**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, record reviews, observations, policy and procedure reviews, local county sheriff's report and interview, and review of the social media video, the facility failed to ensure that the rights of Resident #1 to have respect and dignity were honored when two Certified Nursing Assistants (CNAs) taunted, threatened and abused Resident #1 and posted the videos to social media. Resident #1 was one (1) of three (3) residents that were reviewed for Resident Rights. The evening of 07/22/25 two (2) facility Certified Nursing Assistants (CNA)'s posted a video to social media in which they taunted, threatened and abused Resident #1. The video was seen by the community and the family of the resident.The facility's failure to ensure the right to be treated with dignity placed Resident #1 and other residents at risk in a situation that has caused and is likely to cause serious injury, serious harm, serious impairment, or death. The SA identified Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 07/22/25. The SA notified the facility's Administrator of the IJ and SQC on 07/29/25 at 3:00 PM and provided the Administrator with the IJ templates. The facility provided an acceptable Removal Plan on 7/29/25, in which the facility alleged all corrective actions were completed to remove the IJ on 7/29/25 and the IJ removed on 7/30/25.The SA determined the IJ was removed on 7/30/25, prior to exit, and the scope and severity for CFR S483.10(a)(1) Resident Rights (F550) was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Cross Reference F600Findings Include:Review of the facility's undated policy titled Your Rights and Protections as a Nursing Home Resident read: What are my rights in a nursing home? As a nursing home resident, you have certain rights and protections under Federal and state law that help ensure you get the care and services you need. You have the right. to have your personal information kept private. Be Treated with Respect: You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose.Be Free from Abuse and Neglect: You have the right to be free from verbal, sexual, physical, and mental abuse. Record review of the facility policy titled HIPPA Sanctions Policy dated and revised 06/25 revealed, The Health Insurance Portability and Accountability Act of 1996 (HIPPA) requires that covered entities have and apply appropriate sanctions against members of their workforce who fail to comply with privacy policies and procedures of the covered entity, or the requirements of the HIPPA Security Rule. Accordingly, it is the intention of (name of facility) to ensure the confidentiality and integrity of protected health information as required by law and professional ethics.Review of the facility policy titled Photographing, Videotaping, Video imaging and/or Audiotaping Policy last revised 3/23 revealed, .Patient identifiable information is any piece of information which can potentially be used to identify, contact, or locate an individual. This includes demographic information, voice audio, facial images, or any unique characteristic of an individual. Photographic images are considered protected health information and are not limited to images of the face. Additionally, any characteristic that could uniquely identify the individual is protected health information. Purpose: To protect the patient's dignity and comply with federal and state privacy laws. Patient Authorization Required. Patient authorization is obtained prior to all photography.Review of the facility's Employees Handbook page 30 of 43 revealed: .Recording Devices and Cameras Team members are not permitted to use cameras, camera phones, tape recorders, or other recording devices on duty or while on (name of facility) premises conducting official business unless such use has been approved by management. Accordingly, team members are prohibited from secretly recording, videotaping, or taking pictures of others. Such conduct is grounds for disciplinary action up to and including termination of employment. Record review of the facility investigation and observation of the video footage revealed that on 07/23/25 at approximately 6:40 AM the facility Director of Nursing (DON) was notified by a resident of the local community that there was a video of Resident #1 posted on social media the evening of 07/22/25. The DON immediately began investigating the incident and she obtained a copy of the video which identified Resident #1 and two (2) Certified Nursing Assistants (CNA#1) and (CNA #2). The local law enforcement was notified of the incident, and they also began an investigation. The DON obtained handwritten statements from CNA #1 and CNA #2 and determined through investigation that CNA #1 and CNA #2 had posted videos of Resident #1 on social media without the permission of Resident #1 and/or her Responsible Parties (RP's). The video revealed that CNA #1 and CNA #2 were taunting, threatening and teasing Resident #1 while she was lying in bed, which lead to Resident #1 becoming agitated and upset. The video revealed that CNA #1 threatened Resident #1 with biting her and that she would be sent to Geri psych. CNA #1 was heard on the video asking Resident #1 if she had ever been bitten and if she did not behave she would bite her. The video showed that CNA #1 slapped the back of Resident #1's upper right arm and sat on Resident #1's bed on top of her lower legs. Resident #1 could be heard saying that she was hurting her legs and to get off her. During the entire video CNA #2 could be heard laughing as if she was video taping the events. It was determined through the facility investigation that the video of Resident #1 was taken in her room while she was in her bed at a time between 4:30-5:00 PM on 07/22/2025. The investigation revealed that the unauthorized video was posted to the social media platform by the two (2) facility CNA's and was later shared with other employees of the facility and then it eventually was shared with the family members of other residents in the facility, which lead to the violation of the residents' rights. In viewing the video, it was visible that Resident #1 was upset by the abuse and taunting and was heard on the video cussing the two CNAs as both were laughing at Resident #1.Record review of the facility's documentation of the incident titled: Report of Violation Under Mississippi Vulnerable Adult Act completed and signed by the facility's DON and dated 07/25/25. The report revealed: On July 23, 2025, at approximately 6:40 A.M., a video was received of (CNA #1) assigned to (Resident #1), appearing to upset her. The CNA tapped (Resident #1) on her right arm. The audio is not clear on the video, but laughing can be heard. (CNA #2) admitted during the investigation interview that she was the one that recorded the video. (CNA #2) posted the video on a private story on her (social media) page and tagged approximately six (6) people in it for viewing. (Resident #1) can be seen in the video lying in her bed in (room #). The video was screen recorded by someone and has now spread throughout the community. (Resident #1's) Resident Representative (RR#1) was notified and he voiced that him and his family had plans to come to the facility concerning the matter. (Resident #1's) family arrived at the facility on 07/23/25 at approximately 8:15 A.M. upset and showed staff members a copy of the video on their personal cell phone. The (local county Sheriff's Department) was notified and arrived at the facility to speak with the family and staff members concerning the incident. The two CNAs involved (CNA #1 and CNA#2) were arrested by (local county Sheriff's officer) on July 24, 2025, with pending charges of abuse. (Resident #1) is an [AGE] year-old female admitted to (name of facility) on April 27, 2021, per the services of (name of physician) due to dementia with behavioral disturbances. Resident #1 has a BIMS (Brief Interview of Mental Status) score of 3 indicating severe cognitive impairment. She is usually able to make her needs known and she usually understands others. She is non-ambulatory. She uses a staff propelled wheelchair for mobility. She requires two-person extensive assistance with bed mobility, personal hygiene, bathing, and dressing. She's incontinent with bowel and bladder. The report was dated 07/25/25 and signed by the DON. On 07/29/25 at 9:15 AM during an interview with the Nursing Home Administrator (NHA) he confirmed that two (2) facility CNA's (CNA #1 and CNA#2) had been terminated from the facility for the abuse of Resident #1. He stated that on 07/22/25 at or around 4:30 PM the two CNA ‘s video taped Resident #1 during delivery of care in her room and then posted the video to social media on the evening of 07/22/2025. The NHA stated that the county Sheriff arrested the two CNAs and charged them with abuse of a Vulnerable Adult. In an interview with the DON on 07/29/25 at 9:30 AM she confirmed that she obtained hand-written statements from the two (2) CNA's (CNA #1 and CNA #2) and that they had admitted to her through their statements that they did not view their interactions with Resident #1 as abuse. They stated that they were just playing with Resident #1 and that they were video taping her for her family to have memories of her. The CNAs stated that they should not have posted the video to social media but had only posted it to their private story and invited six (6) guests to view it. They had not thought that the video would be re-posted by others on various other social media platforms. The DON stated that the county Sheriff had arrested the two CNAs for abuse of a Vulnerable Adult and that they had spent the night in jail. The local news station also reported the incident as abuse of a Vulnerable Adult. The DON stated that the family came to the facility on [DATE] at approximately 8:15 AM and they were very upset that the video of Resident #1 was posted on social media the evening of 07/22/2025. The DON first learned about the video and abuse of Resident #1 at approximately 6:40 AM on 07/23/2025. On 07/29/2025 at 10:15 AM an observation and interview with Resident #1 revealed a bed bound resident lying in her bed, aroused easily when spoken to, but confused. Resident #1 was alert to self and able to answer simple questions. Resident #1 was able to tell surveyor her correct date of birth . Resident was oriented to her name but was not oriented to place and time. Resident #1 presented as having dementia. Interview on 07/29/2025 at 11:00 AM with the Quality Assurance Director (QAD) revealed that she had no knowledge of the incident with Resident #1 on 07/22/25 and it was discussed on 07/23/25 that a couple of the CNAs had video taped her during care. QAD stated that all staff are in-serviced and trained that they should never have their phones out during care and that it is a violation of the residents rights to do that and especially to post it on social media.During an interview by telephone on 07/29/2025 at 1:20 PM with Resident Representative (RR#1) revealed that he was contacted on 07/22/2025 at approximately 7:30 PM by his grandson and told that there was a video of Resident #1 posted on social media. RR#1 stated that he had no knowledge of what (proper name of social media) was or how to view it on his cell phone and his grandson sent him the video of Resident #1 being