dated 8/10/21, that beginning at 8:15 PM the Staff Development Coordinator initiated education on Combustible Safety storage and fire prevention with staff and residents to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, Business Office staff, Therapy staff, Dietary staff, and administrative staff on new Combustible Safety Policy. No staff will be allowed to work without completing. 15.-On 08/14/2021 a record review validated that on 8/10/21 at 9:00 PM the facility notified the Mississippi State Department of Health of the 07/26/2021 fire event and of the pending Life Safety written notification. 16.- The SA validated through record review that on 08/14/2021 that on 8/11/21 at 10:30 AM Mississippi State Department of Life Safety notified of fire with unusual incident report submitted. 17.- The SA validated on 08/14/2021 through record review of the QA sign-in/attendance sheet and policy review that on 8/11/21 at 10:45 A.M. Medical Director. Administrator, Director of Nursing, RN Supervisor and LPN #4 held Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further occurrence including new policy on Combustible Safety Storage. Policy includes no flammable materials in Resident's possession regardless of smoking status. 18.- The SA validated through record review on 08/14/2021 that on 8/11/21 at 9:30 A.M. the Resident Council Meeting was held with the Activity Director, Activity Assistant, Admission Coordinator, Resident Council President, and 13 total residents were present to discuss the new policy on Combustible Safety to include facility storage of flammable materials regardless of smoking status. 19.-The SA validated, through record review of the IJ Templates, on 08/14/2021, that on 8/11/21 at 5:30 PM the Mississippi State Department of Health added 3 additional Immediate Jeopardy's (IJ). The additional IJ's were provided to the facility per the written IJ Templates for F610; F656; and F742. 20.- The SA Validated through record review on 08/14/2021, that on 08/11/21 at 6:00 PM Resident #1 had a Smoking evaluation completed by the Director of Nursing (DON) and was deemed as a non-smoker. This was the second smoking evaluation completed on Resident #1 since admission which was on 6/29/21. 21.-On 08/14/2021 at 11:50 P.M. the SA validated through an interview with the Social Services Director (SSD) and through record review of the care plan for Res #1, that on 8/11/2021 at 6:45 PM the Social Services Director (SSD) developed a Plan of Care based on Resident #1's hallucinations that occurred on 7/26/21. 22.-The SA validated through record review on 08/14/2021 that on 08/11/2021 at 7:15 PM Psychosocial interviews were completed by Administrator #2 and Area Director of Business Development (ADBD)on eight (8) Residents with BIMS (Brief Interview Mental Status) of 13 or higher in the seven (7) surrounding rooms to Resident to assess for psychosocial, emotional. or mental distress surrounding fire event with no emotional concerns noted. 23.- The SA validated through record review on 08/14/2021 that on 8/11/2021 at 7:19 PM a body audit was completed on Resident #1 by the MDS (Minimum Data Set) Coordinator to assess for any injuries with no negative findings. 24.- The SA validated through record review and through interview on 08/14/2021 at 10:00 A.M. with the facility ADM that on 08/11/2021 at 7:30 P-M. the Administrator and Director of Nursing received education on proper Abuse and Neglect Reporting and investigation guidelines following State and Federal Regulations by Senior Administrator from a sister facility. 25.- The SA validated on 08/14/2021 through record review of the QA sign-in/attendance sheets that on 08/11/2021 at 8:40 P.M. Medical Director. Administrator, Director of Nursing, Corporate Clinical Specialist (CCS) and Area Director of Business Development (ADBD ) held an Ad-Hoc Quality Assurance Performance Improvement Meeting to include notification of additional Immediate Jeopardy (IJ) tags F610, F656 and F742 with no further recommendations. 26.- On 08/14/2021 from 10:54 A.M.-12:05 P.M. the SA interviewed seven (7) CNA's; two (2) RN's; Two (2) dietary workers; two(2) office staff; two (2) house keeping staff; four (4) LPN's; two (2) Social Workers; the facility ADM and the DON, to validate that all staff working on 8/11/2021 at approximately 9:30 P.M. were in-serviced and validated that in-services were initiated to include Care Plans with a focus on behaviors and investigations of unusual occurrences. The SA validated through interview and record review on 08/14/2021 with the ADM and DON, that no staff members will be able to work until they are in-serviced. 27.-The SA validated on 08/14/2021 from 10:00 A.M. through 12:25 PM via observations, record reviews, staff interviews, and policy and procedure reviews that the facility submitted a Removal Plan for the IJ. The SA validated through record reviews, staff interviews, observations, and policy and procedure reviews, that the facility had completed all the tasks outlined in the Removal Plan on 08/11/2021 and the IJ 's were removed on 08/12/2021. On 08/14/2021 the State Agency (SA) validated, through interviews, record reviews, observations and policy and procedure reviews, that all corrective actions to remove the IJ, were completed on 08/11/2021 and the IJ was removed on 08/12/2021.

Based on record reviews, staff interviews, resident interviews, and policy and procedure reviews, the facility failed to thoroughly access and evaluate the treatment needs for Resident #1's mental and behavioral health, and failed to address Resident #1's psychosocial well-being, following a fire on 07/26/2021 that Resident #1 started in the facility. Resident #1 was one (1) of seven (7) residents reviewed for psychosocial well-being and mental and behavioral health. The facility's failed to adequately assess and develop a plan of care to reflect Resident #1's psychosocial well-being and failed to supervise Resident #1 during his admission adjustment to the facility. The facility's failure to prevent the potential for accidents and hazards resulted in Resident #1 setting his bed linens on fire and throwing them out into the hallway causing a fire that set off the fire alarms and caused the Fire Department to be dispatched to the facility in the early morning hours of 1:30 AM on 07/26/2021. This placed this resident and other residents at risk, in a situation that was likely to cause serious harm, injury, impairment or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 07/26/2021 when the facility's failure to provide supervision of Resident #1 as he obtained a cigarette lighter in his room and lit his bed linen on fire and threw the burning bed linens out into the hallway of the facility. On 08/11/2021 at 5:30 PM, the State Agency (SA) notified the facility Administrator of the IJ and SQC and the facility was presented with the IJ template. The facility submitted a credible Removal Plan on 08/12/2021 at 5:29 PM in which the facility alleged all corrective actions to remove the IJ were completed on 08/11/2021 and the IJ removed as of 08/12/2021. The SA validated the Removal Plan on 08/14/2021 and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CFR 483.40(b)(1) Treatment and Services for Mental/Psychosocial Concerns (F742) was lowered from a J level scope and severity to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy Behavioral Health Services dated 7/22/2018 revealed, Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This involves an interdisciplinary approach to care, with qualified staff who demonstrate the competencies and skills necessary to provide appropriate services to the resident. Individualized approaches to care (including direct care and activities) are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities . Observation and interviews on 08/10/2021 at 6:15 AM of Resident #1 ' s room revealed that the floor in front of his room had an area of moderate size to be discolored with brown marks that would not rub off when surveyor rubbed the brown marks with her shoes. Registered Nurse (RN) #4 stated that she was not sure of what the brown discoloration was on the floor in front of Resident #1 ' s room. At that time a staff member identifying herself as Physical Therapy (PT) staff interrupted and said, those brown marks are from Res #1 throwing his burning bed linens out in to the hall. Those brown marks were not there prior to the fire. PT denied witnessing the fire. PT stated that the other staff had informed her about the fire and had shown her the brown marks to be where Res #1's burning bed linens were thrown. Interview on 8/10/2021 at 6:54 A.M. with the Director of Nursing (DON) revealed that she had no knowledge of a fire at the facility in July 2021. Interview on 08/10/2021 at 7:35 AM, with Certified Nursing Assistant (CNA#4) revealed CNA #4 had no knowledge of Res #1 having been placed on close observation or on regular rounds checks following the fire. CNA #4 stated that she had not been interviewed or questioned concerning Res #1's mental or physical health after the fire he set on 07/26/2021. Interview and observation on 08/10/2021 at 7:38 A.M. with Resident #1 (Res #1) Res #1 stated that he was having one of those bad days. He stated, I really don't know what happened. Res #1 stated that he really believed that he was on too much medicine and that being over medicated caused him to set the fire. Res #1 stated that he really did not know what he set on fire or where he got it from but I threw it out into the hallway. Res #1 stated that the fire department did come to the unit for the fire. Res #1 stated that the fire alarm was sounded when he threw the fire out in to the hallway. Res #1 stated that he knew now that he was not supposed to have a lighter in his possession. Res #1 stated that the fire had burned the floor tiles in front of his bedroom. Res #1 denied any injury from the fire. I was ok, I did not get hurt. During the interview with Res #1 on 08/10/2021, he had rapid disconnected speech. At times, when he was talking, he appeared to lose his concentration. The rhythm of his speech was pressured, and his command of his native English language was poor. At times, during the interview, Res #1 was difficult to understand. He rambled and mumbled in a soft rapid low voice. Resident #1 had a flat affect with little animation of facial expressions during the interview. The record review of Res #1's Face Sheet revealed that he had been admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 (Res #1) had been living in the facility for 28 days when he set the fire on 07/26/2021. Record review revealed that Resident #1 had been assessed for smoking but there were no psychosocial evaluations/assessments of his mental and behavioral health after the fire was set by Res #1 on 07/26/2021. The record review revealed that there was no mention of a fire in the interdisciplinary progress notes. Interviews on 08/10/2021 at 9:06 A.M. with the two (2) facility Social Services (SS) revealed that Director of SS (DSS) revealed the SS's have no knowledge of any assessments/evaluations that were done for Res #1 immediately following the fire on 07/26/2021. SS stated that they had very little information for a Social History Report for Res #1 because he was his own Responsible Party (RP). The SS's stated that the facility's Nurse Practitioner was supposed to have done an assessment on Res #1 following the fire, but they are not aware if it was completed as of 08/10/2021. The SS's stated that they will look for paperwork. Interview on 08/10/2021 at 2:22 PM, with LPN#5, stated that she called the social worker, and asked her to come up and interview Res #1. She stated that he was not acting like he normally acted. LPN#5 thought he was pacing and walking about his room and appeared anxious. LPN#5 thought that Res #1 needed to be assessed. LPN#5 stated that Res #1 was on a lot of medication. LPN#5 had not documented anything in the medical records of Res #1. LPN#5 did not have any conversation with the facility ADM or DON concerning Res #1. LPN#5 had no knowledge of Res #1 having been placed on rounds checks through the night and day and had no knowledge of Res #1 having been placed on close observation after the fire on 07/26/2021. Record review of Res #1's medical records revealed there were no mental health assessments conducted for Res #1 following the fire of 07/26/2021. The record review revealed that the psychiatric nurse practitioner had not re-assessed Res #1. The Social Worker conducted a Brief Interview for Mental Status (BIMS) on 07/26/2021 and lowered his BIMS score one (1) point, from BIMS of 13, to BIMS of 12 which indicated mild cognitive impairment. No mood changes noted with the BIMS score. The record review revealed no progress notes documented by either of the two (2) Social Workers (SS's) for the fire of 07/26/2021.There was no documentation in the medical records of Res #1 that documented the reason why the Social Worker Director (SSD) had completed the BIMS for Res #1 on 07/26/2021. Interviews on 08/10/2021 at 3:45 PM, with the LPN #7 and RN #2 revealed that the 24-hour report that was kept at the nursing station on second floor contained no reports of the fire set by Res #1 on 07/26/2021. No assessments or change in conditions documented in the 24-hour report for Res #1 on 07/26/2021. Both nurses stated that all changes in conditions, changes in mental status, changes in medications, and incidents/accidents were to be documented in the 24-hour report and maintained at the nursing station. Both nurses confirmed that the fire set by Res #1 should have been an event that was documented in the 24-hour report at the nursing station. Both nurses confirmed that there was no documentation on 07/25/2021; 07/26/2021; and 07/27/2021 contained in the 24-hour report concerning Res #1 and the fire he set on the second floor. Record review of the 24-hour reports were obtained and there was no fire documented on the 24-hour report for 7/25/2021-7/27/2021. There was no report of Res #1 documented in the 24-hour report. There was no change in condition for Res #1 documented in the 24-hour report. Interview on 08/10/2021 at 3:51 P.M. with the ADM and the DON confirmed that they had not completed behavioral health assessments. The facility did not place Res #1 on close observation after the fire on 07/26/2021. Record review of the admission History and Physical for Res #1, completed on July 1, 2021, by the facility's Doctor of Nurse Practitioner (DNP) NP revealed, Social History: Light Smoker EtOH (alcohol) 6 cans a week H/O (history of) marijuana use . Interview on 08/11/2021 at 11:21 A.M. with the two (2) Social Workers (SSD) and (ASSD) revealed that they had not made referrals for services such as hospice, behavioral and mental health assessments, and services. SSD stated that neither of the Social Workers had documented their conversations and/or observations of Res #1. SSD stated that the progress notes for Res #1 have not been updated following the fire on 07/26/2021. They stated Res #1 was delusional on 07/26/2021 and was unable to give a sound reason for starting the fire. The SSD stated that there is no documentation available in Res #1's medical records to address his mental health and no care plan to address Res #1's medication adjustments. Interviews on 08/11/2021 at 2:47 P.M. with the three (3) second shift Certified Nursing Assistances (CNA#6, CNA #8, CNA #9) that were assigned to the second floor, revealed All three CNA's confirmed that they have not been instructed to look for behaviors of Res #1 following the fire he set. The CNA's stated that Res #1 was private and was not involved in facility activities and that Res #1 did not exchange in conversation with them. CNA #9 stated that she was an agency employee and had worked at the facility on second shift for a while and that she knew very little about Res #1. CNA #9 stated: he acts weird. CNA #8 stated that Res #1 does his own thing and doesn't often respond. CNA #8 stated that Res #1 refuses a lot. CNA #6 stated that Res #1 was a private person and the CNA's had little interaction with him because he was a private person. Interview on 08/12/2021 at 12:40 PM, with LPN#2 confirmed that they did not remove any residents from the building, and they did not assess any residents after the fire. LPN #2 stated that they did not place Res #1 on a suicide watch, nor did they place Res #1 on any safety rounds checks after he set the fire on 07/26/2021. LPN#2 stated that Res #1 told them that he just woke up and could not believe he had set the fire. Res #1 did not verbalize why he set the fire. He told the nurses that he was sitting in a car with some friends and decided to light a cigarette when he saw the fire. LPN #2 stated that Res #1 was quiet and rather calm after the fire. Res #1 never did admit to setting the fire. LPN#2 asked Res #1 if he was hurt, and he said no. LPN #2 stated that she was told by other staff on second floor that Res #1 was not acting like he usually acted and they had thought he was not himself. But because she had not worked with Res #1 prior to 07/26/2021 she had nothing to compare his actions too. LPN #2 stated that she stayed over until the morning shift and verbally reported what had happened with the fire to the morning staff, and she called the social worker to come up and talk to Res #1 because she thought he may need to have a talk with some staff that knew him better. Interview on 08/12/2021 at 4:18 PM, with the Psychiatric Nurse Practitioner (PNP), confirmed that the facility had not notified him to assess Res #1 following the fire on 07/26/2021. He reported that he had no knowledge of the fire until 08/10/2021 after the surveyor entered the building to conduct an investigation. He stated that he would have usually been contacted after an event like setting a fire but had not been contacted. PNP stated that he happened to be in the facility on 08/10/2021, when a staff member approached him and asked him to talk to Res #1 because he had set a fire on 07/26/2021. PNP stated that he had not seen Res #1 since his admission assessment. PNP stated that Res #1 did not want to take anti-depressant medications and did not admit to having depression or anxiety. PNP stated that he did feel that Res #1 was depressed and somewhat anxious but that Res #1 denied these symptoms. PNP stated that he wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . PNP stated that he did a medication review of all of Res #1's medications on 08/10/2021 when he saw Res #1. Interview on 08/12/2021 at 8:30 PM, with LPN#1, revealed that she had been the one that put the fire out on the unit. LPN #1 stated that she and LPN #3 had gone in to talk to Res #1 immediately after the fire was put out on 07/26/2021 and he appeared scared and anxious. LPN #1 stated that he was not acting like he normally had and that he volunteered to give them the cigarette lighter from his pocket. She stated there were not any close observations or rounds checks following the fire on 07/26/2021. LPN #1 stated that Res #1 did not realize what he had done and when the Fire Department came to the unit he was pacing and walking in his room and was anxious. Interview on 08/14/2021 at 10:54 AM, with (LPN #3) revealed that Res #1 was unaware of what he had done. He told LPN #3 that he was cold and was trying to get warm. LPN #3 stated that she had not worked with Res #1 prior and she thought maybe he had had a dream or something. Res #1 talked about cars being in his room and friends talking to him and giving him a cigarette to light. LPN #3 stated that she had no knowledge of Res #1's assessments following the fire. Record review of the progress notes for Res #1 since his admission of 06/29/2021, contained no information of his mental or behavioral assessments and/or monitoring of behaviors. There was no documentation in Res #1's progress notes documenting the fire of 07/26/2021. The record review revealed that Res #1 had voiced delusional thoughts following the fire that he set on 07/26/2021. The facility record review did not reveal documentation that the facility had appropriately addressed Res #1's delusions. The facility had not documented any attempts at obtaining behavioral health services for Res #1 immediately following the fire set by Res #1 on 07/26/2021. REMOVAL PLAN The facility submitted a Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Brief Summary of Events On 7//26/21 at approximately 1:30 am Licensed Practical Nurse LPN#1 reported witnessing a small fire and heard fire alarm sounding simultaneously. Fire was located in middle of second floor A wing hall outside of Resident #1's room (210). Fire was located in center hall not encountering outside walls. LPN (Licensed Practical Nurse) #1 immediately extinguished fire by smothering with a blanket. LPN #! inspected area surrounding previous fire for any further active fires with none found. LP #2 contacted local fire department. LPN #1 and LPN #3 were going room to room with in location of the incident and reported Resident #1 was up sitting on edge of the bed upon entering the room. LPN #1 questioned Resident #1 on awareness of fire starting. Resident #1 reported he lit the fire because he was cold but when he started to get hot, he threw it out the room. Resident #1 was immediately assessed by LPN #1 for any injury with no injuries found. Resident#1 reported he was in possession of a lighter. Lighter was removed by LPN #1. After room search completed, a second lighter was removed by LPN #3. Resident #1 denied any pain. Resident #1 refused to answer on where he obtained the lighter from. Resident #1 reported he had lighter to keep him warm. No other Residents were in surrounding incident. Resident #1 had no roommate. Corrective Actions 1- On 07/26/21 at approximately 1:30 A.M. LPN #2 called 91 1 while facility alarm was sounding. Sprinkler systems were not activated as fire induced levels did not reach needed levels to activate. 2 -On 7/26/21 at approximately 1:33 A.M. Resident #1 was assessed by LPN #1 and found to have no injuries. The facility has no outside legal representative for Resident #1. Resident #1 is his own Responsible Party. 3- On 7/26/21 at 1:39 A.M. Yazoo City File Department arrived on scene. 4.- On 7/26/21 at 1:43 A-M. LPN#2 contacted Administrator and Director of Nursing via text message. 5.- On 7/26/21 at 1:50 A. M. Administrator contacted facility. 6.- On 7/26/21 at I A.M. Yazoo City Fire Department cleared the scene and departed the facility. 