Based on interviews, record review, the facility's investigation, and facility policy review, the facility failed to ensure residents' right to be free from physical and verbal abuse when Certified Nurse Aide (CNA) 1 was reported by two staff members (CNA #2 and CNA #3) to have physically abused Resident #1 on 3/7/25 at 6:45 AM and verbally abused Resident #2 date/time unknown, both vulnerable residents, and the facility did not take immediate protective action for two (2) of four (4) sampled residents. Additionally, the Administrator was not informed of the allegation until 3/17/25, at which time CNA #1 was suspended. This left residents vulnerable for ten (10) days after the abuse was initially witnessed by staff. The facility's failure to provide immediate protective action placed these residents and other vulnerable residents at risk for serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 3/7/25 when CNA #1 was witnessed physically abusing Resident #1. The facility Administrator was notified of the IJ and SQC and was presented with an IJ Template on 4/3/25 at 5:00 PM. The facility provided an acceptable Removal Plan on 4/3/25, in which they alleged all corrective action to remove the IJ was completed on 4/3/25 and the IJ was removed on 4/4/25. The State Agency (SA) validated the Removal Plan on 4/4/25 and determined the IJ was removed on 4/4/25, prior to exit. Therefore, the scope and severity for CFR 483.12(a)(1)(5) Freedom from Abuse, Neglect, and Exploitation (F600) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's policy, Abuse, Neglect, Exploitation & (and) Misappropriation revised 11/16/2022, revealed .It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights., including the right to be free from abuse, neglect, mistreatment, exploitation and or misappropriation of property .Employees of the center are charged with the continuing obligation to treat residents so they are free from abuse . No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment and or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. Definitions .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Physical abuse includes but is not limited to . corporal punishment, which is physical punishment, is used as a means to correct or control behavior. Corporal punishment includes, but is not limited to; spanking, slapping of hands, flicking or hitting with an object. Verbal abuse .includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance regardless of age, ability to comprehend, or disability . A review of the facility's investigation, dated 3/17/25, revealed that on Monday, 3/17/25, at 10:44 AM, the facility's Administrator found two (2) different anonymous pieces of paper on his desk that stated CNA #1 had been abusing residents. Interviews were conducted with all residents able to effectively communicate and there were no complaints on staff received from the residents interviewed. There were no obvious signs of abuse on any of the residents who were unable to communicate. Interviews with staff members that work around or directly with CNA #1 were conducted. Upon those interviews, a witness stated she was changing a resident and heard CNA #1 tell Resident #2 that if she (expletive) out the bed like she did yesterday, she was going to beat her (expletive). Another witness stated she was assisting CNA #1 with providing care to a combative resident, when she grabbed the residents nose, causing it to leak blood and told the combative resident, It how you deal with crazy (expletive) like you. Resident #1 A record review of the admission Record revealed the facility admitted Resident #1 on 3/08/2013 with current diagnoses including Parkinson's Disease and Dementia. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated her cognition was moderately impaired. Resident #2 A record review of the admission Record revealed the facility admitted Resident #2 on 10/3/2019 with current diagnoses including Hypertension and Major Depressive Disorder. A record review of the Quarterly MDS with an ARD of 3/12/25 revealed Resident #2 had a BIMS score of 3 which indicated her cognition was severely impaired. Section GG revealed Resident #2 is dependent on staff for toileting hygiene. Record review of the facility's Assignment sheets, dated 3/6/25, revealed CNA #1 and CNA #3 were scheduled on the same hall on 3/7/25 at 6:20 AM. Record review of the facility's time sheets, dated 3/6/25 through 3/7/25, revealed CNA #1 and CNA #3 worked the 11-7 shift and were present at the facility at 6:20 AM. On 04/02/25 at 11:00 AM, during an interview with CNA #3, she stated that on 03/07/25 at approximately 6:20 AM, she was working the overnight shift (11:00 PM - 7:00 AM), although her normal schedule was the 7:00 AM - 3:00 PM shift. CNA #3 explained that Licensed Practical Nurse (LPN) #1 asked her to assist CNA #1 with providing care to Resident #1, as the resident was reportedly combative. As care began, Resident #1 swung at both CNAs. CNA #3 reported that she held the resident's hands gently and reassured her, telling her everything was okay. The resident then pulled away from her grasp and grabbed CNA #1 by the hair. CNA #3 reported that in response, CNA #1 grabbed the resident's nose and twisted it upwards, which