abused by two (2) CNA's. RR#1 stated that this was very upsetting to him and his family. RR#1 stated that RR#2 was most upset about the posting of the video and the abuse of Resident #1. RR#1 stated that he came to the facility on [DATE] to talk to the staff about Resident #1 and to get an explanation as to why this video was posted on social media. RR#1 stated that he received numerous phone calls from all over the community and out of state to tell him that there was a video of Resident #1 posted on social media. RR #1 stated that he felt that Resident #1 had been abused by the two (2) CNAs seen on the video. RR #1 stated that the two (2) CNAs seen on the video with Resident #1 were arrested by the county Sheriff's office for abuse of Resident #1. RR #1 stated that the posting of the video was very embarrassing to his family and to Resident #1. On 07/29/2025 at 1:55 PM an interview with RR#2 revealed that she had worked at the facility for many years and had retired from that facility. RR#2 stated that she had placed Resident #1 at the facility in 2021 because she was of the impression that she would be safe and treated well. RR#2 stated that she was very upset over the abusive way the two CNAs had treated Resident #1 on the video. RR#2 stated that she felt that if they were comfortable enough to record and post videos of abuse of Resident #1, she just wonders how long they have been doing this and to who else. RR#2 stated that on 07/23/2025 she went to her mother's room to assess her and to look at her legs and feet where the CNA #1 had sat on her. RR#2 stated that Resident #1 had a dark bruise on her right ankle. RR #2 stated that she felt that the bruise was a result of CNA #1 sitting on top of her in her bed as seen on the video. On 07/29/2025 at 2:00 PM during an interview with the County Sheriff Deputy that arrested the two (2) CNAs revealed that he arrested CNA #1 and CNA #2 for simple assault of a Vulnerable Adult. He stated that CNA #1 and CNA #2 had been placed in jail overnight and the next day they posted bail and obtained attorneys. The Deputy Sheriff provided the surveyors with a copy of the Sheriff's report dated 07/24/2025. The Deputy Sheriff confirmed that he obtained written statements from the two (2) CNAs while they were in custody, and it would be shared with the grand jury for criminal charges. The record review of the Minimum Data Set (MDS) dated [DATE] Section C-Cognitive Patterns documented that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3 which indicated that she was severely cognitively impaired. Section G-Functional Status of the MDS dated [DATE] documented that Resident #1 was a two (2) person assist for Activities of Daily Living (ADL) Assistance. The record review of the handwritten statement of CNA #1 that she gave to the facility DON revealed that CNA #1's written statement was very different from what was viewed on the video and posted on social media. CNA #1's handwritten statement that she gave to the facility's DON and was signed by CNA #1 and dated 7/23/2025 revealed: On July 22nd appr. 4:30 or no later than I took (name of Resident #1) to put her to bed. She was very combative holding on to the walls I then had to tell her it was time for her to go to bed before the other shift came. I then had to strap her on the lift, and she was refusing She punched me multiple times in doing so I was replying stop hitting me and you have to go to bed She replied with she is not going to bed. I then put her in her bed, and she was hanging on to the lift so me and (name of another staff) proceeded to remove her hands. I stated multiple times if she didn't stop she was going to hurt herself She was cussing and fighting I was trying to change her when she grabbed me by my hair. I got away from her and proceeded with the care. She then still didn't let me pull off her clothes so I then tricked her into letting me get them off when she realize I was trying to clean her she became combative again I then was changed her in a hurry and I was trying to sit her up in bed when she continued to hit me she stated Do you wanna fight I then begin to play with her and gave her a little playful tap on the shoulder after the situation was done She looked at me and said I love you sister, will you come back to sit with me I gave her a hug and told her I would see her Friday and that was the last time we talked till I picked up her supper tray and even then we were so nice to each other. Signed by CNA #1 and dated 07/23/2025 and placed in the DON's investigation. Record review of the handwritten statement given to the DON by CNA #2 and dated 7/23/2025 revealed: This is (name of CNA #2) statement. I take full responsibility for the video that's been brought to your attention. I made a huge mistake by violating HIPPA but also my resident rights. The video that was seen was a misunderstanding. As we were only playing with her I could see how it looked on the outside. This is something we're used to. When (name of Resident #1) doesn't wanna lay down she cusses, throws fits, hits everything. This was something we were used to, so we never really paid any mind. I never charted her bad behavior; I didn't see it that way because it would only be when it was time to lay down. Then she does have a touch of dementia she didn't know what she was doing, she just knew she didn't want to go to bed. But to help night shift we try to lay as many people down before they come in. Just to kind of help. In the video you do hear her cussing (CNA #1) out and hitting her, you do see (CNA #1) messing/playing with her back. This was something they often did. It was never any physical or verbal abuse. We shouldn't be playing with residents I'm aware. But it was never out of anger or anything. We just got so comfortable with her a grew a tight bond with her. She became one of our favorite residents, which I love them all and I do love my job. I made a very terrible mistake, and I truly am sorry. I am willing to prove and do anything to show whoever that this wasn't a case of abuse in any type of way. She shouldn't have been recorded I am aware and own up to my wronging. But I wouldn't allow any abuse in my presence. I didn't look at it being abuse because this something we was so use to happening. It was just a mistake and misunderstanding. Anybody in the facility could tell you we wouldn't hurt anyone and we love everyone. We did inform a nurse that was their about her hitting and cussing. I am truly sorry for what it looked like but abuse in any way wasn't the case. The date the video was taking was on July 22nd approx. after 4PM to 5ish. Handwritten statement signed by CNA #2 and dated 7/23/25 and placed in the DON's investigation. Record review of the County Sheriff's Report revealed that on 07/24/2025 CNA #1 and CNA #2 were arrested for Abuse/Neglect of A Vulnerable Adult and Exploitation of Vulnerable Adult. The narrative written on the sheriff's report read: On July 24, 2025, (name of county Sheriff's office) received a report of a (Proper name of social media) video going around that showed two health care workers assaulting an elderly female at the (name of the facility). In the video, you can see that a health care worker was in the patient's room while the other worker was videoing it. After reviewing the video, it showed that the health care worker hit the female patient. The workers were identified as (CNA #2 and CNA #1). (Name of Sheriff's Deputy interviewed both suspects. Both suspects admitted to the allegations, and both wrote out a statement. Both individuals were arrested and charged. The SA was unable to interview CNA #1 and CNA #2 because both had obtained lawyers and would not speak to us during the time the SA was investigating the abuse case.Review of the Removal Plan revealed that the facility took the following actions: The removal plan below is provided in response to the Immediate Jeopardy (IJ) received on 7/29/2025. The State Agency notified the facility administrator of the IJ on 7/29/2025. Brief Description: On July 22, 2025, at 4:30 PM, the facility failed to prevent staff from exploiting and abusing Resident #1 by allowing staff to record and share video footage on their phones of demeaning, degrading content involving the resident by staff members that were assigned to care for her in the facility. The video was posted to a social media platform where the family saw the video footage of the event. Immediate Action started on July 23, 2025, at approximately 6:40 AM: On 7/23/2025 at 6:37 AM, Director of Nursing (DON) was notified by an external source about a video of Resident #1 was posted on a social media platform. On 7/23/2025 at 6:37 AM, DON notified Nursing Home Administrator (NHA). On 7/23/2025 at 7:18 AM, Assistant Director of Nursing (ADON) received a call from NHA requesting to initiate reporting. On 7/23/2025 at 7:49 AM, ADON spoke with DON to discuss the process of reporting to State and AG. On 07/23/2025 at 8:08 AM, ADON reported the incident to MS Department of Health. On 7/23/2025 at 8:18 AM, ADON reported the incident to the Attorney General. On 7/23/2025 at 8:18 AM, ADON notified Responsible Party (RP). On 7/23/2025 at 8:30 AM, ADON and Staff Development Specialist (SDS) performed full body assessment of Resident #1. The findings were this nurse performed a full body audit that was completed per protocol. Elder's skin assessed from head to toe, including behind the ears, under the breast, axillae, abdomen, groin, back and all extremities. No bruising or lacerations noted. Elder has no wounds. Elder's skin is warm, dry and intact. Elder is alert to self only and talkative. Word salad noted. Elder tolerated assessment without distress. On 7/23/2025 at 8:45 AM, SDS continued to complete full body assessments and interviews of all residents under the care of the staff in question. No negative assessments or outcomes were found. On 7/23/2025 at 9:00 AM, Resident #1's family arrived at facility and met with ADON, Risk Manager (RM), Human Resources Manager (HRM), Licensed Social Worker (LSW), and Head Nurse (HN). On 7/23/2025 at 9:05 AM, Police Department notified. On 7/23/2025 at 9:35 AM, Chief of Police arrived at facility. On 7/23/2025 at 10:03 AM, ADON notified Ombudsmen. On 7/23/2025 at 10:49 AM, ADON notified Primary Care Provider (PCP). On 7/23/2025 at 2:30 PM, LSW discussed with Ombudsmen. On 7/23/2025 at 3:07 PM, Certified Nursing Assistant (CNA) #1 suspended and terminated on 7/23/2025. On 7/23/2025 at 3:47 PM, CNA #2 suspended and terminated on 7/23/2025. On 7/23/2025 at 4:30 PM, SDS began in-services on HIPAA, Reporting Abuse, Cell phone usage, and Vulnerable Adult Policy until 100% is completed. No staff will be allowed to work until in serviced. On 7/28/2025 at 9:30 AM, Psychiatric Mental Health Nurse Practitioner (PMHNP) evaluated Resident #1 for psychosocial harm. No issues were identified. On 7/29/2025 at 4:20 PM, an emergency QAPI meeting was held to review the immediate jeopardy related to Residents Rights and Abuse and exploitation and review policies and procedures for changes. Attendees were NHA, Nursing Home Medical Staff Director (NHMSD), DON, ADON, Quality Improvement Officer (QIO), Care Plan Nurse (CPN), SDS, HRM, and RM. Policies were reviewed and changes were made to the Quality Assurance and Performance Improvement Policy. The policy update included