7.- On 7/26/21 beginning at approximately 8:30 A.M. Director of Nursing, RN Supervisor #1, RN Supervisor #2, Assistant Director of Nursing (ADON), Medical Records, and Activity Director began resident room checks of the entire facility to ensure all lighters were removed. Room checks were completed, and no lighters were found. 8.- On 7/26/21 beginning at approximately 10:30 A.M. Staff Development Coordinator (SDC) 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 and Flammable materials and storage. 9.- On 7/28/21 at 12:30 P.M., the Medical Director, Administrator, Director Assistant Director of Nursing, Social Services, Nurse Practitioner, Activity Director Business Office Manager, Wound Care Nurse and Medical Records held Quality Assurance Performance Improvement Committee meeting where the file was discussed and Resident Safety. 10.- On 8/10/21 at approximately 12:30 P.M. Psychiatric Nurse Practitioner #1 assessed Resident #1 fi)r psychosocial, emotional, and mental distress along with a review of all of Resident #1 current medications. Psychiatric Nurse Practitioner #1 recommended a medication addition to assist with anxiousness- Resident #1 declined medication 11.- On 8/10/21 at 4:02 P.M. State Agency (SA) notified facility Administrator, Director Nursing and Assistant Director of Nursing of Immediate Jeopardy (IJ) with substandard quality of care. State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. 12.- On 8/10/21 at approximately 5:15 P.M. Director of Nursing, RN Supervisor #1, RN Supervisor #2, RN Supervisor #3, Assistant Director of Nursing (ADON), Medical Records, Business Office Manager, Assistant Business Office Manager, Admission Coordinator, Maintenance Director, and Activity Director began resident room cheeks to ensure that all lighters were removed. Room checks were completed, and no lighters were found. Room checks completed at approximately 6:00 P.M. on 8/10/21 of all rooms in the building. 13.- On 8/10/21 at 7:09 P.M. facility Administrator initiated automated phone reporting system alert to resident families and staff of combustible safety storage, including facility storage of lighters, asking families not to purchase flammable materials including new policy implementation of combustible safety to use in conjunction with the current fire prevention policy. This combustible safety policy was created by the Quality Assurance Performance Improvement committee and approved by the facility medical director. The system automatically sends alerts and contacts families and staff listed in resident's records and payroll system. 14.- On 8/10/21 beginning at 8:15 P.M. Staff Development Coordinator initiated education on Combustible Safety storage and fire prevention with staff and residents to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, Business Office staff, Therapy staff, Dietary staff, and administrative staff on new Combustible Safety Policy. No staff will be allowed to work without completing. 15.- On 8/10/21 at 9:00 P.M. Mississippi State Department of Health notified of event and pending Life Safety notification. 16.- On 8/1 1/21 at 10:30 A.M Mississippi State Department of Life Safety notified of fire with unusual incident report submitted. 17.- On 8/11/21 at 10:45 A.M. Medical Director. Administrator, Director of Nursing, RN Supervisor and RN Supervisor #4, LPN #4 held Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further occurrence including new policy on Combustible Safety Storage. Policy includes no flammable materials in Resident's possession regardless of smoking status. 18.- On 8/11/21 at 9:30 A.M. Resident Council Meeting Held with Activity Director, Activity Assistant, Admission Coordinator, Resident Council President, and 13 total residents were present to discuss the new policy on Combustible Safety to include facility storage of flammable materials regardless of smoking status. 19.- On 8/11/21 at 5:30 P.M. Mississippi State Department of Health added 3 additional Immediate Jeopardy's (IJ). 20.- On 08/11/21 at 6:00 P.M. Resident had a Smoking evaluation completed by Director of Nursing (DON) and deemed currently as non-smoker. This is second smoking evaluation completed on Resident since admission which was on 6/29/21. 21.- On 8/11/2021 at 6:45 P.M. Social Services Director (SSD) developed a plan of care based on Resident #1 hallucinations occuring on 7/26/21. Adjustments to be made to the plan of care in event of further behaviors on an as needed basis. 22.- On 08/11/2021 at 7:15 P.M. Psychosocial interviews were completed by Administrator #2 and Area Director of Business Development (ADBD)on eight (8) Residents with BIMS (Brief Interview Mental Status) of 13 or higher in the seven (7) surrounding rooms to Resident to assess for psychosocial, emotional. or mental distress surrounding fire event with no emotional concerns noted. 23.- On 8/11/2021 at 7:19 P.M. a body audit was completed on Resident #1 by the MDS (Minimum Data Set) Coordinator to assess for any injuries with no negative findings. 24.- On 08/1 1/2021 at 7:30 P-M. the Administrator and Director of Nursing received education on proper Abuse and Neglect Reporting and investigation guidelines following State and Federal Regulations by Senior Administrator from a sister facility. 25.- On 08/11/2021 at 8:40 P.M. Medical Director. Administrator, Director of Nursing, Corporate Clinical Specialist (CCS) and Area Director of Business Development (ADBD) held an Ad-Hoc Quality Assurance Performance Improvement Meeting to include notification of additional Immediate Jeopardy (IJ) tags F610, F656 and F742 with no further recommendations. 26.- On 8/11/2021 at approximately 9:30 P.M. in-services were initiated to include Care Plans with a focus on behaviors and investigations of unusual occurrences. No staff members will be able to work until they are in-serviced. 27.- Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 08/11/21, and the Immediate Jeopardy was removed 08/12/21. On Saturday August 14, 2021 the State Agency (SA) validated the facility's Removal Plan for the Immediate Jeopardy (IJ). Validations of the facility's Removal Plan was conducted through staff interview, observations, policy and procedure review, and record reviews. The SA's validations on 08/14/2021 revealed that the facility took the following actions to remove the IJ: 1-The SA validated through interview with LPN#3 on 08/14/2021 at 10:54 AM that on 07/26/21 at approximately 1:30 AM the facility fire alarm was sounding and the facility sprinkler systems were not activated as fire induced levels did not reach needed levels to activate the sprinkler system. LPN#3 validated that she called the Maintenance Director on 07/26/2021 at approximately 2:00 AM to obtain instructions as to how to reset the fire alarm after the fire had been extinguished by the facility staff. 2 -The SA validated through interview on 08/14/2021 at 10:54 AM with LPN#3, that she and LPN#1 had verbally assessed resident #1 on 7/26/21 at approximately 1:33 AM Resident #1 was verbally assessed by LPN #1 and found to have no injuries. The facility has no outside legal representative for Resident #1. Resident #1 is his own Responsible Party. 3- On 08/14/2021 at 9:00 AM the SA validated through record review of the City Fire Department's written report, that on 7/26/21 at 1:39 AM the City File Department arrived on the scene at the facility and the facility ' s fire alarm was sounding. Record review of the written City Fire Report validated that the fire was extinguished prior to their arrival at the facility. 4.- The SA validated through interview on 08/14/2021 at 10:54 AM with LPN#3 that on 7/26/21 at approximately 1:43 AM. LPN#3 had contacted the Administrator and Director of Nursing via text message that there had been a fire at the facility on 07/26/2021. 5.-The SA validated through interview on 08/14/2021 at 10:54 AM with LPN#3 that on 7/26/21 at 1:50 AM the Administrator contacted LPN#3 concerning the fire. 6.- The SA validated on 08/14/2021 through record review of the City Fire Department's Report that on 7/26/21 at 1:53 AM the City Fire Department cleared the scene and departed the facility. The SA also validated through interview on 08/14/2021 at 10:54 AM with LPN#3 that the City Fire Department came to the facility on [DATE] at approximately 1:30 AM and left the facility at approximately 1:53 AM on 07/26/2021. 7.- The SA validated on 08/14/2021 through record review that on 7/26/21 beginning at approximately 8:30 AM Director of Nursing, RN Supervisor #1, RN Supervisor #2, Assistant Director of Nursing (ADON), Medical Records, and Activity Director began resident room checks of the entire facility to ensure all lighters were removed. Room checks were completed and no lighters were found. 8.-The SA validated on 08/14/2021 through record review of the In-Services sign-in/attendance sheets, that on 7/26/21 beginning at approximately 10:30 AM Staff Development Coordinator (SDC) 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 and Flammable materials and storage. 9.- The SA validated through interview, and record review of the QA Meeting ' s sign-in/attendance sheet dated 07/28/2021, and with the facility Administrator (ADM) interview on 08/14/2021 at 10:00 AM that on 7/28/21 at 12:30 PM, the Medical Director, Administrator, Director Assistant Director of Nursing, Social Services, Nurse Practitioner, Activity Director Business Office Manager, Wound Care Nurse and Medical Records held Quality Assurance Performance Improvement Committee meeting where the file was discussed and Resident Safety. 10.-On 08/14/2021 the SA validated through record review that on 8/10/21 at approximately 12:30 PM the facility's Psychiatric Nurse Practitioner assessed Resident #1 for psychosocial, emotional, and mental distress along with a review of all of Resident #1 current medications. Psychiatric Nurse Practitioner recommended a medication addition to assist with anxiousness- Resident #1 declined medication. 11.-The SA validated on 08/14/2021 through record review that the IJ Templates were provided to the facility on [DATE] at 4:02 PM the SA validated through record review, that the notification of the IJ was provided to the facility Administrator, Director Nursing and Assistant Director of Nursing. The validation on 08/14/2021 by record review documented that the Immediate Jeopardy (IJ) with Substandard Quality of Care was provided in writing, to the facility, per the submission of the IJ Templates dated 08/10/2021 at 4:02 PM. 12.-On 08/14/2021 the SA validated through record review that on 8/10/21 at approximately 5:15 PM Director of Nursing, RN Supervisor #1, RN Supervisor #2, RN Supervisor #3, Assistant Director of Nursing (ADON), Medical Records, Business Office Manager, Assistant Business Office Manager, Admission Coordinator, Maintenance Director, and Activity Director began resident room cheeks to ensure that all lighters were removed. Room checks were completed, and no lighters were found. Room checks completed at approximately 6:00 PM on 8/10/21 of all rooms in the building. 13.-The SA validated on 08/14/2021 at 10:00 A.M. through interview with the facility ADM that on 8/10/21 at 7:09 PM the facility Administrator initiated automated phone reporting system alert to resident families and staff of combustible safety storage, including facility storage of lighters, asking families not to purchase flammable materials including new policy implementation of combustible safety to use in conjunction with the current fire prevention policy. This combustible safety policy was created by the Quality Assurance Performance Improvement committee and approved by the facility medical director. The system automatically sends alerts and contacts families and staff listed in resident's records and payroll system. 14.- On 08/14/2021 the SA validated through a record review, the In-Service sign-in/attendance sheets dated 8/10/21, that beginning at 8:15 PM the Staff Development Coordinator initiated education on Combustible Safety storage and fire prevention with staff and residents to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, Business Office staff, Therapy staff, Dietary staff, and administrative staff on new Combustible Safety Policy. No staff will be allowed to work without completing. 15.-On 08/14/2021 a record review validated that on 8/10/21 at 9:00 PM the facility notified the Mississippi State Department of Health of the 07/26/2021 fire event and of the pending Life Safety written notification. 16.- The SA validated through record review that on 08/14/2021 that on 8/11/21 at 10:30 AM Mississippi Sta [TRUNCATED]

Based on record review, staff interview, resident interview, and policy and procedure review, the facility failed to report a facility fire, that was set by a resident, to the appropriate State Agency(s) for one (1) of seven (7) residents reviewed for accidents/hazards. Resident #1 set his bed linen on fire with a cigarette lighter and threw it out in the hallway of the facility which sounded the fire alarm and deployed the fire department to the facility on [DATE]. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 07/26/2021, regarding the facility's noncompliance for not reporting and thoroughly investigating accidents/hazards of a facility fire set by Resident #1 on 07/26/2021. The facility failed to supervise and thoroughly assess Resident #1 to avoid the potential for danger to Resident #1 and to the other facility residents and staff. Resident #1 started a facility fire on 07/26/2021 at approximately 1:30 AM when he set his bed linen on fire with a cigarette lighter and threw it out into the hallway of the facility which activated the facility fire alarm and summoned/deployed the fire department to the facility. Immediately following the fire on 07/26/2021 at approximately 1:30 AM, the facility failed to thoroughly investigate the fire, and failed to report the fire as required per Federal and State regulations. The facility failed to devise/revise the comprehensive plan of care for Resident #1 after he ignited his bed linen with a cigarette lighter causing a facility fire of 07/26/2021. The facility failed to thoroughly assess Resident #1's mental and behavioral health in order to address his psychosocial well-being. The facility failed to obtain the appropriate mental health and behavioral health services to address Resident #1's psychosocial well-being after the fire occurred on 07/26/2021. The facility's failure to adequately supervise Resident #1 resulted in his setting his bed linen on fire with a cigarette lighter and throwing it out in to the hallway of the facility which placed this resident and other residents who reside in the facility in a situation that was likely to cause serious harm, injury, impairment or death. On 08/10/2021 at 4:02 PM, the State Agency (SA) notified the facility Administrator of the IJ and SQC and the facility was presented with the IJ templates. The facility submitted an acceptable Removal Plan on 08/12/2021 at 2:29 PM, in which the facility alleged all corrective actions to remove the IJ's were completed on 08/11/2021 and the IJ's were removed on 08/12/2021. The State Agency (SA) validated the Removal Plan on 08/14/2021 and determined the IJ's were removed on 08/12/2021, prior to exit. Therefore, the Scope and Severity for 42 CFR(s): 483.12(c)(4) Reporting (F609); was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory standards. Findings include: Record review of the Abuse Prohibition Policy dated revised 5/28/2021 revealed, .All new current employees will receive training and reinforcement on all aspects of this abuse prohibition program. This will be done at the time of initial employee orientation, annually, and through ongoing in-service. The training will include, but not be limited to . Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical or psychosocial indicators . Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms, include, but are not limited to, the following: i. Aggressive and/or catastrophic reactions of residents; ii. Wandering or elopement -type behaviors; iii. Resistance to care; iv. Outbursts or yelling out; v. and Difficulty in adjusting to new routines or staff. Prevention: 4. Facility staff will immediately correct and intervene in reported or identified situations in which abuse/neglect is at risk for occurring. 5. Residents identified as exhibiting abusive behaviors will be reviewed and have their treatment plans modified as appropriate .Investigation: 1. The facility will thoroughly investigate all alleged violations and take appropriate actions .3. The facility will report the results of the investigation to the enforcement agency in accordance with state law, including the state agency and certification agency .5. Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions .Procedure for Prevention of Misappropriation of Resident Property: 1. Upon admission, the facility will assist the resident /family to identify and label personal possessions. 2. A personal possessions inventory will be completed and maintained in the resident's medical record. 3. Resident /family will be educated on the importance of reporting any significant items being brought in /removed so that the inventory can be updated. Interview on 8/10/2021 at 6:54 AM with the Director of Nursing (DON) revealed upon request by the SA of the Accident and Incident (A&I) Report and verification that that the facility had reported the fire to the SA (State Agency) in a timely manner, she stated she had no knowledge of a fire at the facility in July 2021. DON stated that she had been off some in July 2021 and possibly there had been a fire that she was not informed had occurred. Interview and observation on 08/10/2021 at 7:38 AM, with Resident #1 stated that he was having one of those bad days. He stated: I really don't know what happened. He said that he really believed that he was on too much medicine and that being over medicated caused him to set the fire. Res #1 stated that he had a lighter that he had brought to the facility in his bag upon admission. Res #1 stated that he had been admitted to the facility about a month when he set the fire. Res #1 stated that he use to smoke but I don't smoke anymore and confirmed that he set the fire with his lighter that he had in his room. Res #1 stated that he felt bad most of the time and was in a lot of pain. Res #1 stated that he really did not know what he set on fire or where he got it from but I threw it out into the hallway. He stated that the fire department did come to the unit for the fire and that the fire alarm was sounded when he threw the fire out into the hallway. Res #1 stated that he knew now that he was not suppose to have a lighter in his possession. Res #1 stated that the fire had burned the floor tiles in front of his bedroom. He denied any injury from the fire and stated, I was ok, I did not get hurt. During the interview, he had rapid disconnected speech. At times, when he was talking, he appeared to loose his concentration. At times, during the interview, Res #1 was difficult to understand. He rambled and mumbled in a soft rapid low voice. Res #1 stated that he had not visited with a doctor since the fire and had not left the facility. He stated, I don't know what made me do it. It was one of those bad days. I started hollering 'fire' and the staff came and got it out. Interviews on 08/10/2021 at 7:57 AM, with the facility Administrator (ADM) and the facility Director of Nursing (DON) revealed that ADM had been at the facility for five (5) years and the DON had been at the facility for [AGE] years and had been the DON for six (6) years. DON stated that she had received a text message that there was a possible paper fire that the nurse had put out with a blanket. The ADM stated that the facility was not required to report small fires with no injuries and there was no abuse involved. The ADM stated the small fire did not cause any damage and was not reported. ADM stated that there had not been an investigation completed because there was nothing to investigate, the nurse had put the fire out prior to the fire department's arrival and it was very small. ADM stated that the fire department was called but they did not have to do anything because the small fire was out when the fire department got to the facility. The ADM and DON stated that they were not sure of the exact date of the second fire but that it was 2-3 weeks prior to 08/10/2021. The ADM stated: We will have to look at the text messages in our phones to get the date of the fire. DON and ADM did not give any details or names involved with the second floor facility fire. ADM stated that the resident involved in the fire in July 2021 was not a smoker and that he was a new admission and should not have had a lighter. Interview on 08/10/2021 at 3:15 PM, with the City Fire Chief, revealed that the report was signed by another firemen that had attended to the fire at the facility on 07/26/2021. Fire Chief stated that the fire alarm did sound and the fire department did come to the facility early in the morning just after midnight at approximately 1:39 A.M. on 07/26/2021. The alarm was sounding when they arrived at the facility and the fire had been put out by a nurse on the second floor of the facility. The Fire Chief stated that there were no injuries reported. The fire Chief stated that he would provide a copy of the fire department report to the surveyors. Record review of the City Fire Dept Report confirmed that the 911 call was dispatched through the 911 services. The 911 dispatch report was obtained and reviewed. The report documented the fire alarm dispatched the Fire Department at 1:31 AM and the Fire Department arrived at 1:39 AM The fire was controlled at 1:53 AM and the unit was cleared at 1:53 AM No other details were documented on the fire department report or the 911 dispatch report. Record review of the 24 hour reports were obtained and there was no fire documented on the 24 hour report for 7/25/2021-7/27/2021. There was no report of Res #1 documented in the 24 hour report. There was no change in condition for Res #1 documented in the 24 hour report. Interview on 08/10/2021 at 3:51 PM with the ADM and the DON confirmed that they had not investigated the fire set by Res #1 on 07/26/2021 and they had not reported the fire set by Res #1 to any State agencies. The ADM stated that she received a text message from the facility at approximately 2:00 AM on 07/26/2021 that Res #1 had set a small