caused the resident's nose to bleed. According to CNA #3, CNA #1 then stated, This is how you deal with crazy (expletive) like you. CNA #3 recalled telling CNA #1, You can't treat and talk to her like that, and stated she attempted to leave the room to locate the nurse but did not see her nearby. Not wanting to leave the resident alone with CNA #1, CNA #3 returned to the room and offered to finish providing care. She stated that CNA #1 appeared to ignore her and refused to leave the room. CNA #1 continued providing care, cleaned the blood from the resident's face using the resident's gown, finished dressing her, and transferred her to the chair before exiting the room. CNA #3 stated that she did not report the incident to the nurse, Director of Nursing (DON), or Administrator until 03/17/25 because she feared retaliation from other staff. She confirmed she had previously received training and in-services regarding abuse, neglect, and the requirement to report such incidents. On 04/02/25 at 11:15 AM, during an interview with CNA #2, she stated she was in Resident #2's room providing care to the roommate when she overheard CNA #1 say to Resident #2, If you (expletive) in the bed like you did yesterday, I'm going to beat your (expletive). CNA #2 stated she immediately told CNA #1 that she could not speak to a resident in that manner, to which CNA #1 replied, I bet it works. CNA #2 explained she did not report the incident at the time because she was afraid of retaliation from staff, stating that people had recently been losing their jobs and there were concerns about false allegations being made through the compliance hotline. CNA #2 confirmed she had received prior training and in-service education on abuse, neglect, and reporting requirements. On 04/02/25 at 11:30 AM, during an interview with CNA #4, she stated that she occasionally worked on the same hall as CNA #1 and observed CNA #1 speaking to residents in an aggressive and assertive manner. CNA #4 expressed concern about the tone and way CNA #1 communicated with residents but stated she was told by other staff members that that's just her personality and not to take it seriously. CNA #4 explained that, based on those comments, she did not report the behavior to the Director of Nursing (DON), believing it was not considered a serious issue by other staff. On 04/02/25 at 11:45 AM, during an interview with CNA #5, he stated that he worked alongside CNA #1 on the same hall and often heard her speak to residents in an angry tone of voice. CNA #5 stated he initially believed it was just part of her personality and admitted he did not pay much attention to her behavior at the time. On 04/02/25 at 12:01 PM, during an interview with CNA #1, she denied physically abusing Resident #1 and verbally abusing Resident #2. CNA #1 stated she believed the accusations were fabricated by another CNA because she was not part of the clique among staff at the facility. She further stated she had never worked with CNA #3 on the hall and that CNA #3's primary responsibility was providing showers. CNA #1 confirmed she had received training and in-service education on abuse, neglect, and reporting requirements. On 04/02/25 at 12:05 PM, during an interview with LPN #1, she stated she was the nurse assigned to the hall on 03/07/25. LPN #1 explained that CNA #1 approached her that morning and reported that Resident #1 was combative and refusing care. In response, LPN #1 asked CNA #3 to assist CNA #1 with providing care to the resident. LPN #1 stated she was not made aware of any physical abuse involving the resident and that neither CNA reported any concerns to her. She recalled observing Resident #1 later that shift, seated in a wheelchair, fully dressed, and noted that the resident appeared confused. On 04/02/25 at 1:00 PM, during an interview with the Social Worker, she stated she was not made aware of the allegations of physical and verbal abuse until she was informed by the Administrator on 3/17/25. She reported that after learning of the incident, she checked on the involved residents to assess for any concerns and confirmed that no psychosocial issues were identified at that time. On 04/02/25 at 1:30 PM, during an interview with the Assistant Director of Nursing (ADON) explained that she had been informed by the DON and the Administrator that two (2) anonymous letters were found on the Administrator's desk alleging that CNA #1 had physically abused Resident #1 and verbally abused Resident #2. The ADON reported that she assisted the DON and the Administrator in conducting full body audits on the residents and participating in the investigation of the abuse allegations. She confirmed that no bruises or physical injuries were observed on either resident. On 04/02/25 at 1:45 PM, during an interview with the Administrator, he stated that on 03/17/25, he found two anonymous letters on his desk alleging abuse by CNA #1. The first letter described an incident in which CNA #1 physically abused Resident #1 during incontinent care by grabbing the resident's nose-causing it to bleed-and saying, It's how you deal with crazy (expletive) like you. The second letter alleged that CNA #1 verbally abused Resident #2 by stating, If you (expletive) out the bed like