holding emergency meetings to discuss reportable events during the investigation time frame. The facility alleged that all corrective actions were completed on 7/29/2025, and the IJ removed as of 7/30/2025. The State Agency (SA) validation of the Removal Plan was made on 7/30/25 through interviews, observations, record reviews, and policy and procedure reviews. The SA determined all corrective actions were completed on 7/29/25 by the facility and the IJ was removed on 7/30/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, observations, resident interviews, record reviews, policy and procedure reviews, video review, and sheriff's arrest report review, the facility failed to protect Resident #1's right to be free from abuse when staff created a video during care of the resident, of verbal and physical abuse, of the resident and posted it to social media. Resident #1 was one (1) of three (3) residents reviewed for Abuse and Neglect. The evening of 07/22/25 two (2) facility Certified Nursing Assistants (CNA)'s posted a video to social media in which they taunted, threatened and abused Resident #1. The video was seen by the community and the family of the resident.The facility's failure to ensure the right to be free from abuse placed Resident #1 and other residents at risk for abuse and neglect in a situation that has caused and is likely to cause serious injury, serious harm, serious impairment, or death. The SA identified Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 07/22/25. The SA notified the facility's Administrator of the IJ and SQC on 07/29/25 at 3:00 PM and provided the Administrator with the IJ templates. The facility provided an acceptable Removal Plan on 7/29/25, in which the facility alleged all corrective actions were completed to remove the IJ on 7/29/25 and the IJ removed on 7/30/25.The SA determined the IJ was removed on 7/30/25, prior to exit, and the scope and severity for CFR S483.12(a)(1) Freedom from Abuse, Neglect, and ExploitationF600 was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Cross Reference F550Findings Include:Review of the facility policy titled: Abuse last review/revision 04/25, revealed, .It is the policy of (name of facility) that this facility prohibits mistreatment, neglect, or abuse of residents. The residents must not be subjected to abuse by anyone. The resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion. Major Types of Elder Abuse: Physical Abuse. Exploitation.Psychological Abuse: The infliction of mental anguish, as with insults, swearing, or threats;.Verbal Abuse refers to any oral, written, or gestured language that includes disparaging and derogatory terms to residents. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment, and deprivation. The term abuse is used in its broadest sense and refers to lack of courtesy, teasing, threatening, or overly vigorous restraint of a resident. Review of the facility policy titled Photographing, Videotaping, Video imaging and/or Audiotaping Policy last revised 3/23 revealed, .Patient identifiable information is any piece of information which can potentially be used to identify, contact, or locate an individual. This includes demographic information, voice audio, facial images, or any unique characteristic of an individual. Photographic images are considered protected health information and are not limited to images of the face. Additionally, any characteristic that could uniquely identify the individual is protected health information. Purpose: To protect the patient's dignity and comply with federal and state privacy laws. Patient Authorization Required. Patient authorization is obtained prior to all photography.Review of the facility's Employees Handbook page 30 of 43 revealed: .Recording Devices and Cameras Team members are not permitted to use cameras, camera phones, tape recorders, or other recording devices on duty or while on (name of facility) premises conducting official business unless such use has been approved by management. Accordingly, team members are prohibited from secretly recording, videotaping, or taking pictures of others. Such conduct is grounds for disciplinary action up to and including termination of employment. Record review of the facility investigation and observation of the video footage revealed that on 07/23/25 at approximately 6:40 AM the facility Director of Nursing (DON) was notified by a resident of the local community that there was a video of Resident #1 posted on social media the evening of 07/22/25. The DON immediately began investigating the incident and she obtained a copy of the video which identified Resident #1 and two (2) Certified Nursing Assistants (CNA#1) and (CNA #2). The local law enforcement was notified of the incident, and they also began an investigation. The DON obtained handwritten statements from CNA #1 and CNA #2 and determined through investigation that CNA #1 and CNA #2 had posted videos of Resident #1 on social media without the permission of Resident #1 and/or her Responsible Parties (RP's). The video revealed that CNA #1 and CNA #2 were taunting, threatening and teasing Resident #1 while she was lying in bed, which lead to Resident #1 becoming agitated and upset. The video revealed that CNA #1 threatened Resident #1 with biting her and that she would be sent to Geri psych. CNA #1 was heard on the video asking Resident #1 if she had ever been bitten and if she did not behave she would bite her. The video showed that CNA #1 slapped the back of Resident #1's upper right arm and sat on Resident #1's bed on top of her lower legs. Resident #1 could be heard saying that she was hurting her legs and to get off her. During the entire video CNA #2 could be heard laughing. It was determined through the facility investigation that the video of Resident #1 was taken in her room while she was in her bed at a time between 4:30-5:00 PM on 07/22/2025. The investigation revealed that the unauthorized video was posted to the social media platform by the two (2) facility CNA's and was later shared with other employees of the facility and then it eventually was shared with the family members of other residents in the facility. In viewing the video, it was visible that Resident #1 was upset by the abuse and taunting and was heard on the video cussing thetwo CNAs as both were laughing at Resident #1.Record review of the facility's documentation of the incident titled: Report of Violation Under Mississippi Vulnerable Adult Act completed and signed by the facility's DON and dated 07/25/25. The report revealed: On July 23, 2025, at approximately 6:40 A.M., a video was received of (CNA #1) assigned to (Resident #1), appearing to upset her. The CNA tapped (Resident #1) on her right arm. The audio is not clear on the video, but laughing can be heard. (CNA #2) admitted during the investigation interview that she was the one that recorded the video. (CNA #2) posted the video on a private story on her (social media) page and tagged approximately six (6) people in it for viewing. (Resident #1) can be seen in the video lying in her bed in (room #). The video was screen recorded by someone and has now spread throughout the community. (Resident #1's) Resident Representative (RR#1) was notified and he voiced that he and his family had plans to come to the facility concerning the matter. (Resident #1's) family arrived at the facility on 07/23/25 at approximately 8:15 A.M. upset and showed staff members a copy of the video on their personal cell phone. The (local county Sheriff's Department) was notified and arrived at the facility to speak with the family and staff members concerning the incident. The two CNAs involved (CNA #1 and CNA#2) were arrested by (local county Sheriff's officer) on July 24, 2025, with pending charges of abuse. (Resident #1) is an [AGE] year-old female admitted to (name of facility) on April 27, 2021, per the services of (name of physician) due to dementia with behavioral disturbances. Resident #1 has a BIMS (Brief Interview for Mental Status) score of 3 indicating severe cognitive impairment. She is usually able to make her needs known and she usually understands others. She is non-ambulatory. She uses a staff propelled wheelchair for mobility. She requires two-person extensive assistance with bed mobility, personal hygiene, bathing, and dressing. She's incontinent with bowel and bladder. The report was dated 07/25/25 and signed by the DON. In an interview with the Nursing Home Administrator (NHA) on 07/29/25 at 9:15 AM he confirmed that two (2) facility CNA's (CNA #1 and CNA#2) had been terminated from the facility on 7/23/25 for the abuse of Resident #1. He stated that on 07/22/25 at or around 4:30 PM the two CNA ‘s video taped Resident #1 during delivery of care in her room and then posted the video to social media on the evening of 07/22/2025. The NHA stated that the county Sheriff arrested the two CNAs and charged them with abuse of a Vulnerable Adult. On 07/29/25 at 9:30 AM in an interview with the DON she confirmed that she obtained hand-written statements from the two (2) CNA's (CNA #1 and CNA #2) and that they had admitted to her through their statements that they did not view their interactions with Resident #1 as abuse. They stated that they were just playing with Resident #1 and that they were video taping her for her family to have memories of her. The CNAs stated that they should not have posted the video to social media but had only posted it to their private story and invited six (6) guests to view it. They had not thought that the video would be re-posted by others on various other social media platforms. The DON stated that the county Sheriff had arrested the two CNAs for abuse of a Vulnerable Adult and that they had spent the night in jail. The local news station also reported the incident as abuse of a Vulnerable Adult. The DON stated that the family came to the facility on [DATE] at approximately 8:15 AM and they were very upset that the video of Resident #1 was posted on social media the evening of 07/22/2025. The DON first learned about the video and abuse of Resident #1 at approximately 6:40 AM on 07/23/2025. In an interview on 07/29/25 at 10:00 AM with the Assistant Director of Nursing (ADON) it was revealed that she was working on 07/22/2025 and had gone into Resident #1's room around 4:30 PM to talk to CNA #1 about a full-time position at the facility. ADON stated that she did not see any abuse occurring at that time and had no knowledge of the incident until she was told about it on the next day 07/23/2025. ADON stated that CNA #1 and CNA #2 both had been working at the facility for close to a year and she stated that she hated to think about what occurred to the resident just moments after she left the room from talking to CNA #1 regarding swapping from part time to full time.Observation and interview on 07/29/2025 at 10:15 AM with Resident #1 revealed a bed bound resident lying in her bed, aroused easily when spoken to, but confused. Resident #1 was alert to self and able to answer simple questions. Resident #1 was able to tell surveyor her correct date of birth . Resident was oriented to her name but was not oriented to place and time. Resident #1 presented as having dementia. Interview by telephone on 07/29/2025 at 1:20 PM with Resident Representative (RR#1) revealed that he was contacted on 07/22/2025 at approximately 