fire with a piece of paper. The ADM did not conduct an investigation and did not report the fire. The ADM confirmed that she had not obtained any statements from Res #1 and had not updated and/or revised his plan of care or behavioral health assessments. ADM stated that it was her thoughts that Res #1 set the fire because he was use to setting fires due to his being homeless and living on the streets. ADM stated that the staff were verbally informed that a fire had occurred on 07/26/2021. The ADM stated that she realized now that she had made a mistake by not reporting the fire of 07/26/2021 set by Res #1. ADM stated that they did not conduct a thorough investigation of the fire on 07/26/2021 and that they did not place Res #1 on close observation after the fire on 07/26/2021. The ADM stated that Resident #1 was not a smoker and they were not able to predict that a non-smoker would have a cigarette lighter. Record review of the admission History and Physical for Res #1, completed on July 1, 2021 by the facility's Doctor of Nurse Practitioner (DNP) NP, documented: Social History: Light Smoker Etoh (alcohol) 6 cans a week H/O (history of) marijuana use. Interview on 08/11/2021 at 4:48 PM, with the Corporate Regional Director, revealed that the ADM had contacted him about the fire after it happened on 07/26/2021 and had reported to him that it was a small fire caused by a piece of paper that was lit on fire and that it involved no injuries and the fire was put out easily by an employee with no incidents. The Regional Director confirmed that he had told the ADM not to report the fire to any of the State agencies because it was a non-reportable incident that did not involve abuse. Interview on 08/12/2021 at 12:40 P.M. with LPN#2, the night shift nurse on second floor assigned to Resident #1 on 7/26/2021. LPN#2 confirmed that she was a witness to the fire set by Res #1 on 07/26/2021. LPN #2 stated that the ADM nor the DON had spoken to her about the fire and no investigation had been conducted to her knowledge. LPN#2 stated that LPN #3 had told her to write a brief statement on a piece of plain paper and put it in an envelope and leave it at the nursing station for the DON to pick up the next morning. LPN #2 stated that she had not been spoken to about the fire since it happened on 07/26/2021 at 1:30 AM. LPN #2 stated that she stayed over until the morning shift and verbally reported what had happened with the fire to the morning staff, and she called the social worker to come up and talk to Res #1 because she thought he may need to have a talk with some staff that knew him better. Interview on 08/12/2021 at 8:30 P.M. with LPN#1, revealed that she had been the one that put the fire out on the unit. LPN #1 stated that LPN #2 had talked to LPN #3 and was told by the ADM not to document the fire and to not put anything in the computer or in the 24 hour report book that the fire had occurred. LPN #1 stated that she had worked at the facility for years prior and had worked at State Hospital for [AGE] years prior and that fires had to be well documented and statements taken from all involved. LPN#1 had never been told, until 07/26/2021, to not document a fire. LPN #1 stated that she felt that it was wrong to not report the fire and/or to not document the events of the fire, but she and LPN #2 did what they were instructed to do by LPN #3, who had talked to the ADM. LPN #1 stated that she gave a written statement, for the first time, to the ADM on Tuesday morning 08/10/2021 after the surveyors entered the facility. Interview on 08/14/2021 at 10:54 A.M. with (LPN #3) revealed that she had been the first floor LPN on 07/26/2021. LPN #3 called the Maintenance Director, to tell him of the fire and to get instructions as to how to turn off the fire alarm. LPN #3 stated that she called the ADM and DON and they told her to relay to the staff up on second floor not to document the fire in the computer and not to document in the medical records of Res #1. LPN #3 went back upstairs and told the LPN #1 and LPN #2 not to document the fire, as she had been told by the ADM. LPN #3 stated that she had not been asked about the fire on 07/26/2021 and had not given a statement about the fire until 08/10/2021. LPN #3 has no knowledge of the fire having been reported and or investigated prior to 08/10/2021. Interview on 08/14/2021 at 1:30 P.M. with CNA #1 revealed that she was the second floor CNA on 07/26/2021 and she was the one that discovered the fire burning in the hallway outside of Resident #1's room. CNA #1 stated that she did not document the fire and she was not asked to document any information. REMOVAL PLAN The facility submitted a Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Brief Summary of Events On 7//26/21 at approximately 1:30 am Licensed Practical Nurse LPN#1 reported witnessing a small fire and heard fire alarm sounding simultaneously. Fire was located in middle of second floor A wing hall outside of Resident #1's room (210). Fire was located in center hall not encountering outside walls. LPN (Licensed Practical Nurse) #1 immediately extinguished fire by smothering with a blanket. LPN #! inspected area surrounding previous fire for any further active fires with none found. LP #2 contacted local fire department. LPN #1 and LPN #3 were going room to room with in location of the incident and reported Resident #1 was up sitting on edge of the bed upon entering the room. LPN #1 questioned Resident #1 on awareness of fire starting. Resident #1 reported he lit the fire because he was cold but when he started to get hot, he threw it out the room. Resident #1 was immediately assessed by LPN #1 for any injury with no injuries found. Resident#1 reported he was in possession of a lighter. Lighter was removed by LPN #1. After room search completed, a second lighter was removed by LPN #3. Resident #1 denied any pain. Resident #1 refused to answer on where he obtained the lighter from. Resident #1 reported he had lighter to keep him warm. No other Residents were in surrounding incident. Resident #1 had no roommate. Corrective Actions 1- On 07/26/21 at approximately 1:30 A.M. LPN #2 called 91 1 while facility alarm was sounding. Sprinkler systems were not activated as fire induced levels did not reach needed levels to activate. 2 -On 7/26/21 at approximately 1:33 A.M. Resident #1 was assessed by LPN #1 and found to have no injuries. The facility has no outside legal representative for Resident #1. Resident #1 is his own Responsible Party. 3- On 7/26/21 at 1:39 A.M. Yazoo City File Department arrived on scene. 4.- On 7/26/21 at 1:43 A-M. LPN#2 contacted Administrator and Director of Nursing via text message. 5.- On 7/26/21 at 1:50 A. M. Administrator contacted facility. 6.- On 7/26/21 at I A.M. Yazoo City Fire Department cleared the scene and departed the facility. 7.- On 7/26/21 beginning at approximately 8:30 A.M. Director of Nursing, RN Supervisor #1, RN Supervisor #2, Assistant Director of Nursing (ADON), Medical Records, and Activity Director began resident room checks of the entire facility to ensure all lighters were removed. Room checks were completed and no lighters were found. 8.- On 7/26/21 beginning at approximately 10:30 A.M. Staff Development Coordinator (SDC) 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 and Flammable materials and storage. 9.- On 7/28/21 at 12:30 P.M., the Medical Director, Administrator, Director Assistant Director of Nursing, Social Services, Nurse Practitioner, Activity Director Business Office Manager, Wound Care Nurse and Medical Records held Quality Assurance Performance Improvement Committee meeting where the file was discussed and Resident Safety. 10.- On 8/10/21 at approximately 12:30 P.M. Psychiatric Nurse Practitioner #1 assessed Resident #1 fi)r psychosocial, emotional, and mental distress along with a review of all of Resident #1 current medications. Psychiatric Nurse Practitioner #1 recommended a medication addition to assist with anxiousness- Resident #1 declined medication 11.- On 8/10/21 at 4:02 P.M. State Agency (SA) notified facility Administrator, Director Nursing and Assistant Director of Nursing of Immediate Jeopardy (IJ) with substandard quality of care. State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. 12.- On 8/10/21 at approximately 5:15 P.M. Director of Nursing, RN Supervisor #1, RN Supervisor #2, RN Supervisor #3, Assistant Director of Nursing (ADON), Medical Records, Business Office Manager, Assistant Business Office Manager, Admission Coordinator, Maintenance Director, and Activity Director began resident room cheeks to ensure that all lighters were removed. Room checks were completed, and no lighters were found. Room checks completed at approximately 6:00 P.M. on 8/10/21 of all rooms in the building. 13.- On 8/10/21 at 7:09 P.M. facility Administrator initiated automated phone reporting system alert to resident families and staff of combustible safety storage, including facility storage of lighters, asking families not to purchase flammable materials including new policy implementation of combustible safety to use in conjunction with the current fire prevention policy. This combustible safety policy was created by the Quality Assurance Performance Improvement committee and approved by the facility medical director. The system automatically sends alerts and contacts families and staff listed in resident's records and payroll system. 14.- On 8/10/21 beginning at 8:15 P.M. Staff Development Coordinator initiated education on Combustible Safety storage and fire prevention with staff and residents to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, Business Office staff, Therapy staff, Dietary staff, and administrative staff on new Combustible Safety Policy. No staff will be allowed to work without completing. 15.- On 8/10/21 at 9:00 P.M. Mississippi State Department of Health notified of event and pending Life Safety notification. 16.- On 8/1 1/21 at 10:30 A.M Mississippi State Department of Life Safety notified of fire with unusual incident report submitted. 17.- On 8/11/21 at 10:45 A.M. Medical Director, Administrator, Director of Nursing, RN Superviseor and RN Supervisor #4, LPN #4 held Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further occurrence including new policy on Combustible Safety Storage. Policy includes no flammable materials in Resident's possession regardless of smoking status. 18.- On 8/11/21 at 9:30 A.M. Resident Council Meeting Held with Activity Director, Activity Assistant, Admission Coordinator, Resident Council President, and 13 total residents were present to discuss the new policy on Combustible Safety to include facility storage of flammable materials regardless of smoking status. 19.- On 8/11/21 at 5:30 P.M. Mississippi State Department of Health added 3 additional Immediate Jeopardy's (IJ). 20.- On 08/11/21 at 6:00 P.M. Resident had a Smoking evaluation completed by Director of Nursing (DON) and deemed currently as non-smoker. This is second smoking evaluation completed on Resident since admission which was on 6/29/21. 21.- On 8/11/2021 at 6:45 P.M. Social Services Director (SSD) developed a plan of care based on Resident #1 hallucinations occurring on 7/26/21. Adjustments to be made to the plan of care in event of further behaviors on an as needed basis. 22.- On 08/11/2021 at 7:15 P.M. Psychosocial interviews were completed by Administrator #2 and Area Director of Business Development (ADBD)on eight (8) Residents with BIMS (Brief Interview Mental Status) of 13 or higher in the seven (7) surrounding rooms to Resident to assess for psychosocial, emotional. or mental distress surrounding fire event with no emotional concerns noted. 23.- On 8/11/2021 at 7:19 P.M. a body audit was completed on Resident #1 by the MDS (Minimum Data Set) Coordinator to assess for any injuries with no negative findings. 24.- On 08/1 1/2021 at 7:30 P-M. the Administrator and Director of Nursing received education on proper Abuse and Neglect Reporting and investigation guidelines following State and Federal Regulations by Senior Administrator from a sister facility. 25.- On 08/11/2021 at 8:40 P.M. Medical Director. Administrator, Director of Nursing, Corporate Clinical Specialist (CCS) and Area Director of Business Development (ADBD )held an Ad-Hoc Quality Assurance Performance Improvement Meeting to include notification of additional Immediate Jeopardy (IJ) tags F610, F656 and F742 with no further recommendations. 26.- On 8/11/2021 at approximately 9:30 P.M. in-services were initiated to include Care Plans with a focus on behaviors and investigations of unusual occurrences. No staff members will be able to work until they are in-serviced. 27.- Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 08/11/21, and the Immediate Jeopardy was removed 08/12/21. On Saturday August 14, 2021 the State Agency (SA) validated the facility's Removal Plan for the Immediate Jeopardy (IJ). Validations of the facility's Removal Plan was conducted through staff interview, observations, policy and procedure review, and record reviews. The SA's validations on 08/14/2021 revealed that the facility took the following actions to remove the IJ: 1-The SA validated through interview with LPN#3 on 08/14/2021 at 10:54 AM that on 07/26/21 at approximately 1:30 AM the facility fire alarm was sounding and the facility sprinkler systems were not activated as fire induced levels did not reach needed levels to activate the sprinkler system. LPN#3 validated that she called the Maintenance Director on 07/26/2021 at approximately 2:00 AM to obtain instructions as to how to reset the fire alarm after the fire had been extinguished by the facility staff. 2 -The SA validated through interview on 08/14/2021 at 10:54 AM with LPN#3, that she and LPN#1 had verbally assessed resident #1 on 7/26/21 at approximately 1:33 AM Resident #1 was verbally assessed by LPN #1 and found to have no injuries. The facility has no outside legal representative for Resident #1. Resident #1 is his own Responsible Party. 3- On 08/14/2021 at 9:00 AM the SA validated through record review of the City Fire Department's written report, that on 7/26/21 at 1:39 AM the City File Department arrived on the scene at the facility and the facility ' s fire alarm was sounding. Record review of the written City Fire Report validated that the fire was extinguished prior to their arrival at the facility. 4.- The SA validated through interview on 08/14/2021 at 10:54 AM with LPN#3 that on 7/26/21 at approximately 1:43 AM. LPN#3 had contacted the Administrator and Director of Nursing via text message that there had been a fire at the facility on 07/26/2021. 5.-The SA validated through interview on 08/14/2021 at 10:54 AM with LPN#3 that on 7/26/21 at 1:50 AM the Administrator contacted LPN#3 concerning the fire. 6.- The SA validated on 08/14/2021 through record review of the City Fire Department's Report that on 7/26/21 at 1:53 AM the City Fire Department cleared the scene and departed the facility. The SA also validated through interview on 08/14/2021 at 10:54 AM with LPN#3 that the City Fire Department came to the facility on [DATE] at approximately 1:30 AM and left the facility at approximately 1:53 AM on 07/26/2021. 7.- The SA validated on 08/14/2021 through record review that on 7/26/21 beginning at approximately 8:30 AM Director of Nursing, RN Supervisor #1, RN Supervisor #2, Assistant Director of Nursing (ADON), Medical Records, and Activity Director began resident room checks of the entire facility to ensure all lighters were removed. Room checks were completed and no lighters were found. 8.-The SA validated on 08/14/2021 through record review of the In-Services sign-in/attendance sheets, that on 7/26/21 beginning at approximately 10:30 AM Staff Development Coordinator (SDC) 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 and Flammable materials and storage. 9.- The SA validated through interview, and record review of the QA Meeting ' s sign-in/attendance sheet dated 07/28/2021, and with the facility Administrator (ADM) interview on 08/14/2021 at 10:00 AM that on 7/28/21 at 12:30 PM, the Medical Director, Administrator, Director Assistant Director of Nursing, Social Services, Nurse Practitioner, Activity Director Business Office Manager, Wound Care Nurse and Medical Records held Quality Assurance Performance Improvement Committee meeting where the file was discussed and Resident Safety. 10.-On 08/14/2021 the SA validated through record review that on 8/10/21 at approximately 12:30 PM the facility's Psychiatric Nurse Practitioner assessed Resident #1 for psychosocial, emotional, and mental distress along with a review of all of Resident #1 current medications. Psychiatric Nurse Practitioner recommended a medication addition to assist with anxiousness- Resident #1 declined medication. 11.-The SA validated on 08/14/2021 through record review that the IJ Templates were provided to the facility on [DATE] at 4:02 PM the SA validated through record review, that the notification of the IJ was provided to the facility Administrator, Director Nursing and Assistant Director of Nursing. The validation on 08/14/2021 by record review documented that the Immediate Jeopardy (IJ) with Substandard Quality of Care was provided in writing, to the facility, per the submission of the IJ Templates dated 08/10/2021 at 4:02 PM. 12.-On 08/14/2021 the SA validated through record review that on 8/10/21 at approximately 5:15 PM Director of Nursing, RN Supervisor #1, RN Supervisor #2, RN Supervisor #3, Assistant Director of Nursing (ADON), Medical Records, Business Office Manager, Assistant Business Office Manager, Admission Coordinator, Maintenance Director, and Activity Director began resident room cheeks to ensure that all lighters were removed. Room checks were completed, and no lighters were found. Room checks completed at approximately 6:00 PM on 8/10/21 of all rooms in the building. 13.-The SA validated on 08/14/2021 at 10:00 A.M. through interview with the facility ADM that on 8/10/21 at 7:09 PM the facility Administrator initiated automated phone reporting system alert to resident families and staff of combustible safety storage, including facility storage of lighters, asking families not to purchase flammable materials including new policy implementation of combustible safety to use in conjunction with the current fire prevention policy. This combustible safety policy was created by the Quality Assurance Performance Improvement committee and approved by the facility medical director. The system automatically sends alerts and contacts families and staff listed in resident's records and payroll system. 14.- On 08/14/2021 the SA validated through a record review, the In-Service sign-in/attendance sheets dated 8/10/21, that beginning at 8:15 PM the Staff Development Coordinator initiated education on Combustible Safety storage and fire prevention with staff and residents to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, Business Office staff, Therapy staff, Dietary staff, and administrative staff on new Combustible Safety Policy. No staff will be allowed to work without completing. 15.-On 08/14/2021 a record review validated that on 8/10/21 at 9:00 PM the facility notified the Mississippi State Department of Health of the 07/26/2021 fire event and of the pending Life Safety written notification. 16.- The SA validated through record review that on 08/14/2021 that on 8/11/21 at 10:30 AM Mississippi State Department of Life Safety notified of fire with unusual incident report submitted. 17.- The SA validated on 08/14/2021 through record review of the QA sign-in/attendance sheet and policy review that on 8/11/21 at 10:45 A.M. Medical Director. Administrator, Director of Nursing, RN Supervisor and LPN #4 held Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further occurrence including new policy on Combustible Safety Storage. Policy includes no flammable materials in Resident's possession regardless of smoking status. 18.- The SA validated through record review on 08/14/2021 that on 8/11/21 at 9:30 A.M. the Resident Council Meeting was held with the Activity Director, Activity Assistant, Admission Coordinator, Resident Council President, and 13 total residents were present to discuss the new policy on Combustible Safety to include facility storage of flammable materials regardless of smoking status. 19.-The SA validated, through record review of the IJ Templates, on 08/14/2021, that on 8/11/21 at 5:30 PM the Mississippi State Department of Health added 3 additional Immediate Jeopardy's (IJ). The additional IJ's were provided to the facility per the written IJ Templates for F610; F656; and F742. 20.- The SA Validated through record review on 08/14/2021, that on 08/11/21 at 6:00 PM Resident #1 had a Smoking evaluation completed by the Director of Nursing (DON) and was deemed as a non-smoker. This was the second smoking evaluation completed on Res [TRUNCATED]