you did yesterday, I'm going to beat your (expletive), while CNA #1 was providing care. The Administrator stated CNA #1 was immediately suspended pending an investigation and was terminated on 03/18/25. As part of the investigation, full body audits were conducted for all residents on the 200 hall where CNA #1 had worked, and cognitive residents were interviewed regarding potential abuse. The Administrator reported that an in-service on abuse and neglect was provided to staff, and a Quality Assurance (QA) meeting was held on 03/26/25. He confirmed the abuse allegations were substantiated based on the statements from two CNAs: CNA #3, who witnessed physical abuse of Resident #1, and CNA #2, who witnessed verbal abuse directed at Resident #2. On 04/03/25 at 12:10 PM, during an interview with LPN #2, she described CNA #1 as having good days and bad days, noting that if CNA #1 arrived smiling, it was typically a good day, but if she arrived and did not speak to others, it was a bad day. LPN #2 also stated CNA #1 did not follow instructions well and often argued when asked to perform tasks. She acknowledged she had not documented or reported these concerns to the Director of Nursing (DON) but stated the tasks generally got done. LPN #2 reported she was unaware of any allegations of physical or verbal abuse involving CNA #1. On 04/03/25 at 12:45 PM, during an interview with Registered Nurse (RN) #1, she stated she was the Unit Manager and had observed that CNA #1 often demonstrated a negative attitude. She further stated CNA #1 had shown increased frustration, particularly when the staff schedule was modified or when she was asked to complete specific tasks. On 04/03/25 at 1:00 PM, during an interview with the Director of Nursing (DON), she stated she was informed about the anonymous letters that had been placed on the Administrator's desk. She reported that CNA #1 was immediately suspended following the allegations. The DON stated that body audits were conducted on all cognitively impaired residents on Station 2, and interviews were completed with cognitively intact residents to assess for any physical or verbal abuse. Staff members working on Station 2 were also interviewed. The DON confirmed that the CNAs failed to report the allegations of abuse until 03/17/25, despite having received in-service training on abuse and neglect at the time of hire. The Facility presented the following Removal Plan on 4/4/25: On 4/2/25 Quality Assurance (QAPI) Committee met at 5:45 pm to review, develop, and implement the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause. The root cause was determined to be that employees were afraid of retaliation from other employees. Attendees were the Executive Director, (ED), Minimum Data Service (MDS) nurse, Medical Records (MRC), Regional Director of Clinical Services, (RDCS), Assistant Director of Nursing (ADON), Medical Director, Social Services (SSD) Staff Development/ Infection Preventionist nurse, Activities Director (AD), Human Resources (HR) Housekeeping, Dietary Manager, Therapy director, Unit Managers and the admission Coordinator. There were no changes made to the policy and procedure. The areas that were discussed were the re-education of staff members on the abuse and neglect policy with an emphasis on reporting requirements and that failure to do so is a crime. On 3/17/25 body audits were completed on Resident # 1 and Resident #2 by the Staff Development nurse and a licensed nurse. No signs of physical abuse was identified. On 3/17/25 interviews were conducted by SSD with alert and oriented residents on side 2. No residents voiced complaints of abuse. On 3/17/25 the physician and the Resident Representatives of Resident # 1 and Resident 2 were notified. On 3/17/25 education was started by the Staff Development Nurse. On 3/26/25 the Quality Assurance Performance Improvement Committee met to review the physical and verbal abuse. On 4/2/25 Social Services completed a psychosocial follow up with Resident # 1 and Resident #2. On 4/2/25 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse. No residents were identified. On 4/2/25 the ED was educated on the abuse policy by the RDCS and timely reporting of abuse within 2 hours to the state agency, attorney general and the abuse and neglect policy. On 4/2/25 the SSD and the Admissions Coordinator interviewed all alert and oriented residents (census) using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse. There were no residents that voiced any complaints of abuse. The Staff Development nurse started education with licensed nurses, CNA's and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements on 4/2/25 and 100 % has been completed on 4/3/25. All facility staff members were interviewed by the ED, HR, and ADON by phone on 4/2/25 to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements and that failure to do so is a crime. CNA # 2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime. New hires will be educated during orientation. Corrective Actions were completed on 4/3/25, and the Immediate Jeopardy was removed. Validation: The SA validated on 4/4/25, through interview and record review, that all corrective actions had been completed as of 4/3/25, and the IJ removed on 4/4/25.