7:30 PM by his grandson and told that there was a video of Resident #1 posted on social media. RR#1 stated that he had no knowledge of what (proper name of social media) was or how to view it on his cell phone and his grandson sent him the video of Resident #1 being abused by two (2) CNA's. RR#1 stated that this was very upsetting to him and his family. RR#1 stated that RR#2 was most upset about the posting of the video and the abuse of Resident #1. RR#1 stated that he came to the facility on [DATE] to talk to the staff about Resident #1 and to get an explanation as to why this video was posted on social media. RR#1 stated that he received numerous phone calls from all over the community and out of state to tell him that there was a video of Resident #1 posted on social media. RR #1 stated that he felt that Resident #1 had been abused by the two (2) CNAs seen on the video. RR #1 stated that the two (2) CNAs seen on the video with Resident #1 were arrested by the county Sheriff's office for abuse of Resident #1. RR #1 stated that the posting of the video was very embarrassing to his family and to Resident #1. Interview on 07/29/2025 at 1:55 PM with RR#2 revealed that she had worked at the facility for many years and had retired from that facility. RR#2 stated that she had placed Resident #1 at the facility in 2021 because she was of the impression that she would be safe and treated well. RR#2 stated that she was very upset over the abusive way the two CNAs had treated Resident #1 on the video. RR#2 stated that she felt that if they were comfortable enough to record and post videos of abuse of Resident #1, she just wonders how long they have been doing this and to who else. RR#2 stated that on 07/23/2025 she went to her mother's room to assess her and to look at her legs and feet where the CNA #1 had sat on her. RR#2 stated that Resident #1 had a dark bruise on her right ankle. RR #2 stated that she felt that the bruise was a result of CNA #1 sitting on top of her in her bed as seen on the video. Interview on 07/29/2025 at 2:00 PM with the County Sheriff Deputy that arrested the two (2) CNAs revealed that he arrested CNA #1 and CNA #2 for simple assault of a Vulnerable Adult. He stated that CNA #1 and CNA #2 had been placed in jail overnight and the next day they posted bail and obtained attorneys. The Deputy Sheriff provided the surveyors with a copy of the Sheriff's report dated 07/24/2025. The Deputy Sheriff confirmed that he obtained written statements from the two (2) CNAs while they were in custody, and it would be shared with the grand jury for criminal charges. The record review of the Minimum Data Set (MDS) dated [DATE] Section C-Cognitive Patterns documented that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3 which indicated that she was severely cognitively impaired. Section G-Functional Status of the MDS dated [DATE] documented that Resident #1 was a two (2) person assist for Activities of Daily Living (ADL) Assistance. The record review of the handwritten statement of CNA #1 that she gave to the facility DON revealed that CNA #1's written statement was very different from what was viewed on the video and posted on social media. CNA #1's handwritten statement that she gave to the facility's DON and was signed by CNA #1 and dated 7/23/2025 revealed: On July 22nd appr. 4:30 or no later than I took (name of Resident #1) to put her to bed. She was very combative holding on to the walls I then had to tell her it was time for her to go to bed before the other shift came. I then had to strap her on the lift, and she was refusing She punched me multiple times in doing so I was replying stop hitting me and you have to go to bed She replied with she is not going to bed. I then got her in her bed, and she was hanging on to the lift so me and (name of another staff) proceeded to remove her hands. I stated multiple times if she didn't stop she was going to hurt herself She was cussing and fighting I was trying to change her when she grabbed me by my hair. I got away from her and proceeded with the care. She then still didn't let me pull off her clothes so I then tricked her into letting me get them off when she realize I was trying to clean her she became combative again I then was changed her in a hurry and I was trying to sit her up in bed when she continued to hit me she stated Do you wanna fight I then begin to play with her and gave her a little playful tap on the shoulder after the situation was done She looked at me and said I love you sister, will you come back to sit with me I gave her a hug and told her I would see her Friday and that was the last time we talked till I picked up her supper tray and even then we were so nice to each other. Signed by CNA #1 and dated 07/23/2025 and placed in the DON's investigation. Record review of the handwritten statement given to the DON by CNA #2 and dated 7/23/2025 revealed: This is I (name of CNA #2) statement. I take full responsibility for the video that's been brought to your attention. I made a huge mistake by violating HIPPA but also my resident rights. The video that was seen was a misunderstanding. As we were only playing with her I could see how it looked on the outside. This is something we're used to. When (name of Resident #1) doesn't wanna lay down she cusses, throws fits, hits everything. This was something we were used to, so we never really paid any mind. I never charted her bad behavior; I didn't see it that way because it would only be when it was time to lay down. Then she does have a touch of dementia she didn't know what she was doing, she just knew she didn't want to go to bed. But to help night shift we try to lay as many people down before they come in. Just to kind of help. In the video you do hear her cussing (CNA #1) out and hitting her, you do see (CNA #1) messing/playing with her back. This was something they often did. It was never any physical or verbal abuse. We shouldn't be playing with residents I'm aware. But it was never out of anger or anything. We just got so comfortable with her a grew a tight bond with her. She became one of our favorite residents, which I love them all and I do love my job. I made a very terrible mistake, and I truly am sorry. I am willing to prove and do anything to show whoever that this wasn't a case of abuse in any type of way. She shouldn't have been recorded I am aware and own up to my wrongings. But I wouldn't allow any abuse in my presence. I didn't look at it being abuse because this something we was so use to happening. It was just a mistake and misunderstanding. Anybody in the facility could tell you we wouldn't hurt anyone and we love everyone. We did inform a nurse that was their about her hitting and cussing. I am truly sorry for what it looked like but abuse in any way wasn't the case. The date the video was taking was on July 22nd approx. after 4PM to 5ish. Handwritten statement signed by CNA #2 and dated 7/23/25 and placed in the DON's investigation. Record review of the County Sheriff's Report revealed that on 07/24/2025 CNA #1 and CNA #2 were arrested for Abuse/Neglect of A Vulnerable Adult and Exploitation of Vulnerable Adult. The narrative written on the sheriff's report read: On July 24, 2025, (name of county Sheriff's office) received a report of a Snapchat video (social media) going around that showed two health care workers assaulting an elderly female at the (name of the facility). In the video, you can see that a health care worker was in the patient's room while the other worker was videoing it. After reviewing the video, it showed that the health care worker hit the female patient. The workers were identified as (CNA #2 and CNA #1). Sheriff's Deputy's interviewed both suspects. Both suspects admitted to the allegations, and both wrote out a statement. Both individuals were arrested and charged. The SA was unable to interview CNA #1 and CNA #2 because both had obtained lawyers and would not speak to us during the time the SA was investigating the abuse case.Review of the Removal Plan revealed that the facility took the following actions: The removal plan below is provided in response to the Immediate Jeopardy (IJ) received on 7/29/2025. The State Agency notified the facility administrator of the IJ on 7/29/2025. Brief Description: On July 22, 2025, at 4:30 PM, the facility failed to prevent staff from exploiting and abusing Resident #1 by allowing staff to record and share video footage on their phones of demeaning, degrading content involving the resident by staff members that were assigned to care for her in the facility. The video was posted to a social media platform where the family saw the video footage of the event. Immediate Action started on July 23, 2025, at approximately 6:40 AM: On 7/23/2025 at 6:37 AM, Director of Nursing (DON) was notified by an external source about a video of Resident #1 was posted on a social media platform. On 7/23/2025 at 6:37 AM, DON notified Nursing Home Administrator (NHA). On 7/23/2025 at 7:18 AM, Assistant Director of Nursing (ADON) received a call from NHA requesting to initiate reporting. On 7/23/2025 at 7:49 AM, ADON spoke with DON to discuss the process of reporting to State and Attorney General (AG). On 07/23/2025 at 8:08 AM, ADON reported the incident to MS Department of Health. On 7/23/2025 at 8:18 AM, ADON reported the incident to the Attorney General. On 7/23/2025 at 8:18 AM, ADON notified Responsible Party (RP). On 7/23/2025 at 8:30 AM, ADON and Staff Development Specialist (SDS) performed full body assessment of Resident #1. The findings were this nurse performed a full body audit that was completed per protocol. Elder's skin assessed from head to toe, including behind the ears, under the breast, axillae, abdomen, groin, back and all extremities. No bruising or lacerations noted. Elder has no wounds. Elder's skin is warm, dry and intact. Elder is alert to self only and talkative. Word salad noted. Elder tolerated assessment without distress. On 7/23/2025 at 8:45 AM, SDS continued to complete full body assessments and interviews of all residents under the care of the staff in question. No negative assessments or outcomes were found. On 7/23/2025 at 9:00 AM, Resident #1's family arrived at facility and met with ADON, Risk Manager (RM), Human Resources Manager (HRM), Licensed Social Worker (LSW), and Head Nurse (HN). On 7/23/2025 at 9:05 AM, Police Department notified. On 7/23/2025 at 9:35 AM, Chief of Police arrived at facility. On 7/23/2025 at 10:03 AM, ADON notified Ombudsmen. On 7/23/2025 at 10:49 AM, ADON notified Primary Care Provider (PCP). On 7/23/2025 at 2:30 PM, LSW discussed with Ombudsmen. On 7/23/2025 at 3:07 PM, Certified Nursing Assistant (CNA) #1 suspended and terminated on 7/23/2025. On 7/23/2025 at 3:47 PM, CNA #2 suspended and terminated on 7/23/2025. On 7/23/2025 at 4:30 PM, SDS began in-services on HIPAA, Reporting Abuse, Cell phone usage, and Vulnerable Adult Policy until 100% is completed. No staff will be allowed to work until in serviced. On 7/28/2025 at 9:30 AM, Psychiatric Mental Health Nurse Practitioner (PMHNP) evaluated Resident #1 for psychosocial harm. No issues were identified. On 7/29/2025 at 4:20 PM, an emergency QAPI meeting was held to review the immediate jeopardy related to Residents Rights and Abuse and exploitation and review policies and procedures for changes. Attendees were