Based on observation, record review, staff interviews, resident interviews, and policy and procedure reviews the facility failed to thoroughly investigate a facility fire that was set by Resident #1 when he ignited his bed linen with a cigarette lighter and threw them out in to the hallway which resulted in a facility fire. Resident #1 was one (1) of seven (7) residents reviewed for thorough investigations after an accident/hazard. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 07/26/2021, regarding the facility's noncompliance in thoroughly investigating a facility fire set by Resident #1 on 07/26/2021. The facility failed to supervise and thoroughly assess Resident #1 to avoid the potential for danger to Resident #1 and to the other facility residents and staff. Resident #1 started a facility fire on 07/26/2021 at approximately 1:30 AM when he set his bed linen on fire with a cigarette lighter and threw it out into the hallway of the facility which activated the facility fire alarm and summoned/deployed the fire department to the facility. Immediately following the fire on 07/26/2021 at approximately 1:30 AM, the facility failed to thoroughly investigate the fire, and failed to report the fire as required per Federal and State regulations. The facility failed to devise/revise the comprehensive plan of care for Resident #1 after he ignited his bed linen with a cigarette lighter causing a facility fire of 07/26/2021. The facility failed to thoroughly assess Resident #1's mental and behavioral health in order to address his psychosocial well-being. The facility failed to obtain the appropriate mental health and behavioral health services to address Resident #1's psychosocial well-being after the fire occurred on 07/26/2021. The facility's failure to adequately supervise Resident #1 resulted in his setting his bed linen on fire with a cigarette lighter and throwing it out in to the hallway of the facility which placed this resident and other residents who reside in the facility in a situation that was likely to cause serious harm, injury, impairment or death. On 08/10/2021 at 4:02 PM, the State Agency (SA) notified the facility Administrator of the IJ and SQC and the facility was presented with the IJ templates. The facility submitted an acceptable Removal Plan on 08/12/2021 at 2:29 PM, in which the facility alleged all corrective actions to remove the IJ's were completed on 08/11/2021 and the IJ's were removed on 08/12/2021. The State Agency (SA) validated the Removal Plan on 08/14/2021 and determined the IJ's were removed on 08/12/2021, prior to exit. Therefore, the Scope and Severity for 42 CFR(s): 483.12(c)(2)Investigate/Prevent/Correct Alleged Violations (F610), was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory standards. Findings include: The facility policy and procedure titled, Policy for Resident Incident and Visitor Accident Report, revised 7/23/18 and reviewed 10/08/2020 revealed, The facility will conduct an investigation of all incidents involving residents of the facility .The investigation will be conducted by designated personnel and reported to the Administrator/designee . Procedure: Reporting of Resident Incidents and Visitor Accidents: Any employee witnessing or having knowledge of an incident or accident involving a resident or visitor must immediately report such occurrence to his/her supervisor . Regardless of how minor an incident/accident appears to be, it must be reported to the Department Supervisor, Administrator, or DON/designee. As soon as possible after becoming aware of an incident/accident, the Witness Form must be completed by any person witnessing the incident or any person thought to have witnessed the incident. An Incident Report must be completed by the person reporting the incident or the supervisor on the shift that the incident occurred. The Investigation must be initiated by the Department Supervisor or Charge Nurse and completed by the Administrator or DON/designee . Record review of the Abuse Prohibition Policy, dated original 5/01/01 reviewed 10/8/2020 revision 5/28/2021 revealed .All new current employees will receive training and reinforcement on all aspects of this abuse prohibition program. This will be done at the time of initial employee orientation, annually, and through ongoing in-service Investigation: 1. The facility will thoroughly investigate all alleged violations and take appropriate actions .3. The facility will report the results of the investigation to the enforcement agency in accordance with state law, including the state agency and certification agency .5. Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions . Observation on 08/10/2021 at 6:15 A.M. revealed that the floor in the hallway in front of Resident #1's room had an area of moderate size to be discolored with brown marks that would not rub off when surveyor rubbed the brown marks with her shoes. Interview on 8/10/2021 at 6:54 AM,. with the Director of Nursing (DON) revealed that she had no knowledge of a fire at the facility in July 2021. The DON stated that she had been off some in July 2021 and possibly there had been a fire that she was not informed had occurred. The DON stated that she would go check her records to see if a fire was reported without her knowledge. Interview and observation on 08/10/2021 at 7:38 AM, with Resident #1 stated that he was having one of those bad days. He stated: I really don't know what happened. He said that he really believed that he was on too much medicine and that being over medicated caused him to set the fire. Res #1 stated that he had a lighter that he had brought to the facility in his bag upon admission. Res #1 stated that he had been admitted to the facility about a month when he set the fire. Res #1 stated that he use to smoke but I don't smoke anymore and confirmed that he set the fire with his lighter that he had in his room. Res #1 stated that he felt bad most of the time and was in a lot of pain. Res #1 stated that he really did not know what he set on fire or where he got it from but I threw it out into the hallway. He stated that the fire department did come to the unit for the fire and that the fire alarm was sounded when he threw the fire out into the hallway. Res #1 stated that he knew now that he was not suppose to have a lighter in his possession. Res #1 stated that the fire had burned the floor tiles in front of his bedroom. He denied any injury from the fire and stated, I was ok, I did not get hurt. During the interview, he had rapid disconnected speech. At times, when he was talking, he appeared to loose his concentration. At times, during the interview, Res #1 was difficult to understand. He rambled and mumbled in a soft rapid low voice. Res #1 stated that he had not visited with a doctor since the fire and had not left the facility. He stated, I don't know what made me do it. It was one of those bad days. I started hollering 'fire' and the staff came and got it out. Interviews on 08/10/2021 at 7:57 A.M. with the facility Administrator (ADM) and the facility Director of Nursing (DON) revealed the DON stated that she had received a text message that there was a possible paper fire that the nurse had put out with a blanket. The ADM stated that there had not been an investigation completed because there was nothing to investigate, the nurse had put the fire out prior to the fire department's arrival and it was very small. ADM stated that the fire department was called but they did not have to do anything because the small fire was out when the fire department got to the facility. The ADM and DON stated that they were not sure of the exact date of the second fire but that it was 2-3 weeks prior to 08/10/2021. The ADM stated: We will have to look at the text messages in our phones to get the date of the fire. The DON and ADM did not give any details or names involved with the second floor facility fire. Interview on 08/10/2021 at 10:49 A.M. with the two Social Services (2) SS's revealed that they were told by the ADM on 07/26/2021 not to document the incident of the fire set by Res #1 in the computer or in the Medical Record of Res #1. The ADM told them to make a written statement and to give it only to her to keep in her office in a Hot File. The SS's stated that they are totally an electronic charting system and there were no paper charts in the facility. The hand written statements that they made were given to the ADM to keep in her office. Interview on 08/10/2021 at 3:15 P.M. with the City Fire Chief, revealed that the report was signed by another firemen that had attended to the fire at the facility on 07/26/2021. Fire Chief stated that the fire alarm did sound and the fire department did come to the facility early in the morning just after midnight at approximately 1:39 A.M. on 07/26/2021. The alarm was sounding when they arrived at the facility and the fire had been put out by a nurse on the second floor of the facility. Record review of the City Fire Dept Report confirmed that the 911 call was dispatched through the 911 services. The 911 dispatch report was obtained and reviewed. The report documented the fire alarm dispatched the Fire Department at 1:31 A.M. and the Fire Department arrived at 1:39 A.M. The fire was controlled at 1:53 A.M. and the unit was cleared at 1:53 A.M. No other details were documented on the fire department report or the 911 dispatch report. Interview on 08/10/2021 at 3:51 P.M. with the ADM and the DON confirmed that they had not investigated the fire set by Res #1 on 07/26/2021. The ADM stated that she received a text message from the facility at approximately 2:00 A.M. on 07/26/2021 that Res #1 had set a small fire with a piece of paper. The ADM did not conduct an investigation and did not report the fire. The ADM confirmed that she had not obtained any statements from Res #1. Interview on 08/12/2021 at 12:40 P.M. with LPN#2, night shift nurse on second floor. LPN#2 confirmed that she was a witness to the fire set by Res #1 on 07/26/2021. She stated LPN #3 called the DON and the ADM and then came and told LPN#2 not to document the fire in the computer and not to document the fire on the 24 hour report like was usually done. LPN #2 stated that the ADM nor the DON had spoken to her about the fire and no investigation had been conducted to her knowledge. LPN#2 stated that LPN #3 had told her to write a brief statement on a piece of plain paper and put it in an envelope and leave it at the nursing station for the DON to pick up the next morning. LPN #2 stated that she had not been spoken to about the fire since it happened on 07/26/2021 at 1:30 AM. Interview on 08/12/2021 at 8:30 PM, with LPN#1, revealed that she had been the one that put the fire out on the unit. LPN #1 stated that LPN #2 had talked to LPN #3 and was told by the ADM not to document the fire and to not put anything in the computer or in the 24 hour report book that the fire had occurred. LPN #1 stated that she had worked at the facility for years prior and had worked at State Hospital for [AGE] years prior and that fires had to be well documented and statements taken from all involved. LPN#1 had never been told, until 07/26/2021, to not document a fire. LPN #1 stated that she felt that it was wrong to not report the fire and/or to not document the events of the fire, but she and LPN #2 did what they were instructed to do by LPN #3, who had talked to the ADM. LPN #1 stated that she gave a written statement, for the first time, to the ADM on Tuesday morning 08/10/2021 after the surveyors entered the facility. Interview on 08/14/2021 at 10:54 A.M. with (LPN #3) revealed that she had been the first floor LPN on 07/26/2021. LPN #3 stated that she called the ADM and DON and they told her to relay to the staff up on second floor not to document the fire in the computer and not to document in the medical records of Res #1. LPN #3 went back upstairs and told the LPN #1 and LPN #2 not to document the fire, as she had been told by the ADM. LPN #3 stated that she had not been asked about the fire on 07/26/2021 and had not given a statement about the fire until 08/10/2021. LPN #3 has no knowledge of the fire having been investigated prior to 08/10/2021. REMOVAL PLAN The facility submitted a Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Brief Summary of Events On 7//26/21 at approximately 1:30 am Licensed Practical Nurse LPN#1 reported witnessing a small fire and heard fire alarm sounding simultaneously. Fire was located in middle of second floor A wing hall outside of Resident #1's room (210). Fire was located in center hall not encountering outside walls. LPN (Licensed Practical Nurse) #1 immediately extinguished fire by smothering with a blanket. LPN #! inspected area surrounding previous fire for any further active fires with none found. LP #2 contacted local fire department. LPN #1 and LPN #3 were going room to room with in location of the incident and reported Resident #1 was up sitting on edge of the bed upon entering the room. LPN #1 questioned Resident #1 on awareness of fire starting. Resident #1 reported he lit the fire because he was cold but when he started to get hot, he threw it out the room. Resident #1 was immediately assessed by LPN #1 for any injury with no injuries found. Resident#1 reported he was in possession of a lighter. Lighter was removed by LPN #1. After room search completed, a second lighter was removed by LPN #3. Resident #1 denied any pain. Resident #1 refused to answer on where he obtained the lighter from. Resident #1 reported he had lighter to keep him warm. No other Residents were in surrounding incident. Resident #1 had no roommate. Corrective Actions 1- On 07/26/21 at approximately 1:30 A.M. LPN #2 called 91 1 while facility alarm was sounding. Sprinkler systems were not activated as fire induced levels did not reach needed levels to activate. 2 -On 7/26/21 at approximately 1:33 A.M. Resident #1 was assessed by LPN #1 and found to have no injuries. The facility has no outside legal representative for Resident #1. Resident #1 is his own Responsible Party. 3- On 7/26/21 at 1:39 A.M. Yazoo City File Department arrived on scene. 4.- On 7/26/21 at 1:43 A-M. LPN#2 contacted Administrator and Director of Nursing via text message. 5.- On 7/26/21 at 1:50 A. M. Administrator contacted facility. 6.- On 7/26/21 at I A.M. Yazoo City Fire Department cleared the scene and departed the facility. 7.- On 7/26/21 beginning at approximately 8:30 A.M. Director of Nursing, RN Supervisor #1, RN Supervisor #2, Assistant Director of Nursing (ADON), Medical Records, and Activity Director began resident room checks of the entire facility to ensure all lighters were removed. Room checks were completed and no lighters were found. 8.- On 7/26/21 beginning at approximately 10:30 A.M. Staff Development Coordinator (SDC) 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 and Flammable materials and storage. 9.- On 7/28/21 at 12:30 P.M., the Medical Director, Administrator, Director Assistant Director of Nursing, Social Services, Nurse Practitioner, Activity Director Business Office Manager, Wound Care Nurse and Medical Records held Quality Assurance Performance Improvement Committee meeting where the file was discussed and Resident Safety. 10.- On 8/10/21 at approximately 12:30 P.M. Psychiatric Nurse Practitioner #1 assessed Resident #1 for psychosocial, emotional, and mental distress along with a review of all of Resident #1 current medications. Psychiatric Nurse Practitioner #1 recommended a medication addition to assist with anxiousness- Resident #1 declined medication 11.- On 8/10/21 at 4:02 P.M. State Agency (SA) notified facility Administrator, Director Nursing and Assistant Director of Nursing of Immediate Jeopardy (IJ) with substandard quality of care. State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. 12.- On 8/10/21 at approximately 5:15 P.M. Director of Nursing, RN Supervisor #1, RN Supervisor #2, RN Supervisor #3, Assistant Director of Nursing (ADON), Medical Records, Business Office Manager, Assistant Business Office Manager, Admission Coordinator, Maintenance Director, and Activity Director began resident room cheeks to ensure that all lighters were removed. Room checks were completed, and no lighters were found. Room checks completed at approximately 6:00 P.M. on 8/10/21 of all rooms in the building. 13.- On 8/10/21 at 7:09 P.M. facility Administrator initiated automated phone reporting system alert to resident families and staff of combustible safety storage, including facility storage of lighters, asking families not to purchase flammable materials including new policy implementation of combustible safety to use in conjunction with the current fire prevention policy. This combustible safety policy was created by the Quality Assurance Performance Improvement committee and approved by the facility medical director. The system automatically sends alerts and contacts families and staff listed in resident's records and payroll system. 14.- On 8/10/21 beginning at 8:15 P.M. Staff Development Coordinator initiated education on Combustible Safety storage and fire prevention with staff and residents to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, Business Office staff, Therapy staff, Dietary staff, and administrative staff on new Combustible Safety Policy. No staff will be allowed to work without completing. 15.- On 8/10/21 at 9:00 P.M. Mississippi State Department of Health notified of event and pending Life Safety notification. 16.- On 8/1 1/21 at 10:30 A.M Mississippi State Department of Life Safety notified of fire with unusual incident report submitted. 17.- On 8/11/21 at 10:45 A.M. Medical Director. Administrator, Director of Nursing, RN Superviseor and RN Supervisor #4, LPN #4 held Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further occurrence including new policy on Combustible Safety Storage. Policy includes no flammable materials in Resident's possession regardless of smoking status. 18.- On 8/11/21 at 9:30 A.M. Resident Council Meeting Held with Activity Director, Activity Assistant, Admission Coordinator, Resident Council President, and 13 total residents were present to discuss the new policy on Combustible Safety to include facility storage of flammable materials regardless of smoking status. 19.- On 8/11/21 at 5:30 P.M. Mississippi State Department of Health added 3 additional Immediate Jeopardy's (IJ). 20.- On 08/11/21 at 6:00 P.M. Resident had a Smoking evaluation completed by Director of Nursing (DON) and deemed currently as non-smoker. This is second smoking evaluation completed on Resident since admission which was on 6/29/21. 21.- On 8/11/2021 at 6:45 P.M. Social Services Director (SSD) developed a plan of care based on Resident #1 hallucinations occuring on 7/26/21. Adjustments to be made to the plan of care in event of further behaviors on an as needed basis. 22.- On 08/11/2021 at 7:15 P.M. Psychosocial interviews were completed by Administrator #2 and Area Director of Business Development (ADBD)on eight (8) Residents with BIMS (Brief Interview Mental Status) of 13 or higher in the seven (7) surrounding rooms to Resident to assess for psychosocial, emotional. or mental distress surrounding fire event with no emotional concerns noted. 23.- On 8/11/2021 at 7:19 P.M. a body audit was completed on Resident #1 by the MDS (Minimum Data Set) Coordinator to assess for any injuries with no negative findings. 24.- On 08/1 1/2021 at 7:30 P-M. the Administrator and Director of Nursing received education on proper Abuse and Neglect Reporting and investigation guidelines following State and Federal Regulations by Senior Administrator from a sister facility. 25.- On 08/11/2021 at 8:40 P.M. Medical Director. Administrator, Director of Nursing, Corporate Clinical Specialist (CCS) and Area Director of Business Development (ADBD )held an Ad-Hoc Quality Assurance Performance Improvement Meeting to include notification of additional Immediate Jeopardy (IJ) tags F610, F656 and F742 with no further recommendations. 26.- On 8/11/2021 at approximately 9:30 P.M. in-services were initiated to include Care Plans with a focus on behaviors and investigations of unusual occurrences. No staff members will be able to work until they are in-serviced. 27.- Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 08/11/21, and the Immediate Jeopardy was removed 08/12/21. On Saturday August 14, 2021 the State Agency (SA) validated the facility's Removal Plan for the Immediate Jeopardy (IJ). Validations of the facility's Removal Plan was conducted through staff interview, observations, policy and procedure review, and record reviews. The SA's validations on 08/14/2021 revealed that the facility took the following actions to remove the IJ: 1-The SA validated through interview with LPN#3 on 08/14/2021 at 10:54 AM that on 07/26/21 at approximately 1:30 AM the facility fire alarm was sounding and the facility sprinkler systems were not activated as fire induced levels did not reach needed levels to activate the sprinkler system. LPN#3 validated that she called the Maintenance Director on 07/26/2021 at approximately 2:00 AM to obtain instructions as to how to reset the fire alarm after the fire had been extinguished by the facility staff. 2 -The SA validated through interview on 08/14/2021 at 10:54 AM with LPN#3, that she and LPN#1 had verbally assessed resident #1 on 7/26/21 at approximately 1:33 AM Resident #1 was verbally assessed by LPN #1 and found to have no injuries. The facility has no outside legal representative for Resident #1. Resident #1 is his own Responsible Party. 3- On 08/14/2021 at 9:00 AM the SA validated through record review of the City Fire Department's written report, that on 7/26/21 at 1:39 AM the City File Department arrived on the scene at the facility and the facility ' s fire alarm was sounding. Record review of the written City Fire Report validated that the fire was extinguished prior to their arrival at the facility. 4.- The SA validated through interview on 08/14/2021 at 10:54 AM with LPN#3 that on 7/26/21 at approximately 1:43 AM. LPN#3 had contacted the Administrator and Director of Nursing via text message that there had been a fire at the facility on 07/26/2021. 5.-The SA validated through interview on 08/14/2021 at 10:54 AM with LPN#3 that on 7/26/21 at 1:50 AM the Administrator contacted LPN#3 concerning the fire. 6.- The SA validated on 08/14/2021 through record review of the City Fire Department's Report that on 7/26/21 at 1:53 AM the City Fire Department cleared the scene and departed the facility. The SA also validated through interview on 08/14/2021 at 10:54 AM with LPN#3 that the City Fire Department came to the facility on [DATE] at approximately 1:30 AM and left the facility at approximately 1:53 AM on 07/26/2021. 7.- The SA validated on 08/14/2021 through record review that on 7/26/21 beginning at approximately 8:30 AM Director of Nursing, RN Supervisor #1, RN Supervisor #2, Assistant Director of Nursing (ADON), Medical Records, and Activity Director began resident room checks of the entire facility to ensure all lighters were removed. Room checks were completed and no lighters were found. 8.-The SA validated on 08/14/2021 through record review of the In-Services sign-in/attendance sheets, that on 7/26/21 beginning at approximately 10:30 AM Staff Development Coordinator (SDC) 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 and Flammable materials and storage. 9.- The SA validated through interview, and record review of the QA Meeting ' s sign-in/attendance sheet dated 07/28/2021, and with the facility Administrator (ADM) interview on 08/14/2021 at 10:00 AM that on 7/28/21 at 12:30 PM, the Medical Director, Administrator, Director Assistant Director of Nursing, Social Services, Nurse Practitioner, Activity Director Business Office Manager, Wound Care Nurse and Medical Records held Quality Assurance Performance Improvement Committee meeting where the file was discussed and Resident Safety. 10.