Based on interviews, record review, and facility policy review, the facility failed to implement its abuse policy, allowing an abusive act to occur without staff intervening or prompt reporting for two (2) of four (4) sampled residents. Resident #1 was physically abused on 3/7/25 by Certified Nurse Aide (CNA) #1 which was witnessed by CNA #3 and Resident #2 was verbally abused by CNA #1 and was witnessed by CNA #2. CNA #1 and CNA #2 did not intervene to prevent the violation of the residents' rights to be free from abuse. The facility's failure to intervene and immediately report to the Administrator placed Resident #1, Resident #2 and other residents at risk for similar abuse including the risk for serious harm, injury, impairment, or death. The situation was determined to Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 3/7/25 when CNA #1 was witnessed physically abusing Resident #1. The State Agency (SA) notified the facility's Administrator of the IJ and SQC on 4/3/25 at 5:00 PM and the facility provided an acceptable Removal Plan on 4/3/25 and the IJ was removed on 4/4/25. The SA validated the Removal Plan on 4/4/25 and determined the IJ was removed on 4/4/25, prior to exit. Therefore, the scope and severity for 42 CFR(s): 483.12(b)(1) Implement Written Policies (F607) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's, Abuse, Neglect, Exploitation & (and) Misappropriation revised 11/16/22, revealed, .Procedure .2. Training .Employee obligation All employees have a duty to respect the rights of all residents .and to prevent others from violating their rights. Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, .to a resident, is obligated to report such information, but no later than 2 hours after the allegation is made .to the Administrator and to other officials in accordance with State Law. An employee shall be deemed to have violated his obligations .if he does any of the following .Fails to report an incident of abuse witnessed by or known to him/her . Resident #1 A record review of the admission Record revealed the facility admitted Resident #1 on 3/08/2013 with current diagnoses including Parkinson's Disease and Dementia. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated her cognition was moderately impaired. Resident #2 A record review of the admission Record revealed the facility admitted Resident #2 on 10/3/2019 with current diagnoses including Hypertension and Major Depressive Disorder. A record review of the Quarterly MDS with an ARD of 3/12/25 revealed Resident #2 had a BIMS score of 3 which indicated her cognition was severely impaired. Section GG revealed Resident #2 is dependent on staff for toileting hygiene. In an interview on 4//2/25 at 11:00 AM with CNA # 3, she stated that on 3/07/25 at approximately 6:20 AM, she was working the overnight shift (11:00 PM - 7:00 AM) and Licensed Practical Nurse (LPN) #1 asked her to assist CNA #1 with providing care to Resident #1 because she was reportedly combative. As care began, Resident #1 swung at both CNAs. The resident grabbed CNA #1 by the hair and in response, CNA #1 grabbed the resident's nose and twisted it upwards, which caused the resident's nose to bleed. According to CNA #3, CNA #1 then stated, This is how you deal with crazy (expletive) like you. CNA #3 recalled telling CNA #1, You can't treat and talk to her like that, and stated she attempted to leave the room to locate the nurse but did not see her nearby. Not wanting to leave the resident alone with CNA #1, CNA #3 returned to the room and offered to finish providing care. She stated that CNA #1 appeared to ignore her and refused to leave the room. CNA #1 continued providing care, cleaned the blood from the resident's face using the resident's gown, finished dressing her, and transferred her to the chair before exiting the room. CNA #3 admitted that she did not report the incident to the nurse, Director of Nursing (DON), or Administrator until 03/17/25, leaving all residents at risk for potential abuse from CNA #1. CNA #3 revealed she was aware that she should have intervened and reported the abuse immediately because she had been trained on the facility's abuse policy, but she feared retaliation from other staff. In an interview with CNA #2 on 4/02/25 at 11:15 AM, she stated she was in Resident #2's room providing care to the roommate when she overheard CNA #1 say to Resident #2, If you (expletive) in the bed like you did yesterday, I'm going to beat your (expletive). CNA #2 stated she immediately told CNA #1 that she could not speak to a resident in that manner, to which CNA #1 replied, I bet it works. CNA #2 explained she did not report the incident at the time because she was afraid of retaliation from staff, stating that people had recently been losing their jobs and there were concerns about false allegations being made through the compliance