NHA, Nursing Home Medical Staff Director (NHMSD), DON, ADON, Quality Improvement Officer (QIO), Care Plan Nurse (CPN), SDS, HRM, and RM. Policies were reviewed and changes were made to the Quality Assurance and Performance Improvement Policy. The policy update included holding emergency meetings to discuss reportable events during the investigation time frame. The facility alleged that all corrective actions were completed on 7/29/2025, and the IJ removed as of 7/30/2025. The State Agency (SA) validation of the Removal Plan was made on 7/30/25 through interviews, observations, record reviews, and policy and procedure reviews. The SA determined all corrective actions were completed on 7/29/25 by the facility and the IJ was removed on 7/30/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review and facility policy review, the facility failed to protect the resident's right to be free from sexual abuse for one (1) of 20 residents on the Special Care Unit. Resident #56. Resident #56 was found on 4/24/25 at approximately 3:00 PM, by a Certified Nursing Assistant (CNA) with Resident #16 in the bed and on top of her, with his hand inside her incontinence brief, performing jabbing motions. Resident #16 became violent with the staff when they tried to remove him from Resident #16's room where he hit a staff member with his fist. The facility's failure to prevent the sexual abuse of Resident #56 placed Resident #56 and other residents at risk for sexual assault, in a situation that caused and was likely to cause serious injury, serious harm, serious impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 11/05/24 when Resident #16 began to exhibit sexual behaviors towards staff and the facility did not implement interventions to prevent further sexual behaviors. The SA notified the facility's Administrator of the IJ and SQC on 4/30/25 at 1:20 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on 5/02/25, in which they alleged all corrective actions to remove the IJ and SQC were completed on 5/1/25, and the IJ removed on 5/2/25. The SA validated the Removal Plan on 5/05/25 and determined the IJ and SQC was removed on 5/2/25, prior to exit. Therefore, the scope and severity for 42 CFR: 483.12 (a)(1)- Free from Abuse, Neglect and Exploitation (F600), was lowered from a scope and severity of 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. Cross Reference F609, F656 Findings Include: Record review of the facility policy Abuse and or Suspected Crimes Reporting Under the Elder Justice Act, last reviewed 3/24 revealed, .Sexual abuse includes .sexual assault . It is the policy of [Proper Name of Facility] that all residents will be free from physical, mental, and/or verbal abuse . Record review of the facility investigation revealed that on 4/24/25 at approximately 3:00 PM, a Certified Nursing Assistant (CNA) was walking down the hall and saw Resident #16 on top of Resident #56 in an inappropriate manner. Both residents were clothed. The CNA called for assistance from other staff to remove Resident #16 from Resident #56's bed. Upon assessment by the Registered Nurse (RN), Resident #56 was noted to have scratches on her upper legs and scratches and bruising on her labia. The CNA reported that Resident #16's hand was down inside Resident #56's diaper, and he was making a jabbing motion with his hand. Record review of the Default Flowsheet Data for Resident #56, under Genitourinary on 4/24/25 at 4:13 PM, documented scratches, skin discoloration, and slight edema noted to the labia; maroon/purple and pale overall paleness; maroon/purple bruising noted to the left thigh; maroon/purple bruising with yellow outer edges noted to the left lateral eyebrow; and scratches noted to the left thigh and bilateral outer labia with bruising and redness to both areas. Record review of the Nursing Note for Resident #56, dated 4/29/25, written by Licensed Practical Nurse (LPN) #2 revealed a late entry for 4/24/25 that stated, This nurse alerted by CNA to come to elder's room. When this nurse entered room, observed a male elder on top of this female elder, both were fully clothed, male elder refuses to get off of female elder and required 2 (two) more CNA to assist, male elder becomes violent and punches one of the CNAs in the nose, male elder removed from this elder's room and taken back to his room with supervision. [Proper Name of Administrator] aware . Social Worker (SW) aware and she talked to family, and [Proper Name of Physicians] aware per this nurse . Record review of the Nursing Note for Resident #16, dated 4/24/25, documented that a CNA doing a visual check observed the elder in a female elder's room on top of her. The clothes were intact. When attempts were made to remove this elder, he became violent and punched a CNA in the nose. He was returned to his room, and supervision was provided at his doorway to maintain the female resident's safety. In an interview with CNA #3 on 4/29/25 at 10:45 AM, she stated that on the afternoon of 4/24/25, she came out of another resident's room and heard a commotion. She saw staff going into Resident #56's room, so she followed and saw Resident #16 lying on top of Resident #56. Both residents were fully dressed, and Resident #16 had his hand up Resident #56's pants leg. She said staff were attempting to remove him and he became agitated, hitting a CNA in the face. She stated it took about four staff members to remove him. CNA #3 further stated that Resident #16 frequently makes inappropriate statements about wanting sex and has grabbed CNAs between their legs, but she had never seen him attempt to touch another resident in this way. She said CNAs usually take two people when giving him care and try to discourage his behavior, but that he still grabs staff between their legs. After the incident, he was taken to his room, and the CNAs on duty conducted visual checks, but he was not on 1:1 supervision. At some point, he came out of his room and was in the dining area making sexual statements in front of other residents, so they returned him to his room. In an interview with the Administrator on 4/29/25 at 12:50 PM, he stated that on 4/24/25 at approximately 3:20 PM, he was notified by LPN #2 that Resident #16 was found on top of Resident #56, and he called for a Registered Nurse (RN) to assess her. He stated that at that time he was not informed that Resident #16 had his hands in Resident #56's brief. He stated that the resident's responsible party was notified by the Social Worker, and the physician was also notified. He verified that he reported the incident online to the Attorney General's Office. The Administrator stated that staff working the unit were instructed to supervise Resident #16 until he was transferred to the geriatric hospital on the afternoon of 4/25/25. He verified that no other residents were assessed for signs of abuse at that time and no other body audits were performed. The Administrator confirmed that this is a memory care unit that both Resident #56 and Resident #16 reside on. In an interview with RN #3 on 4/30/25 at 9:15 AM, she stated that on 4/24/25 around 4:00 PM, she was called to assess Resident #56 after Resident #16 was found on top of her. Resident #56 was noted to have irregularly shaped scratches and bruising on her left thigh, approximately the size of a quarter, bruising to her left eye, and scratches and bruising on both sides of her labia. She stated she notified the Administrator and Social Worker of her finding in the body audit. In an interview with CNA #6, #7, and #8 on 4/30/25 at 10:00 AM, they all stated that Resident #16 has a history of touching and grabbing staff's private parts and making comments like give me that p**** in front of other residents. They stated they had never seen him attempt to touch other residents, but he does touch staff and that he makes inappropriate sexual comments to other residents. They said that after the incident on 04/24/25, while Resident #16 was in the dining area on 4/25/25, he was fondling himself, making sexual gestures at female residents, and making inappropriate sexual statements, after which he was returned to his room. In an interview with LPN #3 on 4/30/25 at 10:15 AM she stated that Resident #16 has always exhibited aggressive verbal sexual behaviors. He makes sexual gestures toward anyone who walks by and says things like I want your p****. She stated he grabs CNAs during Activity of Daily Living (ADL) care and masturbates in common areas. She said that on the morning of 4/25/25, she was instructed to keep him under supervision in the dining room, but he continued to display inappropriate sexual behaviors. Although he was returned to his room, he is ambulatory and would come right back out. She added that he wanders and walks around the unit and, if his roommate is in the bathroom, he will go into other resident's room to use the restroom. In a telephone interview with CNA #2 on 4/30/25 at 2:00 PM, she confirmed that on the afternoon of 4/24/25, she was returning from filling the ice cart and saw Resident #16 on top of Resident #56 with his hand under her pants, fondling her forcefully. She stated that she witnessed Resident #56 lying on her back with her hands shaking and held over her head and face, while Resident #16 held her down forcefully with his left arm. CNA #2 yelled for help, and three other CNAs came. They physically removed Resident #16, who was aggressive, agitated, and combative, hitting and kicking at staff. She stated he hit her, CNA #3, in the face with his fist. After much effort, the staff removed him from Resident #56's bed and returned him to his room for supervision. She described him as violent and said he has always made sexual statements and grabbed staff. In a telephone interview with LPN #2 on 4/30/25 around 2:30 PM, she stated she was called to Resident #56's room on the afternoon of 4/24/25 and witnessed Resident #16 on top of Resident #56. Both were clothed, and she did not see his hand in her brief. She confirmed Resident #16 had a history of inappropriate sexual verbalizations, but she had not seen him touch other residents. She verified she notified the Administrator. In a telephone interview with the Psychiatric Nurse Practitioner (NP) on 5/1/25 at 10:15 AM, she stated that the staff keep her updated on Resident #16's behaviors and notify her if he has any increases. She verified that Resident #16 had inappropriate sexual behaviors and had an increase of these behaviors in November of last year and at that time his Depakote was increased on 11/4/25. During a further record review of the medical record for Resident#16 the notes below were revealed: Record review of Nursing Note for Resident #16 dated 11/5/24 revealed elder has inappropriate behaviors of groping at staff .sexually inappropriate behaviors, regularly touch his genitalia in public . Record review of Psychiatric Progress Note and Case Conceptualization note for Resident #16 dated 11/7/24 completed by Nurse Practitioner, revealed a diagnosis of Dementia. Review of the Case Conceptualization note revealed His Depakote was recently increased due to increase in inappropriate behaviors Record review of Psychiatric Progress Noted for Resident #16 dated 1/9/25 completed by Nurse Practitioner, revealed Staff reports that patient continues to exhibit inappropriate sexual behaviors . Record review of Social Work note, for Resident #16 dated 2/3/25 revealed Elder made eye contact with the Social Worker and made sexual statements during the interview .According to staff, the resident makes inappropriate sexual comments to staff routinely . Record review of Progress Notes, for Resident #16 dated 2/12/25, and signed by the PTA revealed Pt (patient) stated, 'I'll go for a walk with you if you give me some sugar' Then patient attempted to use his foot to inappropriately touch Licensed Physical Therapy Assistant (LPTA) where he stated give me some p**** . Record review of Progress Notes, for Resident #16 dated 2/17/25, and signed by the Physical Therapy Assistant (PTA) revealed Attempted Physical Therapy Treatment where patient was very inappropriate where he kept attempting to inappropriately touch Licensed Physical Therapy Assistant (LPTA) .patient kept attempting to inappropriately touch LPTA while saying very inappropriate stuff. LPTA discontinued treatment. Nursing staff notified. Record review of Nurses Notes, for Resident #16 dated 2/20/25 revealed .elder stuck his foot between CNA's legs in a sexual manner . Record review of the Nursing Note for Resident #16, dated 4/25/25, revealed that the elder ambulated off the unit with staff times two for transfer to [Proper Name of Facility]. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/3/25 for Resident #16 revealed a Brief Interview for Mental Status Score (BIMS) score of 3 indicating severe cognitive impairment. Record review of Psychiatric Progress Note for Resident #16 revealed a diagnosis of Dementia and he was admitted to the facility on [DATE]. Record review of the MDS with an ARD of 2/13/25 for Resident #56 revealed a BIMS score of 7 indicating severe cognitive impairment. Record review of the demographic page for Resident #56 revealed that the facility admitted her on 4/15/21 with diagnosis to include Alzheimer's Disease. Review of the removal plan revealed that the facility took the following actions: Immediate Action started on 4/24/2025 at approximately 2:53 PM: 1. On 04/24/2025 at 2:53 PM, Certified Nursing Assistant (CNA) 1 saw Resident #16 on top of Resident #56. CNA 1 yelled for help. Licensed Practical Nurse (LPN) 1 and CNA 1, CNA 2, and CNA 3 entered the room and removed Resident #16 and took him back to his room where supervision was provided by CNA 2. 2. On 04/24/2025 at 3:05 PM, Licensed Master Social Worker (LMSW) and Nursing Home Administrator (NHA) notified by LPN of the incident. 3. On 4/24/2025 at 3:06 PM, a CNA was stationed outside the door of Resident #16 until transportation arrived to take him to an inpatient geropsychiatric unit. 4. On 4/24/2025 at 3:50 PM, LMSW went to evaluate Resident #16 for mood or behavior changes, and none were noted. 5. On 04/24/2025 at 4:13 PM, Staff Development Specialist (SDS) performed a full body audit on Resident # 56. The findings included red purple bruising with yellow edges noted to left outer eyebrow, scratches, skin discoloration and slight edema noted to exterior labia overall paleness maroon/purple bruising noted to left thigh approximate size of a quarter scratches noted to left thigh and bilateral outer labia with bruising and redness noted to both areas. 6. On 04/24/2025 at 4:21 PM, Nursing Home Medical Staff Director (NHMSD) notified by phone by RN 1 of findings from body audit. No orders received. 7. On 04/24/2025 at 4:28 PM, NHA notified the Ombudsman of the incident. 8. On 04/24/2025 at 5:49 PM, the LMSW notified Resident #56's Responsible Party (RP) of the incident. 9. On 04/24/2025 at 5:54 PM, NHA and Risk Manager (RM) notified the Director of Risk Management (DRM) of the event. to discuss the event and necessary actions steps needed to be implemented immediately to prevent any further harm. The recommended actions included continuing to seek inpatient geropsychiatric unit placement for Resident # 16 and continuing supervision. 10. On 04/24/2025 at 6:00 PM, RP of Resident # 16 was notified by LMSW regarding the incident and an order for inpatient geriatric psych placement. 11. On 04/24/2025 at 7:00 PM, LMSW verified that a CNA was placed outside Resident #16's room. 12. On 4/25/2025 at 11:23 AM, NHA notified the Mississippi State Department of Health (MSDH) of the incident by telephone. 13. On 04/25/2025 at 12:19 PM a follow-up weekly body audit completed on Resident # 56. No additional injuries identified. 14. On 04/25/2025 at 1:32 PM, Primary physician notified of Resident # 16 acceptance at behavioral health facility. 15. On 04/25/2025 at 3:46 PM, NHA notified the Attorney General's Office of the incident. 16. On 04/25/2025 at 3:53 PM, NHA sent an email reporting the incident to the MSDH via email to facilityreportedincidents@msdh.ms.gov. 17. On 04/25/2025 at 4:16 PM, Resident # 16 was transferred to a behavioral health facility. 18. On 04/30/2025 at 8:30 AM, NHA notified local law enforcement of the incident. 19. On 04/30/2025 at 3:30 PM, local law enforcement on-site. 20. On 04/30/2025 at 4:48 PM, Incident report received from local law enforcement. 21. On 4/30/2025 at 5:00 PM, the Director of Risk Management in-serviced the NHA and the Interim Director of Nursing (IDON) on timely reporting of suspected abuse. 22. On 4/30/2025 at 6:00 PM, the Interim Director of Nursing and SDS initiated Abuse training to include types of abuse, prevention and employee responsibilities for reporting suspected abuse for all 129 employees. No staff will be allowed to work until in serviced. 23. On 4/30/2025 at 6:00 PM, the IDON and SDS initiated an in-service for all Nursing Staff on implementing and developing Comprehensive Care Plans to include interventions that address inappropriate sexual behaviors. No staff will be allowed to work until in serviced. 24. No staff, including the Director of Nursing, will be allowed to work until in serviced. 25. On 4/30/2025 at 7:30 PM, an Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, interim-Director of Nursing (DON), Infection Control Nurse Manager (ICNM), and RM. 26. On 5/1/2025 at 3:29 PM, a Follow-up Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, DON, ICNM, RM, Human Resources Manager (HRM), and RN 1. 27. On 5/1/2025 at 5:30 PM, the Minimum Data Set Nurse (MDSN) completed a 100% care plan audit for behaviors for all 95 residents to include residents at risk for sexual behaviors. Findings of the audit revealed that no other residents had inappropriate sexual behaviors. Facility alleged Immediate Jeopardy was removed as of 5/2/25. Validation: The State Agency (SA) validation of the Removal Plan was made during an on-site survey through record review and interviews on 5/5/25. The SA determined all corrective actions were completed on 5/1/25 by the facility and the IJ was removed on 5/2/25.

Based on record review, staff interviews, and facility policy review, the facility failed to report alleged violations of sexual abuse that occurred within the two (2) hour timeframe to the proper authorities for one (1) of one (1) allegations of sexual abuse. Resident # 56 On 4/24/25 at approximately 3:00 PM, Resident #56 was found by a Certified Nursing Assistant (CNA) with Resident #16 in the bed and on top of her, with his hand inside her incontinence brief, performing jabbing motions. Resident #16 became violent with the staff when they tried to remove him from Resident #16's room where he hit a staff member with his fist. The facility's failure to report sexual abuse of Resident #56 to the proper authorities within prescribed timeframes placed Resident #56 and other residents at risk for sexual assault, in a situation that caused and was likely to cause serious injury, serious harm, serious impairment, or death. The SA identified Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 4/24/25 when Resident #16 was found in the bed and on top of Resident #56, with his hand inside her incontinence brief, performing jabbing motions. The SA notified the facility's Administrator of the IJ and SQC on 4/30/25 at 1:20 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on 5/02/25, in which they alleged all corrective actions to remove the IJ and SQC were completed on 5/1/25, and the IJ removed on 5/2/25. The SA validated the Removal Plan on 5/5/25 and determined the IJ and SQC was removed on 5/2/25, prior to exit. Therefore, the scope and severity for 42 CFR: 483.12 (c)(1)-Reporting of alleged violations (F609)-Scope and Severity J, was lowered from a scope and severity of 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. Cross Reference F600, F656 Findings Include: Record review of the facility policy Abuse and or Suspected Crimes Reporting Under the Elder Justice Act, last reviewed 3/24 revealed Elder Justice Act-refers to Section 1150B of the Social Security Act, as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010. Section 1150B of the Act requires certain individuals in a federally funded long-term care facility to timely report any reasonable suspicion of a crime committed against a resident of that facility. Those reports must be submitted to at least one law enforcement agency of jurisdiction and the State Survey Agency . Procedure: 1. If the reportable event involves serious bodily injury to a resident receiving care in this facility, the staff member shall report the suspicion immediately, but not later than two (2) hours after forming the suspicion . Record review of the facility investigation revealed that on 4/24/25 at approximately 3:00 PM, a Certified Nursing Assistant (CNA) was walking down the hall and saw Resident #16 on top of Resident #56 in an inappropriate manner. Both residents were clothed. The CNA called for assistance from other staff to remove Resident #16 from Resident #56's bed. Upon assessment by the Registered Nurse (RN), Resident #56 was noted to have scratches on her upper legs and scratches and bruising on her labia. The CNA reported that Resident #16's hand was down inside Resident #56's diaper, and he was making a jabbing motion with his hand. Record review of the Default Flowsheet Data for Resident #56 under Genitourinary on 4/24/25 at 4:13 PM documented scratches, skin discoloration, and slight edema noted to the labia; maroon/purple and pale overall paleness; maroon/purple bruising noted to the left thigh; maroon/purple bruising with yellow outer edges noted to the left lateral eyebrow; and scratches noted to the left thigh and bilateral outer labia with bruising and redness to both areas. Record review of the Nursing Note for Resident #56, dated 4/29/25, written by Licensed Practical Nurse (LPN) #2 revealed a late entry for 4/24/25 that stated, This nurse alerted by CNA to come to elder's room. When this nurse entered room, observed a male elder on top of this female elder, both were fully clothed, male elder refuses to get off of female elder and required 2 (two) more CNA to assist, male elder becomes violent and punches one of the CNAs in the nose, male elder removed from this elder's room and taken back to his room with supervision. [Proper Name of Administrator] aware . Social Worker (SW) aware and she talked to family, and [Proper Name of Physicians] aware per this nurse . Record review of the Nursing Note for Resident #16, dated 4/24/25, documented that a CNA doing a visual check observed the elder in a female elder's room on top of her. The clothes were intact. When attempts were made to remove this elder, he became violent and punched a CNA in the nose. He was returned to his room, and supervision was provided at his doorway to maintain the female resident's safety. In an interview with the Administrator on 5/2/25 at 12:50 PM he confirmed that he did not identify this as sexual abuse at first and therefore did not report the incident to the State Department within two (2) hours. He revealed that he thought he had 24 hours to report it, so he called the report in the next day on 4/25/25. He further stated that he did not report the incident to the local police department because he did not see it as a crime. Review of the removal plan revealed that the facility took the following actions: Immediate Action started on 4/24/2025 at approximately 2:53 PM: 1. On 04/24/2025 at 2:53 PM, Certified Nursing Assistant (CNA) 1 saw Resident #16 on top of Resident #56. CNA 1 yelled for help. Licensed Practical Nurse (LPN) 1 and CNA 1, CNA 2, and CNA 3 entered the room and removed Resident #16 and took him back to his room where supervision was provided by CNA 2. 