-On 08/14/2021 the SA validated through record review that on 8/10/21 at approximately 12:30 PM the facility's Psychiatric Nurse Practitioner assessed Resident #1 for psychosocial, emotional, and mental distress along with a review of all of Resident #1 current medications. Psychiatric Nurse Practitioner recommended a medication addition to assist with anxiousness- Resident #1 declined medication. 11.-The SA validated on 08/14/2021 through record review that the IJ Templates were provided to the facility on [DATE] at 4:02 PM the SA validated through record review, that the notification of the IJ was provided to the facility Administrator, Director Nursing and Assistant Director of Nursing. The validation on 08/14/2021 by record review documented that the Immediate Jeopardy (IJ) with Substandard Quality of Care was provided in writing, to the facility, per the submission of the IJ Templates dated 08/10/2021 at 4:02 PM. 12.-On 08/14/2021 the SA validated through record review that on 8/10/21 at approximately 5:15 PM Director of Nursing, RN Supervisor #1, RN Supervisor #2, RN Supervisor #3, Assistant Director of Nursing (ADON), Medical Records, Business Office Manager, Assistant Business Office Manager, Admission Coordinator, Maintenance Director, and Activity Director began resident room cheeks to ensure that all lighters were removed. Room checks were completed, and no lighters were found. Room checks completed at approximately 6:00 PM on 8/10/21 of all rooms in the building. 13.-The SA validated on 08/14/2021 at 10:00 A.M. through interview with the facility ADM that on 8/10/21 at 7:09 PM the facility Administrator initiated automated phone reporting system alert to resident families and staff of combustible safety storage, including facility storage of lighters, asking families not to purchase flammable materials including new policy implementation of combustible safety to use in conjunction with the current fire prevention policy. This combustible safety policy was created by the Quality Assurance Performance Improvement committee and approved by the facility medical director. The system automatically sends alerts and contacts families and staff listed in resident's records and payroll system. 14.- On 08/14/2021 the SA validated through a record review, the In-Service sign-in/attendance sheets dated 8/10/21, that beginning at 8:15 PM the Staff Development Coordinator initiated education on Combustible Safety storage and fire prevention with staff and residents to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, Business Office staff, Therapy staff, Dietary staff, and administrative staff on new Combustible Safety Policy. No staff will be allowed to work without completing. 15.-On 08/14/2021 a record review validated that on 8/10/21 at 9:00 PM the facility notified the Mississippi State Department of Health of the 07/26/2021 fire event and of the pending Life Safety written notification. 16.- The SA validated through record review that on 08/14/2021 that on 8/11/21 at 10:30 AM Mississippi State Department of Life Safety notified of fire with unusual incident report submitted. 17.- The SA validated on 08/14/2021 through record review of the QA sign-in/attendance sheet and policy review that on 8/11/21 at 10:45 A.M. Medical Director. Administrator, Director of Nursing, RN Supervisor and LPN #4 held Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further occurrence including new policy on Combustible Safety Storage. Policy includes no flammable materials in Resident's possession regardless of smoking status. 18.- The SA validated through record review on 08/14/2021 that on 8/11/21 at 9:30 A.M. the Resident Council Meeting was held with the Activity Director, Activity Assistant, Admission Coordinator, Resident Council President, and 13 total residents were present to discuss the new policy on Combustible Safety to include facility storage of flammable materials regardless of smoking status. 19.-The SA validated, through record review of the IJ Templates, on 08/14/2021, that on 8/11/21 at 5:30 PM the Mississippi State Department of Health added 3 additional Immediate Jeopardy's (IJ). The additional IJ's were provided to the facility per the written IJ Templates for F610; F656; and F742. 20.- The SA Validated through record review on 08/14/2021, that on 08/11/21 at 6:00 PM Resident #1 had a Smoking evaluation completed by the Director of Nursing (DON) and was deemed as a non-smoker. This was the second smoking evaluation completed on Resident #1 since admission which was on 6/29/21. 21.-On 08/14/2021 at 11:50 P.M. the SA validated through an interview with the Social Services Director (SSD) and through record review of the care plan for Res #1, that on 8/11/2021 at 6:45 PM the Social Services Director (SSD) developed a Plan of Care based on Resident #1's hallucinations that occurred on 7/26/21. 22.-The SA validated through record review on 08/14/2021 that on 08/11/2021 at 7:15 PM Psychosocial interviews were completed by Administrator #2 and Area Director of Business Development (ADBD)on eight (8) Residents with BIMS (Brief Interview Mental Status) of 13 or higher in the seven (7) surrounding rooms to Resident to assess for psychosocial, emotional. or mental distress surrounding fire event with no emotional concerns noted. 23.- The SA validated through record review on 08/14/2021 that on 8/11/2021 at 7:19 PM a body audit was completed on Resident #1 by the MDS (Minimum Data Set) Coordinator to assess for any injuries with no negative findings. 24.- The SA validated through record review and through interview on 08/14/2021 at 10:00 A.M. with the facility ADM that on 08/11/2021 at 7:30 P-M. the Administrator and Director of Nursing received education on proper Abuse and Neglect Reporting and investigation guidelines following State and Federal Regulations by Senior Administrator from a sister facility. 25.- The SA validated on 08/14/2021 through record review of the QA sign-in/attendance sheets that on 08/11/2021 at 8:40 P.M. Medical Director. Administrator, Director of Nursing, Corporate Clinical Specialist (CCS) and Area Director of Business Development (ADBD ) held an Ad-Hoc Quality Assurance Performance Improvement Meeting to include notification of additional Immediate Jeopardy (IJ) tags F610, F656 and F742 with no further recommendations. 26.- On 08/14/2021 from 10:54 A.M.-12:05 P.M. the SA interviewed seven (7) CNA's; two (2) RN's; Two (2) dietary workers; two(2) office staff; two (2) house keeping staff; four (4) LPN's; two (2) Social Workers; the facility ADM and the DON, to validate that all staff working on 8/11/2021 at approximately 9:30 P.M. were in-serviced and validated that in-services were initiated to include Care Plans with a focus on behaviors and investigations of unusual occurrences. The SA validated through interview and record review on 08/14/2021 with the ADM and DON, that no staff members will be ab [TRUNCATED]

Based on observations, record reviews, resident interviews, staff interviews, and facility policy review, the facility failed to ensure resident's safety by not supervising the smoking area during resident smoke times, failing to ensuring residents were not smoking in the presence of oxygen, not administering timely smoking safety assessments, not abiding by the assessments recommendations, and administration having knowledge of residents with lighters and combustible smoking paraphernalia in their rooms and failing to secure them for 20 of 20 smokers out of a total of 133 residents, with a sample of seven (7), Residents #1, #2, #3, #4, #5, #6 and #7. The facility's failure to provide supervision for the smoking process placed residents at risk, and in a situation, which caused serious injury and death for one (1) resident, Resident #1, and was likely to cause serious injury, harm, impairment, or death for others. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the facility's failure to provide supervision of residents while smoking, failure to ensure they were not smoking in the presence of oxygen (O2) or combustible chemicals, and failure to ensure the removal of lighters and combustible materials from residents rooms resulted in a resident smoking in his bed, with his oxygen on, causing a fire in the facility that gave him third degree [CONDITION(S)] to his right shoulder, right front chest, and right upper back which required surgical removal of devitalized skin and adipose layers, as well as extensive skin grafts. He also suffered from inhalation [CONDITION(S)], which later contributed to his demise. The facility also had to relocate 23 residents to alternate beds within the facility who incurred loss of personal property, with a loss of 32 beds within the facility to water damage. On [DATE] at 2:00 PM, the State Agency (SA) informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The IJ and SQC existed at: 42 CFR(s): §483.25(d)(1)(2) - Accidents/Supervision (F689) - Scope and Severity - L. The facility submitted a credible Removal Plan on [DATE] at 4:40 PM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CFR(s): §483.25(d)(1)(2) - Accidents/Supervision (F689) was lowered from an L level of scope and severity to an F while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Resident Acknowledgement - Facility Smoking Policy, revised on [DATE] revealed: Safe Smoking Environment: It is the responsibility of the facility to provide a safe and hazard free environment for those residents having been assessed as safe for Facility smoking privileges. The Oxygen cylinders will not be permitted in any authorized smoking area. Facility smoking policies through verbal means, distribution and posting. This policy is intended to minimize the risks to: Residents who smoke, including possible adverse effects on treatment, passive smoke to others, and fire. Smoking Accommodation: This policy does not include chewing tobacco. Residents may maintain their own tobacco supplies in their room and do not have to be supervised. E-Cigarettes will be treated like cigarettes per policy. At no time will E-Cigarettes be permitted for use inside of the facility. The smoking of marijuana is prohibited in an Nexion Facility. The facility is responsible for enforcement of smoking policies. Smoking is prohibited in any room, ward, or compartment within the facility with exception being the designated smoking room on the first floor. Smoking is prohibited where flammable liquids, combustible gas or oxygen are stored, and in any other hazardous location. These areas are posted with nonsmoking area signs. Residents wishing to smoke while at the facility will have a Smoking Safety Evaluation completed by the interdisciplinary team to determine the resident's ability to follow smoking policies safely. All residents who wish to smoke must provided finds to purchase their own smoking paraphernalia. Oxygen carrying devices will not be permitted in any authorized smoking area. Check Option that applies to facility: 1. All smoking in this facility is SUPERVISED and at designated times. Staff will maintain/keep all smoking materials (e.g., cigarettes, pipes, matches, lighters, lighter fluid) and distribute the materials to residents at smoking times. 2. Residents who are deemed safe will be allowed to smoke unsupervised and may be permitted to keep cigarettes on their persons. If resident is deemed unsafe, they will be required to surrender all smoking paraphernalia to facility. Staff will maintain/keep all smoking materials (e.g., cigarettes, E-Cigarettes, pipes, matches, lighters, lighter fluid) and distribute the materials to residents at smoking times. Furthermore, a smoking schedule will be posted, and resident will be required to smoke with supervision only, according to schedule. Smoking Infraction: The first infraction of the smoking policy results in a warning. This warning may be verbal. The warning is given to both the resident and their family member of contact. a safe smoking reassessment of that resident is performed to determine supervision required. The second infraction of the smoking policy may result in notice of discharge. The reason for discharge would be endangerment to the health and safety of residents. On [DATE], at 7:20 PM, during an interview with the Administrator she stated Resident #1, the resident who started the facility fire, was his own Resident Representative (RR). His Brief Interview for Mental Status (BIMS) score was 15 deeming him able to make his own decisions. He left the facility three (3) times a week for [CONDITION(S)] and would come and go as he pleased. She felt it was a violation of his rights for the staff to go through his belongings every time he would return from an outing. She stated she was aware there were several residents that probably had lighters before the fire because they were not consistently going through the smoker's belongings or monitoring what they were getting in packages from family or for themselves. The administrator stated there were several lighters confiscated after the fire, and the new smoking rules were reviewed with each smoker. When asked by the SA if they had removed all the lighters from the current smokers, she stated, she hoped so, but they did not go through every drawer, and closet. They took what they were able to find, and what the residents gave to them. She again stated, several of them went out on pass as their own RP and they were not searched when they came back. She stated they had hired staff to do supervised smoking from 8:00 AM - 10:00 PM. The Nurse Practitioner (NP) came and assessed everybody after the fire to check for smoke inhalation and they had the Psych provider come and assess residents for Post-Traumatic Stress Disorder (PTSD) from the event. They are committed to doing random checks for lighters, etc., five (5) times a week for four (4) weeks, then three (3) times a week for 4 weeks and then as needed. The Administrator stated they had revised the smoking policy to include the first infraction would be a verbal warning and the second infraction could result in a 30 discharge being issued. Resident #1 Record review of Resident #1's Face Sheet revealed he was admitted to the facility on [DATE] was diagnoses of End Stage [CONDITION(S)], [CONDITION(S)] Dependent, Gastric [CONDITION(S)] Reflux Disease, Chronic Pain, [CONDITION(S)], and Bilateral Below the Knee Amputations. His latest quarterly Minimum Data Set (MDS) dated [DATE] indicated he had a Brief Interview for Mental Status (BIMS) score of 15 and was able to make his own decisions. He had no stated behaviors and required supervision up to limited assistance of one staff member for most of his activities of daily living (ADL's). Review of his Nurses Notes (NN) dated [DATE], at 10:44 PM, indicated he had altered mental status, had not been to [CONDITION(S)] in a week, and was requesting to go to the hospital. Record review of Resident #1's Abstract Summary from the hospital, completed on [DATE], revealed his hospital diagnoses to be Fluid Overload secondary to missed [CONDITION(S)] for 1 week, Metabolic Brain Disorder, and an Abrasion to his right hip. A Physicians Progress Note from the hospital, dated [DATE] at 12:40 PM, indicated the following plan: Volume overload from [CONDITION(S)] noncompliance - based on his behavior since admission, I would say he has been refusing [CONDITION(S)], will continue to dialyze here for volume control .since he is refusing all medications, there is nothing I can do for him. Will ask for psych eval, perhaps he would be a (Geriatric Psych Unit) GPU candidate. If not, he will have to be discharged back to his home facility soon. Record review of a Wound Consult note from the hospital, dated [DATE], at 1:05 PM, stated, Patient confused, somewhat aggressive, unable to provide any history on the wounds. Record review of a NN dated [DATE] at 10:57 PM, indicated he had returned from the hospital and voiced no complaints. A Smoking Safety Evaluation dated [DATE] at 9:00 PM stated he was identified as a safe smoker. Record review of a NN dated [DATE], at 12:13 PM, revealed he was lethargic but able to answer questions, he was total care for personal hygiene, bathing, dressing, and transfers and had to use a mechanical lift to transfer. His appetite was noted as poor. Record review of a NN dated [DATE], at 1:00 PM, revealed the nurse was sitting at the desk, heard the smoke alarm, noticed smoke coming from Resident #1's room. She grabbed the fire extinguisher, opened the door and smoke and water poured out. She attempted to go into his room but was unsuccessful due to smoke, so she called his name and after approximately 1 minute, heard the resident yell yall help me. The nurse supervisor and a Certified Nurse Aide (CNA) went in, put him in a wheelchair and rolled him out of the room. They put him in room 107 to assess him. 911 was called and he was sent to the local burn unit. Record review of a NN dated [DATE], at 5:31 PM, titled Incident Note stated the Fire alarm was automatically activated, heavy dark smoke and copious amounts of water was noted coming from room 102 D. Resident noted in the room lying on the floor by the foot of the bed calling out help me. Res. was transferred to wheelchair then to safety by staff. [CONDITION(S)] were noted on the resident's upper right chest, right arm, and upper right back. Resident stated he had a cigarette lighter to light his cigarette but did not reveal where he got the lighter. Record review of a NN dated [DATE], at 10:59 PM, revealed, called (name of local burn unit) to get report on resident and was told he was doing well and was being admitted to the hospital. Record review of an additional Smoking Safety Evaluation that was completed on [DATE] at 11:00 PM, after Resident #1 had been admitted to the hospital, indicated his mental status was alert, decision ability was consistent, his reflexes were quick response, he did NOT only smoke in designated areas, he could safely light and hold a cigarette, he responds quickly to fallen ashes, he did NOT follow the smoking guidelines, he returned his smoking materials to storage, he did not remove his oxygen tubing, and could extinguish his own cigarette. The Evaluation further states, if one response is answered no then resident should be supervised while smoking. There were several items marked no on the form, yet the Summary of Evaluation indicated he was safe to smoke unsupervised, and the Comments stated Resident has been deemed as an unsafe smoker, he has a BIMS of 15 and chooses to smoke unsafely. Resident smokes while O2 is in use while in the bed. On [DATE], at 10:45 AM, during an interview with the Social Services Director (SSD), when asked if she felt the Smoking Safety Evaluation done on Resident #1's readmission to the facility had been accurate given the hospital was referring to him as confused, and the nurses had charted he was lethargic, she stated, probably not, since he was smoking in his room, he may have just answered their admission questions right. During an interview on [DATE], at 11 AM, multiple areas of contradiction on the Smoking Safety Evaluation form which had been completed on [DATE], at 11PM, was reviewed with the Administrator. She agreed the evaluation was not accurately completed and contradictory to itself in several places. She feels it was done hurriedly and attention was not paid to the details on the form. Review of Resident #1's diagnosis list sent from the hospital on [DATE], indicated his primary diagnosis was [CONDITION(S)] with skin graft except extensive 3rd degree [CONDITION(S)], and his secondary diagnosis was Full thickness [CONDITION(S)] with skin grafts or inhalation injury. Resident #1's diagnosis list continued to include 3rd degree [CONDITION(S)] to his trunk, right upper arm, right lower back, and chest wall, with excision of the subcutaneous fat layer and fascia of his back, right upper arm, chest, and right trunk, and replacement transfers of his back, right upper arm and chest. Record review of a Discharge Report, dated [DATE], from the hospital which revealed, he was taken to surgery for a second time for excision of devitalized tissue and had skin grafts placed. After surgery he was alert and responsive however he was having hypertensive episodes. Laboratory (Lab) staff went in during the night to obtain blood work and he was found unresponsive with no vital signs deceased in the bed. He was a Do Not Resuscitate (DNR). Resident #2 Review of Resident #2's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses of [CONDITION(S)] - C5 - C7 incomplete, Anxiety, [CONDITION(S)], Gastro-[CONDITION(S)] Reflux Disease, Deep Tissue Injury (DTI) of the left heel, Pain, and Constipation. Record review of her latest MDS dated [DATE], revealed she had a BIMS of 15 and was able to make her own decisions regarding her care, she required total assistance of two (2) staff members for her ADL's, and the use of a mechanical lift for transfers. Review of Resident #2's nurses notes (see below) revealed multiple times in which she had exhibited behaviors such as the use of foul language, false accusations against staff, refusal to be educated on the new smoking policies, and refusal of all medications except for her pain pill. Review of NN, dated [DATE] at 1:22 PM, revealed .asked to speak to someone in charge .with a smile and smirk said (formal name of aide) called her a derogatory name .After the DON and social worker left the room, resident with a laugh and smirk said I want (formal name of aide) (derogatory word) sent home . Review of NN, dated [DATE] at 11:00 AM, revealed, Resident refuses to allow SW (social worker) in her room to receive education on smoking policy, rules and guidelines . Review of NN dated [DATE] at 9:40 AM, revealed, .Resident raising her voice and using profanity because she didn't want any of her medication except her pain pill . Review of Resident #2's Care Plan for smoking stated, (Formal Name) is a smoker. She has been educated on the new smoking policy and has been deemed safe to smoke unsupervised. On [DATE], - resident was observed with burn marks to her fingers. She states that the [CONDITION(S)] did not come from smoking cigarettes. Resident refused to smoke while supervised. [DATE] - Resident uses vapor cigarettes. [DATE] - chooses not to do BIMS assessment. Record review of Resident #2's 02 Smoking Safety Evaluation dated [DATE], at 10:11 AM, revealed, her manual dexterity is weak, and her grasp is weak, she drops items, her reflexes are diminished in response, she has upper and lower body limitations, she smokes only in designated areas, and cannot safely light her smoking material, she cannot safely hold her smoking material, she can dispose of her ashes, and can quickly respond to fallen ashes, she follows the smoking guidelines per policy, and returns her smoking materials to storage. There is a note on the evaluation which states, if one response is answered NO then resident should be supervised while smoking She has 3 NOs on her form and yet under the Summary of Evaluation it stated she can smoke unsupervised. In the Comments section it stated, resident has upper and lower body impairments, she requires assistance with lighting cigarettes, resident is able to grasp cigarette but r/t upper body impairments, she is at risk for dropping items. During an interview on [DATE], at 11 AM, multiple areas of contradiction on the Smoking Safety Evaluation form which had been completed on [DATE], at 11 PM, was reviewed with the Administrator. She agreed the evaluation was not accurately completed and contradictory to itself in several places. She feels it was done hurriedly and attention was not paid to the details on the form. She stated she was aware Resident #2 refused to get out of bed to go smoke and smoked her E-cigarette unsupervised in her room all the time. She stated she needed to be given a 30-day discharge because she had refused to abide by the rules since her admission. On [DATE], at 11:30 AM, the SA was asked to visit Resident #2, at her request. While meeting with her, an E-cigarette was observed on her bedside table with two battery cartridges. When asked if she was allowed to smoke in her room, she stated, Hell Yeah, because that is not a real cigarette anyway, I ain't no harm to no body. On [DATE], at 1:45 PM., during an interview with R.N.#1, she verified Resident #2 was allowed to smoke her E-cigarette unsupervised in her room because she refused to get out of the bed to go smoke and she refused to be supervised while she was smoking. She stated the management was aware and let her do it. Resident #3 Record review of Resident #3's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Polyneuropathy, Hypertension, [CONDITION(S)], Depression, Anxiety and Gastroesophageal Reflux. Record review of Resident #3's last Quarterly MDS dated [DATE] revealed she had a BIMS of 15 and was able to make her own decisions, and required extensive assistance to get dressed every day, and supervision of staff for all others. Record review of Resident #3's Smoking Care plan revealed an added intervention, dated [DATE] that stated, Resident had cigarette lighter. SW counseled with resident about smoking policy. During an interview on [DATE] at 11:20 AM with the SSD, she was asked if the date reflected the date, she removed the lighter from Resident #3, or just the date she entered the intervention, as [DATE] would have been eleven (11) days after the fire this resident had access to a lighter. She stated, I'm unable to say right now, I don't remember all the dates. On [DATE], at 10:10 AM, during an interview with Resident #3, she stated, I don't have a lighter no more, since they came and got them a week ago. I'll be honest, I don't' know if I still got some of them stashed in all those boxes or not. We been moved around so much for the virus and then the fire that all my stuff is in boxes right now. I keep my cigarettes in my purse. The SA observed a pack of cigarettes laying on her bedside table and another one sticking out of one of her clothing drawers. Resident #4 Record review of Resident #4's Face Sheet revealed she was readmitted to the facility on [DATE], with diagnoses of Alcoholic Dependence in Remission, [CONDITION(S)] of the Liver, [CONDITION(S)], Depression, Anxiety, Hypertension, Overactive Bladder, [CONDITION(S)], and Gastroesophageal Reflux. Record review of Resident #4's latest quarterly MDS dated [DATE], revealed a BIMS score of 15, meaning she is able to make her own decisions, and required supervision for all her ADL's. On [DATE], at 10:15 AM, during an interview with Resident #4, she stated, I keep my cigarettes in my purse next to my bed. I don't have a lighter anymore since the staff came and took them after the fire. Somebody is usually out there from around 8 am - 10 pm, but the weekends are real bad. Last weekend there was nobody here to do the smoking for us all day on Sunday, so we had a staff member light a cigarette for one of us, and then we just tried to light each other's for everybody as they came out the rest of the day. I go out and smoke ,d+[DATE] times a day, and there is usually ,d+[DATE] times a week that no staff member is out there. There is a couple guys that need help smoking, so if they come out there when no staff is there, we try to remember to help put on their aprons and light their cigarettes for them. We try to watch out for each other. Resident #5 Review of Resident #5's Face Sheet revealed, he was admitted to the facility on [DATE] with diagnoses of Intercostal [CONDITION(S)], Hypertensive Heart Disease with Heart Failure, Kachin-Beck Disease, [CONDITION(S)], and Pain. Record Review of Resident #5's latest quarterly MDS, dated [DATE], revealed a BIMS score of 14, making him able to make his own decisions, and requiring supervision for most of his ADL's, except for putting on his clothing, due to only having one arm. On [DATE], at 10:30 AM, during an interview with Resident #5, he stated, I keep my cigs in my room in that lock drawer over there, but I don't have no lighter anymore. They came and took it after that guy lit the place up. If they find a lighter on you, you get a 30-day notice and I been here for almost 6 years. From 8 am-1 there is usually a staff member out there with us, but if no one is out there, we light off each other out of respect for the staff, not having to come out here while they are trying to work. (Formal name of another resident) needs help to smoke, cuz his hands shake so bad, so we try to help him when he rolls out without help .I am out here smoking most of the day. I go in to eat and to take a nap. Resident #6 Record review of Resident #6's Face Sheet revealed, she was admitted to the facility on [DATE] with diagnoses of Biliary [CONDITION(S)], [CONDITION(S)] Depression, [CONDITION(S)], Liver Disease, Chronic Kidney Disease - Stage 4, and [CONDITION(S)]. Record review of Resident #6's latest quarterly MDS, dated [DATE], revealed she has a BIMS of 15, making her able to make her own decisions, and she required supervision for all of her activities of daily living. On [DATE], at 11:38 AM, during an interview with Resident #6, she stated, There are several times a week when there ain't no staff out there for us. This past Sunday there was only a staff out there one time, and that is cuz they wanted to smoke. (Formal name of another resident) needs help to smoke and the aides sometimes push him out and put his apron on and then leave, so we light his cigarette for him. Resident #7 Record review of Resident #7's Face Sheet revealed, he was admitted to the facility on [DATE] with diagnoses of Polyneuropathy, [CONDITION(S)], Chronic [CONDITION(S)] C, Depression, [CONDITION(S)], and Diabetes Type II. Review of Resident #7's latest quarterly MDS dated [DATE], revealed he has a BIMS score of 15, making him able to make his own decisions, and he required limited assistance for all of his activities of daily living. On [DATE], at 11:20 AM, during an interview with Resident #7, he stated, I keep my cigarettes in my pocket or my hat, I don't have a lighter anymore since they came and took them from us. I usually go down there about three times a day and if staff are there, they will light our cigarettes. There is usually someone out there until after 10:00 o'clock at night. If not, we will light each other's cigarettes. (Formal name of another resident) is the man that needs help there and he rolls himself outside. His handshakes bad, so I helped him put the cigarette in his mouth and then we light it with our own cigarettes. There don't always be staff out there all the time when we are smoking. We try to make sure he has his apron on, but I'm sure sometimes he does not . We try to lookout for each other out there to make sure everybody is OK. On [DATE], at 11:10 AM, an observation was made of a letter given to all the smokers, posted on the wall next to their beds. The letter revealed, Effective [DATE] Yazoo City Rehabilitation and Healthcare Center will go to supervised smoking for all residents. At this time, the facility will take control of all smoking paraphernalia including cigarettes, lighters, tobacco pipes, etc. These will be kept in a lock box in the medication room on the first floor and will be brought out for the smoking times. Smoking times are as follows: 7:30, 8:30, 10:15, 1:00. 3:45, 6:00, 8:00 and 9:30. Each smoking time will be 15 to 20 minutes long depending on the number of smokers. Failure to follow these rules will result in to a thirty-day discharge notice being issued. On [DATE], at 2:15 PM, during an interview with the Activities Director (AD), she stated there were two people that needed support to smoke. They were to wear aprons at all times while smoking. One resident could not hold his own cigarette due to shaking from [CONDITION(S)] disease, and the other would often fall asleep when smoking and would drop his cigarette on himself. She stated they had activity staff that stayed outside with the residents from around 8:00 am - 10:00 pm. When asked by the SA what a resident was supposed to do if they wanted to smoke a cigarette at 2:00 AM, she stated they would have to find a staff member willing to light their cigarette for them and sit with those that need to be helped. When asked by the SA about the letter posted beside the beds of all the smokers, she stated the facility was not following the letter because of the uproar the residents made regarding locking up their cigarettes, and not being able to smoke whenever they wanted to, like they are now. The facility submitted an acceptable Removal Plan on [DATE], at 4:40 PM, in which the facility alleged all corrective actions to remove the IJ were completed on [DATE] and the IJ was removed on [DATE]. Removal Plan Brief Summary of Events On [DATE] at 3:06 PM Licensed Practical Nurse (LPN) #1 reported hearing fire alarm sounding. She reported grabbing fire extinguisher and seeing smoke coming out of Resident #1 room. LPN #1 reported calling Residents #1 name and he hollered back help. LPN #1 reported entering room with fire extinguisher, described as thick black smoke with water present, no active fire. LPN #1 did not use fire extinguisher. LPN #1 reported unable to see through the smoke and then RN (Registered Nurse) #1 and CNA (Certified Nursing Assistant) #1 went into Resident #1's room noting a smoke-filled room with no fire, sprinkler system actively pouring water, and found Resident #1 located lying on floor near foot of bed with no active fire. RN (Registered Nurse) #1 and CNA (Certified Nursing Assistant) #1 along with Dietary Aide #1 transferred Resident #1 from floor to wheelchair and removed Resident #1 from the room. Resident #1 denied pain and reported he lit a cigarette while wearing oxygen. Resident #1 refused to answer on where he obtained lighter from. Facility failed to provide adequate supervision ensuring Residents were abiding by established smoking rules/policy regarding smoking materials resulting in Resident #1 obtaining lighter and lighting a cigarette lying in bed with oxygen causing fire in the facility that resulted in [CONDITION(S)] to right shoulder, chest and back. Resident #2 failing to abide by facility policy with possession of electronic cigarette. Corrective Actions 1. On [DATE] at 3:06 pm Receptionist #1 called 911 while facility alarm was sounding. Alarm company also contacted fire department. 2. On [DATE] at 3:12 pm Fire department dispatched EnRoute to facility and arrived at 3:14 pm. Sprinkler system was actively spraying water causing excessive smoke. Sprinkler system extinguished the fire prior to arrival of Fire Department. On [DATE] at 3:15 pm LPN #2 called 911 requested ambulance. 3. On [DATE] at 3: 12 PM Resident #1 was assessed by RN (Registered Nurse) #1. Resident #1 had [CONDITION(S)] to right front and rear shoulder, Right Scapula, and Right side of chest. Ambulance Service arrived at facility at 4:06 PM and begin further evaluation of Resident and transferred to burn center. The facility has no outside legal representative for Resident #1. Resident #1 is his own responsible party. The facility initiated an investigation. 4. On [DATE] at 3:15 PM Remaining twenty-three (23) Residents in fire door area begin being escorted to outside parking lot to account for and ensure safety. 5. On [DATE] at 4:40 PM Nurse Practitioner (NP)#1 assessed a total of twenty-three (23) Residents which previously resided in affected area. No concerns identified. On [DATE] Psychiatric Nurse Practitioner (NP) assessed a total of twenty-three (23) Residents for any emotional distress or trauma as related to the fire with no abnormalities noted. Staff Support hotline posted to provide grief or mental health support due to fire. 6. On [DATE] at 5:02 PM Mississippi State Department of Health was notified of event. 7. On [DATE] at 6:30 PM Fire [NAME] assessed building for any safety issues regarding the fire and cleared the remaining unaffected area to allow occupancy. 8. On [DATE] at 6:30 PM Resident rooms involved in evacuation area were assessed for water damage by outside contractor and Residents were actively being relocated to other areas of the building by facility staff. Relocation of twenty-three (23) Residents were completed by 10:30 PM. From 6:30 PM to 10:30 PM Responsible Parties of Residents residing in facility were contacted regarding event and safety of Residents by administration staff. 9. On [DATE] beginning at approximately 8:00 PM Administrator, Director of Nurses (DON), and Staff Development Coordinator (SD) 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, Emergency Operations Plan, Fire Evacuation, Smoking Evaluations, and Resident Safety regarding fire. No staff will be allowed to return to work without completing. 10. On [DATE] at 5:00 PM, facility Administrator initiated automated phone reporting system alert to Resident families and staff to inform smoking safety including facility storage of lighters, asking families not to purchase flammable materials including new revisions to policy with removal of lighters regardless of smoking safety status. On [DATE] at 8:40 PM facility Administrator initiated automated phone reporting system with updated alert including revisions on smoking policy with facility storage of all smoking materials and assigned smoking times. This system automatically sends alerts and contacts families and staff listed in Resident's record and payroll system. 11. On [DATE] at 4:30 PM, the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing (Infection Preventionist) , Nurse Practitioner, and Clinical Corporate Consultant held Quality Assurance Performance Improvement meeting to include immediate corrective actions following facility fire involving audits on facilities current smoking Residents with room checks, smoking evaluations, smoking safety equipment, room change notifications, [TRUNCATED]

Based on record review, staff interview, and facility policy review, the facility failed to provide administrative oversight of the smoking program to ensure residents' maintained safety and the highest practicable physical, mental, and psychosocial well-being for 20 of 20 smokers out of 133 residents, with a sample of two (2), Residents #1 and #2. The facility's failure to provide administrative oversight and supervision of the smoking process placed residents at risk, and in a situation, which caused serious injury and death for one (1) resident, Resident #1, and was likely to cause serious injury, harm, impairment, or death for others. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the facility's failure to provide administrative oversight and supervision of residents while smoking, failure to ensure they were not smoking in the presence of oxygen (O2) combustible chemicals, and failure to ensure the removal of lighters and combustible materials from residents rooms resulted in a resident smoking in his bed, with his oxygen on, causing a fire in the facility that gave him third degree [CONDITION(S)] to his right shoulder, right front chest, and right upper back which required extensive skin grafts. He also suffered from inhalation [CONDITION(S)], which later contributed to his demise. The facility also had to relocate 23 residents to alternate beds within the facility who incurred loss of personal property, with a loss of 32 beds within the facility to water damage. On [DATE] at 2:00 PM, the State Agency (SA) informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the Administrator with the IJ Template. IJ existed at: 42 CFR(s): §483.70 -Administration (F835) - Scope and Severity - L The facility submitted a credible Removal Plan on [DATE] at 4:40 PM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed prior to exit. Therefore, the scope and severity for IJ existed at: 42 CFR(s): §483.70 -Administration (F835) - was lowered from an L level of scope and severity to an F while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy titled, Resident Acknowledgement - Facility Smoking Policy revised on [DATE] revealed: Safe Smoking Environment: It is the responsibility of the facility to provide a safe and hazard free environment for those residents having been assessed as safe for facility smoking privileges. The Oxygen cylinders will not be permitted in any authorized smoking area. Facility smoking policies through verbal means, distribution and posting. This policy is intended to minimize the risks to: Residents who smoke, including possible adverse effects on treatment, passive smoke to others, and fire. Smoking Accommodation: This policy does not include chewing tobacco. Residents may maintain their own tobacco supplies in their room and do not have to be supervised. E-Cigarettes will be treated like cigarettes per policy. At no time will E-Cigarettes be permitted for use inside of the facility. The smoking of marijuana is prohibited in a Nexion Facility. The facility is responsible for enforcement of smoking policies. Smoking is prohibited in any room, ward, or compartment within the facility with exception being the designated smoking room on the first floor. Smoking is prohibited where flammable liquids, combustible gas or oxygen are stored, and in any other hazardous location. These areas are posted with nonsmoking area signs. Residents wishing to smoke while at the facility will have a Smoking Safety Evaluation completed by the interdisciplinary team to determine the resident's ability to follow smoking policies safely. All residents who wish to smoke must provide funds to purchase their own smoking paraphernalia. Oxygen carrying devices will not be permitted in any authorized smoking area. Check Option that applies to facility: 1. All smoking in this facility is SUPERVISED and at designated times. Staff will maintain/keep all smoking materials (e.g., cigarettes, pipes, matches, lighters, lighter fluid) and distribute the materials to residents at smoking times. 