2. On 04/24/2025 at 3:05 PM, Licensed Master Social Worker (LMSW) and Nursing Home Administrator (NHA) notified by LPN of the incident. 3. On 4/24/2025 at 3:06 PM, a CNA was stationed outside the door of Resident #16 until transportation arrived to take him to an inpatient geropsychiatric unit. 4. On 4/24/2025 at 3:50 PM, LMSW went to evaluate Resident #16 for mood or behavior changes, and none were noted. 5. On 04/24/2025 at 4:13 PM, Staff Development Specialist (SDS) performed a full body audit on Resident # 56. The findings were red purple bruising with yellow edges noted to left outer eyebrow, scratches, skin discoloration and slight edema noted to exterior labia overall paleness maroon/purple bruising noted to left thigh approximate size of quarter scratches noted to left thigh and bilateral outer labia with bruising and redness noted to both areas. 6. On 04/24/2025 at 4:21 PM, Nursing Home Medical Staff Director (NHMSD) notified by phone by RN 1 of findings from body audit. No orders received. 7. On 04/24/2025 at 4:28 PM, NHA notified the Ombudsman of the incident. 8. On 04/24/2025 at 5:49 PM, the LMSW notified the Responsible Party (RP) of the incident. 9. On 04/24/2025 at 5:54 PM, NHA and Risk Manager (RM) notified the Director of Risk Management (DRM) of the event. to discuss the event and necessary actions steps needed to be implemented immediately to prevent any further harm. The recommended actions included continuing to seek inpatient geropsychiatric unit placement for Resident # 16 and continuing supervision. 10. On 04/24/2025 at 6:00 PM, RP of Resident # 16 was notified by LMSW regarding the incident and an order for inpatient geriatric psych placement. 11. On 04/24/2025 at 7:00 PM, LMSW verified that a CNA was placed outside Resident #16 ' s room. 12. On 4/25/2025 at 11:23 AM, NHA notified the Mississippi State Department of Health (MSDH) of the incident by telephone. 13. On 04/25/2025 at 12:19 PM a follow-up weekly body audit completed on Resident # 56. No additional injuries identified. 14. On 04/25/2025 at 1:32 PM, Primary physician notified of Resident # 16 acceptance at behavioral health facility. 15. On 04/25/2025 at 3:46 PM, NHA notified the Attorney General's Office of the incident. 16. On 04/25/2025 at 3:53 PM, NHA sent an email reporting the incident to the MSDH via email to facilityreportedincidents@msdh.ms.gov. 17. On 04/25/2025 at 4:16 PM, Resident # 16 was transferred to a behavioral health facility. 18. On 04/30/2025 at 8:30 AM, NHA notified local law enforcement of the incident. 19. On 04/30/2025 at 3:30 PM, local law enforcement on-site. 20. On 04/30/2025 at 4:48 PM, Incident report received from local law enforcement. 21. On 4/30/2025 at 5:00 PM, the Director of Risk Management in-serviced the NHA and the Interim Director of Nursing (IDON) on timely reporting of suspected abuse. 22. On 4/30/2025 at 6:00 PM, the Interim Director of Nursing and SDS initiated Abuse training to include types of abuse, prevention and employee responsibilities for reporting suspected abuse for all 129 employees. No staff will be allowed to work until in serviced. 23. On 4/30/2025 at 6:00 PM, the IDON and SDS initiated an in-service for all Nursing Staff on implementing and developing Comprehensive Care Plans to include interventions that address inappropriate sexual behaviors. No staff will be allowed to work until in serviced. 24. No staff, including the Director of Nursing, will be allowed to work until they are in-serviced. 25. On 4/30/2025 at 7:30 PM, an Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, interim-Director of Nursing (DON), Infection Control Nurse Manager (ICNM), and RM. 26. On 5/1/2025 at 3:29 PM, a Follow-up Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, DON, ICNM, RM, Human Resources Manager (HRM), and RN 1. 27. On 5/1/2025 at 5:30 PM, the Minimum Data Set Nurse (MDSN) completed a 100% care plan audit for behaviors for all 95 residents to include residents at risk for sexual behaviors. Findings of the audit revealed that no other residents had inappropriate sexual behaviors. Facility alleged Immediate Jeopardy was removed as of 5/2/25. Validation: The State Agency (SA) validation of the Removal Plan was made during an on-site review through record review and interviews on 5/5/25. The SA determined all corrective actions were completed on 5/1/25 and the IJ was removed on 5/2/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #40 Record review of Resident #40's Care Plan revealed that she had Diabetes Mellitus, and the description of care to be received with a start date of 11/25/24 revealed, Diabetic nail care weekly per 7/3 RN. On 4/29/25 at 11:13 AM an observation and interview Resident #40 revealed she liked her fingernails short. She stated she could not remember the last time they were trimmed. This observation confirmed that Resident #40's fingernails long past the tips of her fingers and jagged. On 4/30/25 at 2:22 PM, during an observation and interview Registered Nurse (RN) #1 confirmed that Resident #40's nails looked like it had been a while since they were tended to. She confirmed they were long and jogged, and that the residents plan of care had not been followed. She further stated that the RN's were supposed to do nail care with their weekly body audits. In an interview on 4/30/25 at 3:17 PM, Minimum Data Set (MDS) Nurse #1 confirmed that if Resident #40's nail care was not being done as it was supposed to have been, then it is safe to say that her care plan was not being followed. She revealed she is responsible for developing the residents' care plans and they are developed to identify and address each resident's needs so the staff will know how to care for each resident. Review of the Resident #40's demographic page revealed the resident was admitted to the facility on [DATE] with medical diagnoses of Type 2 Diabetes Mellitus with Diabetic Nephropathy. Record review of Resident #40's Section C of the Annual MDS dated [DATE] revealed the BIMS score was 12, indicating the resident has moderate cognitive impairment. Resident #92 Record review of Resident #92's CNA Care Plan with a start date of 11/25/24 revealed, .nail care weekly . Record review of Resident #92's Skin Care Plan with a start date of 11/25/24 revealed, Finger and toenail care with trimming weekly as needed per RN Supervisor. On 4/29/25 at 11:31 AM an observation and interview revealed Resident #92's fingernails were long and dirty. The resident's nails appeared to be approximately ½ (one-half) inch long and had a brown substance under the nail beds. Resident #92 stated that he had asked them to cut and clean, and they always say they will get back to me. On 4/30/25 at 11:15 AM, during an observation CNA #1 confirmed that Resident #92's fingernails were long and dirty. She confirmed that the CNA's are responsible for cleaning the residents' nails. An observation and interview on 4/30/25 at 11:35 AM, LPN#1 confirmed that Resident #92's nail care, which is in his care plan, was not being followed, and it should have been. She confirmed that the resident's nails needed trimming and cleaning. In an interview on 4/30/25 at 3:05 PM, MDS Nurse #1 revealed that Resident #92's care plan was not followed if his fingernails were long and unkempt. Record review of the Resident #92's demographics revealed the resident was admitted to the facility on [DATE] with medical diagnoses including Metabolic Encephalopathy. Record review of Resident #92's Section C of the Annual MDS dated [DATE] revealed the BIMS score was 11, indicating the resident has a moderate cognitive impairment. Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement a comprehensive care plan for 1) for Resident #16 who was a known risk for sexual behaviors towards others, to prevent the resident from entering Resident #56's room and sexually assaulting her while she lay in her bed, 2) transfer assistance for a dependent resident (Resident #5), and 3) assistance with Activities of Daily Living (ADL) (Resident #40, #90, and #92) for five (5) of 22 resident care plans reviewed. Resident's # 5, #16, #40, #90 and #92. This facility failed to implement the sexual behavior care plan for Resident #16 which led to Resident #56 being sexually assaulted in her room on 4/24/25 at approximately 3:00 PM, when a Certified Nursing Assistant (CNA) observed Resident #16 in the bed on top of Resident #56, with his hand inside her incontinence brief, performing jabbing motions. The facility's failure to prevent the sexual abuse of Resident #56 placed Resident #56 and other residents at risk for sexual assault, in a situation that caused and was likely to cause serious injury, serious harm, serious impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) which began on 11/05/24 when Resident #16 began to exhibit sexual behaviors towards staff and the facility did not implement interventions to prevent further sexual behaviors. The SA notified the facility's Administrator of the IJ on 4/30/25 at 1:20 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on 5/02/25, in which they alleged all corrective actions to remove the IJ were completed on 5/01/25, and the IJ removed on 5/02/25. The SA validated the Removal Plan on 05/05/25 and determined the IJ was removed on 5/02/25, prior to exit. Therefore, the scope and severity for 42 CFR: 483.21(b) Comprehensive Care Plans - (F656) - Scope and Severity J was lowered from a scope and severity of J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include Record review of facility policy titled, Care Plans with a revision date of 11/07/2023, revealed, An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Record review of facility policy titled, Purposes of a Nursing Care Plan dated, 03/14/2024, revealed, Following the resident's current individualized care plan is crucial and a legal duty as a clinical care team member. Following the resident's current care plan ensures we as a team are providing the best care for each resident. Resident # 16 Cross Reference F600 Record review of the Encounter Problems (Active) for Resident #16 revealed Problem: Mood/Behaviors, with a start date of 11/4/24, Description: I exhibit sexually inappropriate behaviors . Review of intervention description revealed .Protect the rights and safety of others .Elder and others will not experience harm from agitated behaviors . Record review of the facility investigation revealed that on 4/24/25 at approximately 3:00 PM, a Certified Nursing Assistant (CNA) was walking down the hall and saw Resident #16 on top of Resident #56 in an inappropriate manner. Both residents were clothed. The CNA called for assistance from other staff to remove Resident #16 from Resident #56's bed. Upon assessment by the Registered Nurse (RN), Resident #56 was noted to have scratches on her upper legs and scratches and bruising on her labia. The CNA reported that Resident #16's hand was down inside Resident #56's diaper, and he was making a jabbing motion with his hand. During an interview with the Care Plan Nurse on 5/01/25 at 8:55 AM she confirmed that staff did not follow the care plan related to Resident #16's sexual behaviors and therefore did not protect the safety of others. She revealed the purpose of the comprehensive care plan is to identify any specific resident needs and direct staff of resident specific care needed. Review of the removal plan revealed that the facility took the following actions: Immediate Action started on 4/24/2025 at approximately 2:53 PM: 1. On 04/24/2025 at 2:53 PM, Certified Nursing Assistant (CNA) 1 saw Resident #16 on top of Resident #56. CNA 1 yelled for help. Licensed Practical Nurse (LPN) 1 and CNA 1, CNA 2, and CNA 3 entered the room and removed Resident #16 and took him back to his room where supervision was provided by CNA 2. 