2. Residents who are deemed safe will be allowed to smoke unsupervised and may be permitted to keep cigarettes on their persons. If resident is deemed unsafe, they will be required to surrender all smoking paraphernalia to facility. Staff will maintain/keep all smoking materials (e.g., cigarettes, E-Cigarettes, pipes, matches, lighters, lighter fluid) and distribute the materials to residents at smoking times. Furthermore, a smoking schedule will be posted, and resident will be required to smoke with supervision only, according to schedule. Smoking Infraction: The first infraction of the smoking policy results in a warning. This warning may be verbal. The warning is given to both the resident and their family member of contact. A safe smoking reassessment of that resident is performed to determine supervision required. The second infraction of the smoking policy may result in notice of discharge. The reason for discharge would be endangerment to the health and safety of residents. Resident #1 Record review of a NN dated [DATE], at 5:31 PM, titled Incident Note stated the Fire alarm was automatically activated, heavy dark smoke and copious amounts of water was noted coming from room [ROOM NUMBER] D. Resident noted in the room lying on the floor by the foot of the bed calling out help me. Res. was transferred to wheelchair then to safety by staff. [CONDITION(S)] were noted on the resident's upper right chest, right arm, and upper right back. Resident stated he had a cigarette lighter to light his cigarette but did not reveal where he got the lighter. A Smoking Safety Evaluation dated [DATE] at 9:00 PM revealed Resident #1 was identified as a safe smoker. An additional Smoking Safety Evaluation was completed on [DATE] at 11:00 PM, after Resident #1 had been admitted to the hospital, that indicated his mental status was alert, decision ability was consistent, his reflexes were quick response, he did NOT only smoke in designated areas, he could safely light and hold a cigarette, he responds quickly to fallen ashes, he did NOT follow the smoking guidelines, he returned his smoking materials to storage, he did not remove his oxygen tubing, and could extinguish his own cigarette. The Evaluation further states, if one response is answered no then resident should be supervised while smoking. There were several items marked no on the form, yet the Summary of Evaluation indicated he was safe to smoke unsupervised, and the Comments stated Resident has been deemed as an unsafe smoker, he has a BIMS of 15 and chooses to smoke unsafely. Resident smokes while O2 is in use while in the bed. On [DATE], at 7:20 PM, during an interview with the Administrator, she stated Resident #1, the resident who started the facility fire, was his own Resident Representative (RR). His Brief Interview for Mental Status (BIMS) score was 15 deeming him able to make his own decisions. He left the facility three (3) times a week for [CONDITION(S)] and would come and go as he pleased. She felt it was a violation of his rights for the staff to go through his belongings every time he would return from an outing. She stated she was aware there were several residents that probably had lighters before the fire because they were not consistently going through the smoker's belongings or monitoring what they were getting in packages from family or for themselves. The administrator stated there were several lighters confiscated after the fire, and the new smoking rules were reviewed with each smoker. When asked by the SA if they had removed all the lighters from the current smokers, she stated, she hoped so, but they did not go through every drawer, and closet. They took what they were able to find, and what the residents gave to them. She again stated, several of them went out on pass as their own RR and they were not searched when they came back. During an interview on [DATE], at 11:00 AM, multiple areas of contradiction on the Smoking Safety Evaluation form which had been completed on [DATE], at 11:00 PM, was reviewed with the Administrator. She agreed the evaluation was not accurately completed and contradictory to itself in several places. She feels it was done hurriedly and attention was not paid to the details on the form. On [DATE] at 2:00 PM, the SA received a Discharge Report, dated [DATE], from the hospital which revealed, he was taken to surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . After surgery he was alert and responsive however he was having hypertensive episodes. Laboratory (Lab) staff went in during the night to obtain blood work and he was found unresponsive with no vital signs deceased in the bed. He was a Do Not Resuscitate (DNR). Resident #2 Review of Resident #2's nurses notes, (see below) revealed multiple times in which she had exhibited behaviors such as the use of foul language, false accusations against staff, refusal to be educated on the new smoking policies, and refusal of all medications except for her pain pill. Review of NN, dated [DATE] at 11:00 AM, revealed, Resident refuses to allow SW (social worker) in her room to receive education on smoking policy, rules and guidelines . Review of Resident #2's Care Plan for smoking stated, (Formal Name) is a smoker. She has been educated on the new smoking policy and has been deemed safe to smoke unsupervised. On [DATE], - resident was observed with burn marks to her fingers. She states that the [CONDITION(S)] did not come from smoking cigarettes. Resident refused to smoke while supervised. [DATE] - Resident uses vapor cigarettes. [DATE] - chooses not to do BIMS assessment. Resident #2's dated 02 Smoking Safety Evaluation dated [DATE], at 10:11 AM, revealed, her manual dexterity is weak, and her grasp is weak, she drops items, her reflexes are diminished in response, she has upper and lower body limitations, she smokes only in designated areas, and cannot safely light her smoking material, she cannot safely hold her smoking material, she can dispose of her ashes, and can quickly respond to fallen ashes, she follows the smoking guidelines per policy, and returns her smoking materials to storage. There is a note on the evaluation which states, if one response is answered NO then resident should be supervised while smoking She has 3 NOs on her form and yet under the Summary of Evaluation it stated she can smoke unsupervised. In the Comments section it stated, resident has upper and lower body impairments, she requires assistance with lighting cigarettes, resident is able to grasp cigarette but r/t upper body impairments, she is at risk for dropping items. On [DATE], at 11:30 AM, the SA was asked to visit Resident #2, at her request. While meeting with her, an E-cigarette was observed on her bedside table with two battery cartridges. When asked if she was allowed to smoke in her room, she stated, Hell Yeah, because that is not a real cigarette anyway, I ain't no harm to no body. On [DATE], at 1:45 PM., during an interview with R.N.#1, she verified Resident #2 was allowed to smoke her E-cigarette unsupervised in her room because she refused to get out of the bed to go smoke and she refused to be supervised while she was smoking. She stated the management was aware and let her do it. During an interview on [DATE], at 11:00 AM, multiple areas of contradiction on the Smoking Safety Evaluation form which had been completed on [DATE], at 11 PM, was reviewed with the Administrator. She agreed the evaluation was not accurately completed and contradictory to itself in several places. She feels it was done hurriedly and attention was not paid to the details on the form. She stated she was aware Resident #2 refused to get out of bed to go smoke and smoked her E-cigarette unsupervised in her room all the time. She stated she needed to be given a 30-day discharge because she had refused to abide by the rules since her admission. The facility submitted an acceptable Removal Plan on [DATE], at 4:40 PM, in which the facility alleged all corrective actions to remove the IJ were completed on [DATE] and the IJ was removed on [DATE]. Removal Plan: Brief Summary of Events On [DATE] at 3:06 PM Licensed Practical Nurse (LPN) #1 reported hearing fire alarm sounding. She reported grabbing fire extinguisher and seeing smoke coming out of Resident #1 room. LPN #1 reported calling Residents #1 name and he hollered back help. LPN #1 reported entering room with fire extinguisher, described as thick black smoke with water present, no active fire. LPN #1 did not use fire extinguisher. LPN #1 reported unable to see through the smoke and then RN (Registered Nurse) #1 and CNA (Certified Nursing Assistant) #1 went into Resident #1's room noting a smoke-filled room with no fire, sprinkler system actively pouring water, and found Resident #1 located lying on floor near foot of bed with no active fire. RN (Registered Nurse) #1 and CNA (Certified Nursing Assistant) #1 along with Dietary Aide #1 transferred Resident #1 from floor to wheelchair and removed Resident #1 from the room. Resident #1 denied pain and reported he lit a cigarette while wearing oxygen. Resident #1 refused to answer on where he obtained lighter from. Facility failed to provide adequate supervision ensuring Residents were abiding by established smoking rules/policy regarding smoking materials resulting in Resident #1 obtaining lighter and lighting a cigarette lying in bed with oxygen causing fire in the facility that resulted in [CONDITION(S)] to right shoulder, chest and back. Resident #2 failing to abide by facility policy with possession of electronic cigarette. Corrective Actions 1. On [DATE] at 3:06 pm Receptionist #1 called 911 while facility alarm was sounding. Alarm company also contacted fire department. 2. On [DATE] at 3:12 pm Fire department dispatched EnRoute to facility and arrived at 3:14 pm. Sprinkler system was actively spraying water causing excessive smoke. Sprinkler system extinguished the fire prior to arrival of Fire Department. On [DATE] at 3:15 pm LPN #2 called 911 requested ambulance. 3. On [DATE] at 3: 12 PM Resident #1 was assessed by RN (Registered Nurse) #1. Resident #1 had [CONDITION(S)] to right front and rear shoulder, Right Scapula, and Right side of chest. Ambulance Service arrived at facility at 4:06 PM and begin further evaluation of Resident and transferred to burn center. The facility has no outside legal representative for Resident #1. Resident #1 is his own responsible party. The facility initiated an investigation. 4. On [DATE] at 3:15 PM Remaining twenty-three (23) Residents in fire door area begin being escorted to outside parking lot to account for and ensure safety. 5. On [DATE] at 4:40 PM Nurse Practitioner (NP)#1 assessed a total of twenty-three (23) Residents which previously resided in affected area. No concerns identified. On [DATE] Psychiatric Nurse Practitioner (NP) assessed a total of twenty-three (23) Residents for any emotional distress or trauma as related to the fire with no abnormalities noted. Staff Support hotline posted to provide grief or mental health support due to fire. 6. On [DATE] at 5:02 PM Mississippi State Department of Health was notified of event. 7. On [DATE] at 6:30 PM Fire [NAME] assessed building for any safety issues regarding the fire and cleared the remaining unaffected area to allow occupancy. 8. On [DATE] at 6:30 PM Resident rooms involved in evacuation area were assessed for water damage by outside contractor and Residents were actively being relocated to other areas of the building by facility staff. Relocation of twenty-three (23) Residents were completed by 10:30 PM. From 6:30 PM to 10:30 PM Responsible Parties of Residents residing in facility were contacted regarding event and safety of Residents by administration staff. 9. On [DATE] beginning at approximately 8:00 PM Administrator, Director of Nurses (DON), and Staff Development Coordinator (SDC) 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, Emergency Operations Plan, Fire Evacuation, Smoking Evaluations, and Resident Safety regarding fire. No staff will be allowed to return to work without completing. 10. On [DATE] at 5:00 PM, facility Administrator initiated automated phone reporting system alert to Resident families and staff to inform smoking safety including facility storage of lighters, asking families not to purchase flammable materials including new revisions to policy with removal of lighters regardless of smoking safety status. On [DATE] at 8:40 PM facility Administrator initiated automated phone reporting system with updated alert including revisions on smoking policy with facility storage of all smoking materials and assigned smoking times. This system automatically sends alerts and contacts families and staff listed in Resident's record and payroll system. 11. On [DATE] at 4:30 PM, the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing (Infection Preventionist) , Nurse Practitioner, and Clinical Corporate Consultant held Quality Assurance Performance Improvement meeting to include immediate corrective actions following facility fire involving audits on facilities current smoking Residents with room checks, smoking evaluations, smoking safety equipment, room change notifications, updated Brief Interview Mental Status (BIMS), and care plan reviews. Smoking policy was discussed with revision to remove wording that residents may retain their lighters if deemed safe. Resident's room checks were initiated on [DATE] with smoking residents to remove all lighters. Room checks were completed on [DATE] with multiple lighters found. 12. On [DATE] at 6:45 PM, the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing and Clinical Corporate Consultant held Quality Assurance Performance Improvement meeting following notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence including new policy and procedure changes. The smoking policy was revised to include supervised smoking of all Residents, assigned smoking times, and facility storage of all smoking material. 13. On [DATE] at 11:01 AM final written investigation was sent to Mississippi Department of Health along with Mississippi State Attorney General at 4:55 PM. 14. On [DATE] at 11:00 AM Mississippi State Department of Health Life Safety Surveyor entered facility to assess affected area with no negative findings. 15. On [DATE] at 3:45 pm E-cigarettes and smoking materials removed from Resident #2 possession, Assistant Director of Nurses (ADON) and Social Service Director (SSD) attempted education on new smoking policy and Resident #2 declined education. At 6:00 PM Smoking evaluation completed by Director of Nurses (DON) on Resident #2 revised to indicate Supervised smoking in designated smoking area during assigned smoking times. On [DATE] 100% room checks of all one hundred and thirty-one (131) resident's room were initiated to remove all smoking materials. No lighters were found. Two electronic cigarettes were removed to include Resident #2. There are no Residents with possession of smoking materials completed on [DATE] at 9:00 am. 16. On [DATE] at 6:00 PM Director of Nursing (DON) initiated new smoking evaluations on residents along with care plan updates on resident that smoke reflecting safety needs and policy changes. One hundred and Thirty-one (131) Resident smoking evaluations were completed with Twenty-one (21) Resident smoking care plans adjusted. On [DATE] at 7:30 am door to smoking area was secured, and scheduled smoking times begin starting at 9:00 am. 17. On [DATE] beginning at approximately 7:00 PM Staff Development Coordinator (SDC) initiated education with staff, including Certified Nursing Assistants, licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on new smoking policy revisions. No staff will be allowed to return to work without completing. 18. On ,d+[DATE]//21 at 9:15 AM education begin on new smoking policy revision with current smoking residents and smoking materials removed from current smoking resident's possession to include lighters, and cigarettes, on [DATE] at 8:30 AM keypad locked entry located at designated smoking area on lower first floor activated to ensure supervised access followed. 19. On [DATE] at 10:15 AM Resident Council Meeting Held with Activities Director, Resident Council President, and fifteen (15) resident members present to discuss new smoking policy revisions with supervised smoking times, and changes in facility storage of smoking materials. 20. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of [DATE], and the Immediate Jeopardy was removed [DATE]. Validation of Removal Plan: The SA validated the Removal Plan on [DATE], and determined the IJ was removed on [DATE], prior to exit. Therefore, the scope and severity for 42 CFR(s): §483.70 -Administration (F835) was lowered from an L to an F, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory compliance. 1. On [DATE] at 3:06 PM Receptionist #1 called 911 while facility alarm was sounding. Alarm company also contacted fire department. - Verified by the SA via review of the call log and interview. 2. On [DATE] at 3:12 pm Fire department dispatched EnRoute to facility and arrived at 3:14 pm. Sprinkler system was actively spraying water causing excessive smoke. Sprinkler system extinguished the fire prior to arrival of Fire Department. On [DATE] at 3:15 PM LPN #2 called 911 requested ambulance. - Verified by the SA via review of the Fire Departments call log journal and report. 3. On [DATE] at 3: 12 PM Resident #1 was assessed by RN (Registered Nurse) #1. Resident #1 had [CONDITION(S)] to right front and rear shoulder, Right Scapula, and Right side of chest. Ambulance Service arrived at facility at 4:06 PM and begin further evaluation of Resident and transferred to burn center. The facility has no outside legal representative for Resident #1. Resident #1 is his own responsible party. The facility initiated an investigation. - Verified by the SA through review of Resident #1's medical record. 4. On [DATE] at 3:15 PM Remaining twenty-three (23) Residents in fire door area begin being escorted to outside parking lot to account for and ensure safety. - Verified by the SA through interview of residents, and review of prior census sheet verses current census sheet of locations. 5. On [DATE] at 4:40 PM Nurse Practitioner (NP)#1 assessed a total of twenty-three (23) Residents which previously resided in affected area. No concerns identified. On [DATE] Psychiatric Nurse Practitioner (NP) assessed a total of twenty-three (23) Residents for any emotional distress or trauma as related to the fire with no abnormalities noted. Staff Support hotline posted to provide grief or mental health support due to fire. - Verified by the SA through interview of residents, and review of visit notes in their medical records. 6. On [DATE] at 5:02 PM Mississippi State Department of Health was notified of event. - Verified by the SA through review of the report. 7. On [DATE] at 6:30 PM Fire [NAME] assessed building for any safety issues regarding the fire and cleared the remaining unaffected area to allow occupancy. - Verified by the SA through review of the Fire [NAME]'s report, and occupy order. 8. On [DATE] at 6:30 PM Resident rooms involved in evacuation area were assessed for water damage by outside contractor and Residents were actively being relocated to other areas of the building by facility staff. Relocation of twenty-three (23) Residents were completed by 10:30 PM. From 6:30 PM to 10:30 PM Responsible Parties of Residents residing in facility were contacted regarding event and safety of Residents by administration staff. - Verified by the SA through resident interview, as most are their own responsible parties, medical record review and family call log review. 9. On [DATE] beginning at approximately 8:00 PM Administrator, Director of Nurses (DON), and Staff Development Coordinator (SDC) 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, Emergency Operations Plan, Fire Evacuation, Smoking Evaluations, and Resident Safety regarding fire. No staff will be allowed to return to work without completing. - Verified by the SA through sign-in sheet review and staff interviews. 10. On [DATE] at 5:00 PM, facility Administrator initiated automated phone reporting system alert to Resident families and staff to inform smoking safety including facility storage of lighters, asking families not to purchase flammable materials including new revisions to policy with removal of lighters regardless of smoking safety status. On [DATE] at 8:40 PM facility Administrator initiated automated phone reporting system with updated alert including revisions on smoking policy with facility storage of all smoking materials and assigned smoking times. This system automatically sends alerts and contacts families and staff listed in Resident's record and payroll system. - Verified by the SA through review of the transcript provided by Voice Friend Reporting and the call times messages were sent out. 11. On [DATE] at 4:30 PM, the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing (Infection Preventionist) , Nurse Practitioner, and Clinical Corporate Consultant held Quality Assurance Performance Improvement meeting to include immediate corrective actions following facility fire involving audits on facilities current smoking Residents with room checks, smoking evaluations, smoking safety equipment, room change notifications, updated Brief Interview Mental Status (BIMS), and care plan reviews. Smoking policy was discussed with revision to remove wording that residents may retain their lighters if deemed safe. Resident's room checks were initiated on [DATE] with smoking residents to remove all lighters. Room checks were completed on [DATE] with multiple lighters found. - Verified by the SA via review of the sign-in sheet, review of the content of the meeting items discussed, and staff interviews. 12. On [DATE] at 6:45 PM, the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing and Clinical Corporate Consultant held Quality Assurance Performance Improvement meeting following notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence including new policy and procedure changes. The smoking policy was revised to include supervised smoking of all Residents, assigned smoking times, and facility storage of all smoking material. - Verified by the SA via review of the sign-in sheet, review of the content of the meeting items discussed, and staff interviews. 13. On [DATE] at 11:01 AM final written investigation was sent to Mississippi Department of Health along with Mississippi State Attorney General at 4:55 PM. - Verified by the SA through review of the report received and a copy of the fax sheet that was timed and dated. 14. On [DATE] at 11:00 AM Mississippi State Department of Health Life Safety Surveyor entered facility to assess affected area with no negative findings. - Verified by the SA through review of the LSC Surveyors report 15. On [DATE] at 3:45 pm E-cigarettes and smoking materials removed from Resident #2 possession, Assistant Director of Nurses (ADON) and Social Service Director (SSD) attempted education on new smoking policy and Resident #2 declined education. At 6:00 PM Smoking evaluation completed by Director of Nurses (DON) on Resident #2 revised to indicate Supervised smoking in designated smoking area during assigned smoking times. On [DATE] 100% room checks of all one hundred and thirty-one (131) resident's room were initiated to remove all smoking materials. No lighters were found. Two electronic cigarettes were removed to include Resident #2. There are no Residents with possession of smoking materials completed on [DATE] at 9:00 am. - Verified by SA via resident interview, reviewing new assessments within the medical records against the checklist of current smokers. 16. On [DATE] at 6:00 PM Director of Nursing (DON) initiated new smoking evaluations on residents along with care plan updates on resident that smoke reflecting safety needs and policy changes. One hundred and Thirty-one (131) Resident smoking evaluations were completed with Twenty-one (21) Resident smoking care plans adjusted. On [DATE] at 7:30 am door to smoking area was secured, and scheduled smoking times begin starting at 9:00 am. - Verified by the SA through review of the new smoking assessments dated for [DATE] in the medical records of all residents currently in the building. 17. On [DATE] beginning at approximately 7:00 PM Staff Development Coordinator (SDC) initiated education with staff, including Certified Nursing Assistants, licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on new smoking policy revisions. No staff will be allowed to return to work without completing. - Verified by the state agency through review of the sign-in sheet and staff interviews. 18. On ,d+[DATE]//21 at 9:15 AM education begin on new smoking policy revision with current smoking residents and smoking materials removed from current smoking resident's possession to include lighters, and cigarettes, on [DATE] at 8:30 AM keypad locked entry located at designated smoking area on lower first floor activated to ensure supervised access followed. - Verified by the SA through interviews with the residents who smoke and the new code pad installed next to the door with numeric code entry to unlock it. 19. On [DATE] at 10:15 AM Resident Council Meeting Held with Activities Director, Resident Council President, and fifteen (15) resident members present to discuss new smoking policy revisions with supervised smoking times, and changes in facility storage of smoking materials. - Verified by the SA through review of the council sign-in form, and resident interview regarding topics discussed and understanding. 20. 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 verified all aspects of the Removal Plan had been carried out as stated, and the Immediate Jeopardy was removed on [DATE], as stated.

Based on observation, record review, resident interviews, staff interviews, and facility policy review, the facility failed to adhere to the smoking policy to ensure resident's safety while smoking for 20 of 20 smokers out of a total of 133 residents, with a sample of seven (7), Residents #1, #2, #3, #4, #5, #6 and #7. The facility's failure to follow the smoking policy placed residents at risk, and in a situation, which caused serious injury and death for one (1) resident, Resident #1, and was likely to cause serious injury, harm, impairment, or death for others. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 02-21-2021, when the facility's failure to follow the smoking policy by providing supervision of residents while smoking, ensuring they were not smoking in the presence of oxygen or combustible chemicals, and ensuring the removal of lighters and combustible materials from residents rooms, resulted in a resident smoking in his bed, with his oxygen on, causing a fire in the facility giving him third degree [CONDITION(S)] to his right shoulder, right front chest, and right upper back which required extensive skin grafts. He also suffered from inhalation [CONDITION(S)], which later contributed to his demise. The facility had to relocate 23 residents to alternate beds within the facility who incurred loss of personal property, and the loss of 32 beds within the facility to water damage. On 03-08-2021, at 2:00 PM, the State Agency (SA) informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the Administrator with the IJ Template. IJ existed at: 42 CFR §483.90(i)(5) - Smoking Policies (F926) - Scope and Severity - L The facility submitted a credible Removal Plan on 03-09-2021, at 4:40 PM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of 03-10-2021. The SA validated the Removal Plan on 03-11-2021 and determined the IJ was removed prior to exit. Therefore, the scope and severity for IJ existed at: 42 CFR §483.90(i)(5) - Smoking Policies (F926) was lowered from an L level of scope and severity to an F while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy titled, Resident Acknowledgement - Facility Smoking Policy revised on 08-11-2020 revealed: Safe Smoking Environment: It is the responsibility of the facility to provide a safe and hazard free environment for those residents having been assessed as safe for facility smoking privileges. The Oxygen cylinders will not be permitted in any authorized smoking area. Facility smoking policies through verbal means, distribution and posting. This policy is intended to minimize the risks to: Residents who smoke, including possible adverse effects on treatment, passive smoke to others, and fire. Smoking Accommodation: This policy does not include chewing tobacco. Residents may maintain their own tobacco supplies in their room and do not have to be supervised. E-Cigarettes will be treated like cigarettes per policy. At no time will E-Cigarettes be permitted for use inside of the facility. The smoking of marijuana is prohibited in a Nexion Facility. The facility is responsible for enforcement of smoking policies. Smoking is prohibited in any room, ward, or compartment within the facility with exception being the designated smoking room on the first floor. Smoking is prohibited where flammable liquids, combustible gas or oxygen are stored, and in any other hazardous location. These areas are posted with nonsmoking area signs. Residents wishing to smoke while at the facility will have a Smoking Safety Evaluation completed by the interdisciplinary team to determine the resident's ability to follow smoking policies safely. All residents who wish to smoke must provide funds to purchase their own smoking paraphernalia. Oxygen carrying devices will not be permitted in any authorized smoking area. Check Option that applies to facility: 1. All smoking in this facility is SUPERVISED and at designated times. Staff will maintain/keep all smoking materials (e.g., cigarettes, pipes, matches, lighters, lighter fluid) and distribute the materials to residents at smoking times. 2. Residents who are deemed safe will be allowed to smoke unsupervised and may be permitted to keep cigarettes on their persons. If resident is deemed unsafe, they will be required to surrender all smoking paraphernalia to facility. Staff will maintain/keep all smoking materials (e.g., cigarettes, E-Cigarettes, pipes, matches, lighters, lighter fluid) and distribute the materials to residents at smoking times. Furthermore, a smoking schedule will be posted, and resident will be required to smoke with supervision only, according to schedule. Smoking Infraction: The first infraction of the smoking policy results in a warning. This warning may be verbal. The warning is given to both the resident and their family member of contact. A safe smoking reassessment of that resident is performed to determine supervision required. The second infraction of the smoking policy may result in notice of discharge. The reason for discharge would be endangerment to the health and safety of residents. On 03-03-2021, at 7:20 PM, during an interview with the administrator she stated Resident #1, the resident who started the facility fire, was his own Resident Representative (RR). His Brief Interview of Mental Status (BIMS) score was 15 deeming him able to make his own decisions. He left the facility three (3) times a week for [CONDITION(S)] and would come and go as he pleased. She felt it was a violation of his rights for the staff to go through his belongings every time he would return from an outing. She stated she was aware there were several residents that probably had lighters before the fire because they were not consistently going through the smoker's belongings or monitoring what they were getting in packages from family or for themselves. The administrator stated there were several lighters confiscated after the fire, and the new smoking rules were reviewed with each smoker. When asked by the SA if they had removed all the lighters from the current smokers, she stated, she hoped so, but they did not go through every drawer, and closet. They took what they were able to find, and what the residents gave to them. She again stated, several of them went out on pass as their own RR and they were not searched when they came back. She stated they had hired staff to do supervised smoking from 8:00 AM - 10:00 PM. Resident #1 The facility's smoking policy also stated, All smoking in this facility is SUPERVISED and at designated times. Staff will maintain/keep all smoking materials (e.g. cigarettes, pipes, matches, lighters, lighter fluid and distribute the materials to residents at smoking times .Furthermore, a smoking schedule will be posted and residents will be required to smoke with supervision only, according to schedule. A Smoking Safety Evaluation dated 02-20-21 at 9:00 PM stated he was identified as a safe smoker. Record review of a NN dated 02-21-21, at 5:31 PM, titled Incident Note stated the Fire alarm was automatically activated, heavy dark smoke and copious amounts of water was noted coming from room [ROOM NUMBER] D. Resident noted in the room lying on the floor by the foot of the bed calling out help me. Res. was transferred to wheelchair then to safety by staff. [CONDITION(S)] were noted on the resident's upper right chest, right arm, and upper right back. Resident stated he had a cigarette lighter to light his cigarette but did not reveal where he got the lighter. An additional Smoking Safety Evaluation was completed on 02-21-21 at 11:00 PM, after Resident #1 had been admitted to the hospital, that indicated his mental status was alert, decision ability was consistent, his reflexes were quick response, he did NOT only smoke in designated areas, he could safely light and hold a cigarette, he responds quickly to fallen ashes, he did NOT follow the smoking guidelines, he returned his smoking materials to storage, he did not remove his oxygen tubing, and could extinguish his own cigarette. The Evaluation further states, if one response is answered no then resident should be supervised while smoking. There were several items marked no on the form, yet the Summary of Evaluation indicated he was safe to smoke unsupervised, and the Comments stated Resident has been deemed as an unsafe smoker, he has a BIMS of 15 and chooses to smoke unsafely. Resident smokes while O2 is in use while in the bed. During an interview on 3/8/21, at 11:00 AM, multiple areas of contradiction on the Smoking Safety Evaluation form which had been completed on 2/21/21, at 11:00 PM, was reviewed with the Administrator. She agreed the evaluation was not accurately completed and contradictory to itself in several places. She feels it was done hurriedly and attention was not paid to the details on the form. Resident #2 The facility failed to follow the smoking policy in multiple ways to include: The facility's smoking policy revealed, E-Cigarettes will be treated like cigarettes per policy. At no time will E-Cigarettes be permitted for use inside of the facility. On 03-05-2021, at 11:30 AM, the SA was asked to visit Resident #2, at her request. While meeting with her, an E-cigarette was observed on her bedside table with two battery cartridges. When asked if she was allowed to smoke in her room, she stated, Hell Yeah, because that is not a real cigarette anyway, I ain't no harm to no body. Record review of her latest MDS dated [DATE], revealed she had a BIMS of 15 and was able to make her own decisions regarding her care, she required total assistance of two (2) staff members for her ADL's, and the use of a mechanical lift for transfers. On 03-05-2021, at 1:45 PM., during an interview with R.N.#1, she verified Resident #2 was allowed to smoke her E-cigarette unsupervised in her room because she refused to get out of the bed to go smoke and she refused to be supervised while she was smoking. She stated the management was aware and let her do it. During an interview on 3/8/21, at 11 AM, multiple areas of contradiction on the Smoking Safety Evaluation form which had been completed on 2/21/21, at 11 PM, was reviewed with the Administrator. She agreed the evaluation was not accurately completed and contradictory to itself in several places. She feels it was done hurriedly and attention was not paid to the details on the form. She stated she was aware Resident #2 refused to get out of bed to go smoke and smoked her E-cigarette unsupervised in her room all the time. She stated she needed to be given a 30-day discharge because she had refused to abide by the rules since her admission. Resident #2's dated 02 Smoking Safety Evaluation dated 02-23-2021, at 10:11 AM, revealed, her manual dexterity is weak, and her grasp is weak, she drops items, her reflexes are diminished in response, she has upper and lower body limitations, she smokes only in designated areas, and cannot safely light her smoking material, she cannot safely hold her smoking material, she can dispose of her ashes, and can quickly respond to fallen ashes, she follows the smoking guidelines per policy, and returns her smoking materials to storage. There is a note on the evaluation which states, if one response is answered NO then resident should be supervised while smoking She has 3 NOs on her form and yet under the Summary of Evaluation it stated she can smoke unsupervised. In the Comments section it stated, resident has upper and lower body impairments, she requires assistance with lighting cigarettes, resident is able to grasp cigarette but r/t upper body impairments, she is at risk for dropping items. Resident #3 On 03-04-2021 at 10:10 AM, during an interview with Resident #3, she stated, I don't have a lighter no more, since they came and got them a week ago. I'll be honest, I don't know if I still got some of them stashed in all those boxes or not. We been moved around so much for the virus and then the fire that all my stuff is in boxes right now. I keep my cigarettes in my purse. The SA observed a pack of cigarettes laying on her bedside table and another one sticking out of one of her clothing drawers. Record review of Resident #3's last Quarterly MDS dated [DATE] revealed she had a BIMS of 15 and was able to make her own decisions, and required extensive assistance to get dressed every day, and supervision of staff for all others. During an interview on 03-08-2021 at 11:20 AM with the SSD, she was asked if the date reflected when she removed the lighter from Resident #3, or just the date she entered the intervention, as 03-01-2021 would have been eleven (11) days after the fire this resident had access to a lighter. She stated, I'm unable to say right now, I don't remember all the dates. Resident #4 On 03-04-2021 at 10:15 AM, during an interview with Resident #4, she stated, I keep my cigarettes in my purse next to my bed. I don't have a lighter anymore since the staff came and took them after the fire. Somebody is usually out there from around 8 am - 10 pm, but the weekends are real bad. Last weekend there was nobody here to do the smoking for us all day on Sunday, so we had a staff member light a cigarette for one of us, and then we just tried to light each other's for everybody as they came out the rest of the day. I go out and smoke 10-12 times a day, and there is usually 5-6 times a week that no staff member is out there. There is a couple guys that need help smoking, so if they come out there when no staff is there, we try to remember to help put on their aprons and light their cigarettes for them. We try to watch out for each other. Record review of Resident #4's latest quarterly MDS dated [DATE], revealed a BIMS score of 15, meaning she is able to make her own decisions, and required supervision for all her Activities of Daily Living (ADL's). Resident #5 On 03-04-2021 at 10:30 AM, during an interview with Resident #5, he stated, I keep my cigs in my room in that lock drawer over there, but I don't have no lighter anymore. They came and took it after that guy lit the place up. If they find a lighter on you, you get a 30-day notice and I been here for almost 6 years. From 8 AM - 1 PM there is usually a staff member out there with us, but if no one is out there, we light off each other out of respect for the staff, not having to come out here while they are trying to work. (Formal name of another resident) needs help to smoke, cuz his hands shake so bad, so we try to help him when he rolls out without help .I am out here smoking most of the day. I go in to eat and to take a nap. Record Review of Resident #5's latest quarterly MDS, dated [DATE], revealed a BIMS score of 14, making him able to make his own decisions, and requiring supervision for most of his ADL's, except for putting on his clothing, due to only having one arm. Resident #6 On 03-04-2021 at 11:38 AM, during an interview with Resident #6, she stated, There are several times a week when there ain't no staff out there for us. This past Sunday there was only a staff out there one time, and that is cuz they wanted to smoke. (Formal name of another resident) needs help to smoke and the aides sometimes push him out and put his apron on and then leave, so we light his cigarette for him. Review of Resident #6's latest quarterly MDS, dated [DATE], revealed she has a BIMS of 15, making her able to make her own decisions, and she required supervision for all of her activities of daily living. Resident #7 On 03-04-2021 at 11:20 AM, during an interview with Resident #7, he stated, I keep my cigarettes in my pocket or my hat, I don't have a lighter anymore since they came and took them from us. I usually go down there about three times a day and if staff are there, they will light our cigarettes. There is usually someone out there until after 10:00 o'clock at night. If not, we will light each other's cigarettes. (Formal name of another resident) is the man that needs help there and he rolls himself outside. His handshakes bad, so I helped him put the cigarette in his mouth and then we light it with our own cigarettes. There don't always be staff out there all the time when we are smoking. We try to make sure he has his apron on, but I'm sure sometimes he does not . We try to lookout for each other out there to make sure everybody is OK. Review of Resident #7's latest quarterly MDS dated [DATE], revealed he has a BIMS score of 15, making him able to make his own decisions, and he required limited assistance for all of his activities of daily living. On 03-07-2021 at 11:10 AM, an observation was made of a letter given to all the smokers, posted on the wall next to their beds. The letter said, Effective 2/15/2021 Yazoo City Rehabilitation and Healthcare Center will go to supervised smoking for all residents. At this time, the facility will take control of all smoking paraphernalia including cigarettes, lighters, tobacco pipes, etc. These will be kept in a lock box in the medication room on the first floor and will be brought out for the smoking times. Smoking times are as follows: 7:30, 8:30, 10:15, 1:00. 3:45, 6:00, 8:00 and 9:30. Each smoking time will be 15 to 20 minutes long depending on the number of smokers. Failure to follow these rules will result in to a thirty-day discharge notice being issued. On 03-07-2021 at 2:15 PM, during an interview with the Activities Director (AD), she stated there were two people that needed support to smoke. They were to wear aprons at all times. One resident could not hold his own cigarette due to shaking from [CONDITION(S)], and the other would often fall asleep when smoking and would drop his cigarette on himself. She stated they had activity staff that stayed outside with the residents from around 8:00 am - 10:00 pm. When asked by the SA what a resident was supposed to do if they wanted to smoke a cigarette at 2:00 AM, she stated they would have to find a staff member willing to light their cigarette for them and sit with those that need to be helped. When asked by the SA about the letter posted beside the beds of all the smokers, she stated the facility was not following the letter because of the uproar the residents made regarding locking up their cigarettes, and not being able to smoke whenever they wanted to, like they are now. The facility submitted an acceptable Removal Plan on 03-09-2021, at 4:40 PM, in which the facility alleged all corrective actions to remove the IJ were completed on 03-09-2021 and the IJ was removed on 03-10-2021. Removal Plan Brief Summary of Events On 2/21/21 at 3:06 PM Licensed Practical Nurse (LPN) #1 reported hearing fire alarm sounding. She reported grabbing fire extinguisher and seeing smoke coming out of Resident #1 room. LPN #1 reported calling Residents #1 name and he hollered back help. LPN #1 reported entering room with fire extinguisher, described as thick black smoke with water present, no active fire. LPN #1 did not use fire extinguisher. LPN #1 reported unable to see through the smoke and then RN (Registered Nurse) #1 and CNA (Certified Nursing Assistant) #1 went into Resident #1's room noting a smoke-filled room with no fire, sprinkler system actively pouring water, and found Resident #1 located lying on floor near foot of bed with no active fire. RN (Registered Nurse) #1 and CNA (Certified Nursing Assistant) #1 along with Dietary Aide #1 transferred Resident #1 from floor to wheelchair and removed Resident #1 from the room. Resident #1 denied pain and reported he lit a cigarette while wearing oxygen. Resident #1 refused to answer on where he obtained lighter from. Facility failed to provide adequate supervision ensuring Residents were abiding by established smoking rules/policy regarding smoking materials resulting in Resident #1 obtaining lighter and lighting a cigarette lying in bed with oxygen causing fire in the facility that resulted in [CONDITION(S)] to right shoulder, chest and back. Resident #2 failing to abide by facility policy with possession of electronic cigarette. Corrective Actions: 1. On 2/21/21 at 3:06 pm Receptionist #1 called 911 while facility alarm was sounding. Alarm company also contacted fire department. 2. On 02/21/21 at 3:12 pm Fire department dispatched EnRoute to facility and arrived at 3:14 pm. Sprinkler system was actively spraying water causing excessive smoke. Sprinkler system extinguished the fire prior to arrival of Fire Department. On 02/21/21 at 3:15 pm LPN #2 called 911 requested ambulance. 3. On 02/21/21 at 3: 12 PM Resident #1 was assessed by RN (Registered Nurse) #1. Resident #1 had [CONDITION(S)] to right front and rear shoulder, Right Scapula, and Right side of chest. Ambulance Service arrived at facility at 4:06 PM and begin further evaluation of Resident and transferred to burn center. The facility has no outside legal representative for Resident #1. Resident #1 is his own responsible party. The facility initiated an investigation. 4. On 02/21/21 at 3:15 PM Remaining twenty-three (23) Residents in fire door area begin being escorted to outside parking lot to account for and ensure safety. 5. On 2/21/21 at 4:40 PM Nurse Practitioner (NP)#1 assessed a total of twenty-three (23) Residents which previously resided in affected area. No concerns identified. On 02/24/21 Psychiatric Nurse Practitioner (NP) assessed a total of twenty-three (23) Residents for any emotional distress or trauma as related to the fire with no abnormalities noted. Staff Support hotline posted to provide grief or mental health support due to fire. 6. On 02/21/21 at 5:02 PM Mississippi State Department of Health was notified of event. 7. On 02/21/21 at 6:30 PM Fire [NAME] assessed building for any safety issues regarding the fire and cleared the remaining unaffected area to allow occupancy. 8. On 02/21/21 at 6:30 PM Resident rooms involved in evacuation area were assessed for water damage by outside contractor and Residents were actively being relocated to other areas of the building by facility staff. Relocation of twenty-three (23) Residents were completed by 10:30 PM. From 6:30 PM to 10:30 PM Responsible Parties of Residents residing in facility were contacted regarding event and safety of Residents by administration staff. 9. On 02/21/21 beginning at approximately 8:00 PM Administrator, Director of Nurses (DON), and Staff Development Coordinator (SDC) 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, Emergency Operations Plan, Fire Evacuation, Smoking Evaluations, and Resident Safety regarding fire. No staff will be allowed to return to work without completing. 10. On 02/22/21 at 5:00 PM, facility Administrator initiated automated phone reporting system alert to Resident families and staff to inform smoking safety including facility storage of lighters, asking families not to purchase flammable materials including new revisions to policy with removal of lighters regardless of smoking safety status. On 03/08/21 at 8:40 PM facility Administrator initiated automated phone reporting system with updated alert including revisions on smoking policy with facility storage of all smoking materials and assigned smoking times. This system automatically sends alerts and contacts families and staff listed in Resident's record and payroll system. 11. On 02/23/21 at 4:30 PM, the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing (Infection Preventionist) , Nurse Practitioner, and Clinical Corporate Consultant held Quality Assurance Performance Improvement meeting to include immediate corrective actions following facility fire involving audits on facilities current smoking Residents with room checks, smoking evaluations, smoking safety equipment, room change notifications, updated Brief Interview Mental Status (BIMS), and care plan reviews. Smoking policy was discussed with revision to remove wording that residents may retain their lighters if deemed safe. Resident's room checks were initiated on 2/21/21 with smoking residents to remove all lighters. Room checks were completed on 2/22/21 with multiple lighters found. 12. On 03/08/21 at 6:45 PM, the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing and Clinical Corporate Consultant held Quality Assurance Performance Improvement meeting following notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence including new policy and procedure changes. The smoking policy was revised to include supervised smoking of all Residents, assigned smoking times, and facility storage of all smoking material. 13. On 02/24/21 at 11:01 AM final written investigation was sent to Mississippi Department of Health along with Mississippi State Attorney General at 4:55 PM. 14. On 03/03/21 at 11:00 AM Mississippi State Department of Health Life Safety Surveyor entered facility to assess affected area with no negative findings. 15. On 03/08/21 at 3:45 pm E-cigarettes and smoking materials removed from Resident #2 possession, Assistant Director of Nurses (ADON) and Social Service Director (SSD) attempted education on new smoking policy and Resident #2 declined education. At 6:00 PM Smoking evaluation completed by Director of Nurses (DON) on Resident #2 revised to indicate Supervised smoking in designated smoking area during assigned smoking times. On 3/9/21 100% room checks of all one hundred and thirty-one (131) resident's room were initiated to remove all smoking materials. No lighters were found. Two electronic cigarettes were removed to include Resident #2. There are no Residents with possession of smoking materials completed on 3/9/21 at 9:00 am. 16. On 03/08/21 at 6:00 PM Director of Nursing (DON) initiated new smoking evaluations on residents along with care plan updates on resident that smoke reflecting safety needs and policy changes. One hundred and Thirty-one (131) Resident smoking evaluations were completed with Twenty-one (21) Resident smoking care plans adjusted. On 3/9/21 at 7:30 am door to smoking area was secured, and scheduled smoking times begin starting at 9:00 am. 17. On 03/08/21 beginning at approximately 7:00 PM Staff Development Coordinator (SDC) initiated education with staff, including Certified Nursing Assistants, licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on new smoking policy revisions. No staff will be allowed to return to work without completing. 18. On 03/09//21 at 9:15 AM education begin on new smoking policy revision with current smoking residents and smoking materials removed from current smoking resident's possession to include lighters, and cigarettes, on 03/09/21 at 8:30 AM keypad locked entry located at designated smoking area on lower first floor activated to ensure supervised access followed. 19. On 03/09/21 at 10:15 AM Resident Council Meeting Held with Activities Director, Resident Council President, and fifteen (15) resident members present to discuss new smoking policy revisions with supervised smoking times, and changes in facility storage of smoking materials. 20. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 03/09/21, and the Immediate Jeopardy was removed 03/10/21. The SA validated the Removal Plan on 03-11-2021, and determined the IJ was removed on 03-10-2021, prior to exit. Therefore, the scope and severity for 42 CFR §483.90(i)(5) - Smoking Policies (F926) - Scope and Severity - L was lowered from an L to an F, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory compliance. 1. On 2/21/21 at 3:06 PM Receptionist #1 called 911 while facility alarm was sounding. Alarm company also contacted fire department. - Verified by the SA via review of the call log and interview. 2. On 02/21/21 at 3:12pm Fire department dispatched EnRoute to facility and arrived at 3:14 pm. Sprinkler system was actively spraying water causing excessive smoke. Sprinkler system extinguished the fire prior to arrival of Fire Department. On 02/21/21 at 3:15 PM LPN #2 called 911 requested ambulance. - Verified by the SA via review of the Fire Departments call log journal and report. 3. On 02/21/21 at 3: 12 PM Resident #1 was assessed by RN (Registered Nurse) #1. Resident #1 had [CONDITION(S)] to right front and rear shoulder, Right Scapula, and Right side of chest. Ambulance Service arrived at facility at 4:06 PM and begin further evaluation of Resident and transferred to burn center. The facility has no outside legal representative for Resident #1. Resident #1 is his own responsible party. The facility initiated an investigation. - Verified by the SA through review of Resident #1's medical record. 4. On 02/21/21 at 3:15 PM Remaining twenty-three (23) Residents in fire door area begin being escorted to outside parking lot to account for and ensure safety. - Verified by the SA through interview of residents, and review of prior census sheet verses current census sheet of locations. 5. On 2/21/21 at 4:40 PM Nurse Practitioner (NP)#1 assessed a total of twenty-three (23) Residents which previously resided in affected area. No concerns identified. On 02/24/21 Psychiatric Nurse Practitioner (NP) assessed a total of twenty-three (23) Residents for any emotional distress or trauma as related to the fire with no abnormalities noted. Staff Support hotline posted to provide grief or mental health support due to fire. - Verified by the SA through interview of residents, and review of visit notes in their medical records. 6. On 02/21/21 at 5:02 PM Mississippi State Department of Health was notified of event. - Verified by the SA through review of the report. 7. On 02/21/21 at 6:30 PM Fire [NAME] assessed building for any safety issues regarding the fire and cleared the remaining unaffected area to allow occupancy. - Verified by the SA through review of the Fire [NAME]'s report, and occupy order. 8. On 02/21/21 at 6:30 PM Resident rooms involved in evacuation area were assessed for water damage by outside contractor and Residents were actively being relocated to other areas of the building by facility staff. Relocation of twenty-three (23) Residents were completed by 10:30 PM. From 6:30 PM to 10:30 PM Responsible Parties of Residents residing in facility were contacted regarding event and safety of Residents by administration staff. - Verified by the SA through resident interview, as most are their own responsible parties, medical record review and family call log review. 9. On 02/21/21 beginning at approximately 8:00 PM Administrator, Director of Nurses (DON), and Staff Development Coordinator (SDC) 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, Emergency Operations Plan, Fire Evacuation, Smoking Evaluations, and Resident Safety regarding fire. No staff will be allowed to return to work without completing. - Verified by the SA through sign-in sheet review and staff interviews. 10. On 02/22/21 at 5:00 PM, facility Administrator initiated automated phone reporting system alert to Resident families and staff to inform smoking safety including facility storage of lighters, asking families not to purchase flammable materials including new revisions to policy with removal of lighters regardless of smok [TRUNCATED]