2. On 04/24/2025 at 3:05 PM, Licensed Master Social Worker (LMSW) and Nursing Home Administrator (NHA) notified by LPN of the incident. 3. On 4/24/2025 at 3:06 PM, a CNA was stationed outside the door of Resident #16 until transportation arrived to take him to an inpatient geropsychiatric unit. 4. On 4/24/2025 at 3:50 PM, LMSW went to evaluate Resident #16 for mood or behavior changes, and none were noted. 5. On 04/24/2025 at 4:13 PM, Staff Development Specialist (SDS) performed a full body audit on Resident # 56. The findings were red purple bruising with yellow edges noted to left outer eyebrow, scratches, skin discoloration and slight edema noted to exterior labia overall paleness maroon/purple bruising noted to left thigh approximate size of a quarter scratches noted to left thigh and bilateral outer labia with bruising and redness noted to both areas. 6. On 04/24/2024 at 4:21 PM, Nursing Home Medical Staff Director (NHMSD) notified by phone by RN 1 of findings from body audit. No orders received. 7. On 04/24/2025 at 4:28 PM, NHA notified the Ombudsman of the incident. 8. On 04/24/2025 at 5:49 PM, the LMSW notified Resident #56's Responsible Party (RP) of the incident. 9. On 04/24/2025 at 5:54 PM, NHA and Risk Manager (RM) notified the Director of Risk Management (DRM) of the event. to discuss the event and necessary actions steps needed to be implemented immediately to prevent any further harm. The recommended actions included continuing to seek inpatient geropsychiatric unit placement for Resident # 16 and continuing supervision. 10. On 04/24/2025 at 6:00 PM, RP of Resident # 16 was notified by LMSW regarding the incident and an order for inpatient geriatric psych placement. 11. On 04/24/2025 at 7:00 PM, LMSW verified that a CNA was placed outside Resident #16's room. 12. On 4/25/2025 at 11:23 AM, NHA notified the Mississippi State Department of Health (MSDH) of the incident by telephone. 13. On 04/25/2025 at 12:19 PM a follow-up weekly body audit completed on Resident # 56. No additional injuries identified. 14. On 04/25/2025 at 1:32 PM, Primary physician notified of Resident # 16 acceptance at behavioral health facility. 15. On 04/25/2025 at 3:46 PM, NHA notified the Attorney General's Office of the incident. 16. On 04/25/2025 at 3:53 PM, NHA sent an email reporting the incident to the MSDH via email to facilityreportedincidents@msdh.ms.gov. 17. On 04/25/2025 at 4:16 PM, Resident # 16 was transferred to a behavioral health facility. 18. On 04/30/2025 at 8:30 AM, NHA notified local law enforcement of the incident. 19. On 04/30/2025 at 3:30 PM, local law enforcement on-site. 20. On 04/30/2025 at 4:48 PM, Incident report received from local law enforcement. 21. On 4/30/2025 at 5:00 PM, the Director of Risk Management in-serviced the NHA and the Interim Director of Nursing (IDON) on timely reporting of suspected abuse. 22. On 4/30/2025 at 6:00 PM, the Interim Director of Nursing and SDS initiated Abuse training to include types of abuse, prevention and employee responsibilities for reporting suspected abuse for all 129 employees. No staff will be allowed to work until in serviced. 23. On 4/30/2025 at 6:00 PM, the IDON and SDS initiated an in-service for all Nursing Staff on implementing and developing Comprehensive Care Plans to include interventions that address inappropriate sexual behaviors. No staff will be allowed to work until in serviced. 24. No staff, including the Director of Nursing, will be allowed to work until they are in-serviced. 25. On 4/30/2025 at 7:30 PM, an Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, interim-Director of Nursing (DON), Infection Control Nurse Manager (ICNM), and RM. 26. On 5/1/2025 at 3:29 PM, a Follow-up Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, DON, ICNM, RM, Human Resources Manager (HRM), and RN 1. 27. On 5/1/2025 at 5:30 PM, the Minimum Data Set Nurse (MDSN) completed a 100% care plan audit for behaviors for all 95 residents to include residents at risk for sexual behaviors. Findings of the audit revealed that no other residents had inappropriate sexual behaviors. Facility alleges Immediate Jeopardy was removed as of 5/2/25. Validation: The State Agency (SA) validation of the Removal Plan was made on-site during the survey through record review and interviews on 5/5/25. The SA determined all corrective actions were completed on 5/2/25 and the IJ was removed on 5/2/24. Resident #5 Record review of facility investigation revealed that on 1/27/25 at approximately 1:35 PM Resident #5 was being assisted from her bed to the wheelchair by two (2) Certified Nursing Assistants (CNA), her legs got weak, and the CNAs assisted her to the floor. She was assisted from the floor without difficulty and the Registered Nurse (RN) assessment revealed no injuries. On 1/28/25 at approximately 4:00 PM, Resident #5 complained of pain to her right leg, the physician was notified, and orders were obtained for a radiographic study. The resident was noted to have bruising and edema to her right leg. Her Responsible Party was notified of the findings, and the resident was transferred to the hospital. Evaluation at the hospital revealed that she had a right tibial plateau fracture. Record review of the Encounter Problems (Active) for Resident #5 revealed Problem: Activities of Daily Living (ADLs) (Certified Nursing Assistant Care Plan) revealed I need assistance with my ADLs because of impaired vision, frequent bladder and bowel incontinence, generalized weakness, falls with right hip fracture . Under intervention description Transfers: Extensive assistance two (2) care partners (using rolling walker). On 4/30/25 at 9:00 AM, in an interview with CNA #5 she stated that she and CNA #4 were assigned to take care of Resident #5 on 1/27/25. She stated that CNA #4 instructed her that they were going to transfer Resident #5 to the wheelchair because she was supposed to transfer to another room. She stated that she had never transferred Resident #5 before, and CNA #4 instructed her to get beside the resident and stand her up by placing her arm under the resident's arm and lifting. She stated that she questioned CNA#4 on the technique because she had never transferred a resident in this way and did not think it was correct, but that CNA #4 instructed her that that was the way to transfer this resident. She stated they stood the resident, but she was not able to bear weight and CNA #4 told her to lower the resident to the floor. She stated as they were lowering the resident her right leg went up underneath her. She stated that she does not recall exactly how the resident was positioned or if the resident complained because she left the room when the resident was put back in the chair because she was upset that the resident had to be lowered to the ground, because she did not feel she had a good hold on the resident during the transfer due to her position beside the resident. She verified that they did not use a rolling walker. She stated that she had not checked the care plan to determine how the resident transferred because CNA #4 had transferred her before. On 5/2/25 at 12:00 PM, during a telephone interview with CNA #4, she stated that on 1/27/25 she and CNA #5 went in to assist Resident #5 to the wheelchair to transport her to another room. She stated that she told CNA #5 to get on one side, and she would get on the other and assist the resident to the wheelchair. She stated during the transfer Resident #5 was unable to bear weight on her legs and they had to lower her to the floor. She stated that she did not notice Resident #5's leg going under her while they were lowering her to the floor. She stated that she called the nurse who came in to check the resident. CNA #4 stated that she always transferred Resident #5 this way and had no problems. She stated she felt like CNA #5 did not have a good hold on the resident during the transfer. CNA #4 admitted that she did not use a walker when transferring the resident, stating that she had never used a walker when transferring the resident. CNA #4 further stated that she did not check the residents care plan to see how she was supposed to transfer but agreed that had she used the walker it is likely that the resident could have used it to help bear weight and would not have had to be lowered to the ground. During an interview with the Care Plan Nurse on 5/01/25 at 8:53 AM, she revealed the purpose of the comprehensive care plan is to identify any specific resident needs and direct staff of resident specific care needed. She also verified that the CNAs are to check the resident ADL Care plans weekly & sign that they have checked them. She revealed after reviewing the ADL care plan for Resident #5 staff did not follow the care plan related to transfers if staff did not use a walker as specified during the resident's transfer. Record review of the demographic page for Resident # 5 revealed the facility admitted her on 6/14/24. Resident #90 Record review of CNA Care Plan with start date 11/6/24 revealed, .nail care weekly . An observation on 4/29/25 at 11:08 AM revealed Resident #90's fingernails were long and jagged with a brown substance under the nail beds. On 4/30/25 at 11:41 AM during an observation and interview with Licensed Practical Nurse (LPN) #3, she confirmed that Resident #90's fingernails were long with a brown substance underneath and needed cleaning and clipping. During an interview on 5/5/25 at 10:00 AM with the Care Plan Nurse, she confirmed Resident #90's care plan was not followed. She revealed that failure to follow the care plan could result in the residents' nails remaining unclean. Record review of Demographics revealed the facility admitted Resident #90 on 2/15/24 with primary diagnosis of Alzheimer's Dementia. Record review of Resident #90's MDS with an ARD of 2/5/25 revealed a BIMS score of 7, which indicated the resident had moderate cognitive impairment.