hotline. CNA #2 also revealed that she had been trained on the facility's abuse policy which instructed staff to report abuse to protect the residents. During an interview with CNA #1 on 4/02/25 at 12:01 PM, she denied physically abusing Resident #1 and verbally abusing Resident #2. CNA #1 stated she believed the accusations were fabricated by another CNA because she was not part of the clique among staff at the facility. She further stated she had never worked with CNA #3 on the hall and that CNA #3's primary responsibility was providing showers. During an interview with the Administrator on 4/02/25 at 1:45 PM, he stated that on 3/17/25, he found two anonymous letters on his desk alleging abuse by CNA #1. The first letter described an incident in which CNA #1 physically abused Resident #1 during incontinent care by grabbing the resident's nose, causing it to bleed, and saying, It's how you deal with crazy (expletive) like you. The second letter alleged that CNA #1 verbally abused Resident #2 by stating, If you (expletive) out the bed like you did yesterday, I'm going to beat your (expletive), while CNA #1 was providing care. The Administrator stated CNA #1 was immediately suspended pending an investigation and was terminated on 03/18/25. The Administrator also confirmed that CNAs #2 and #3 did not receive disciplinary action regarding their inaction of immediately protecting the residents and reporting, however, they were inserviced on the abuse policy. The Facility presented the following Removal Plan on 4/4/25: On 4/2/25 Quality Assurance (QAPI) Committee met at 5:45 pm to review, develop, and implement the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause. The root cause was determined to be that employees were afraid of retaliation from other employees. Attendees were the Executive Director, (ED), Minimum Data Service (MDS) nurse, Medical Records (MRC), Regional Director of Clinical Services, (RDCS), Assistant Director of Nursing (ADON), Medical Director, Social Services (SSD) Staff Development/ Infection Preventionist nurse, Activities Director (AD), Human Resources (HR) Housekeeping, Dietary Manager, Therapy director, Unit Managers and the admission Coordinator. There were no changes made to the policy and procedure. The areas that were discussed were the re-education of staff members on the abuse and neglect policy with an emphasis on reporting requirements and that failure to do so is a crime. On 3/17/25 body audits were completed on Resident # 1 and Resident #2 by the Staff Development nurse and a licensed nurse. No signs of physical abuse was identified. On 3/17/25 interviews were conducted by SSD with alert and oriented residents on side 2. No residents voiced complaints of abuse. On 3/17/25 the physician and the Resident Representatives of Resident # 1 and Resident 2 were notified. On 3/17/25 education was started by the Staff Development Nurse. On 3/26/25 the Quality Assurance Performance Improvement Committee met to review the physical and verbal abuse. On 4/2/25 Social Services completed a psychosocial follow up with Resident # 1 and Resident #2. On 4/2/25 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse. No residents were identified. On 4/2/25 the ED was educated on the abuse policy by the RDCS and timely reporting of abuse within 2 hours to the state agency, attorney general and the abuse and neglect policy. On 4/2/25 the SSD and the Admissions Coordinator interviewed all alert and oriented residents (census) using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse. There were no residents that voiced any complaints of abuse. The Staff Development nurse started education with licensed nurses, CNA's and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements on 4/2/25 and 100 % has been completed on 4/3/25. All facility staff members were interviewed by the ED, HR, and ADON by phone on 4/2/25 to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements and that failure to do so is a crime. CNA # 2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime. New hires will be educated during orientation. Corrective Actions were completed on 4/3/25, and the Immediate Jeopardy was removed. Validation: The SA validated on 4/4/25, through interview and record review, that all corrective actions had been completed as of 4/3/25, and the IJ removed on 4/4/25.

Based on interviews, record review, the facility's investigation and facility policy review, the facility failed to report abuse within the required two (2) hour timeframe (Resident #1 and #2) and failed to submit a completed investigation for an allegation of abuse (Resident #3) to the State Agency (SA) within five (5) working days for (3) of four (4) sampled residents. Resident #1 was physically abused on 3/7/25 by Certified Nurse Aide (CNA) 1 which was witnessed by CNA #3 and Resident #2 was verbally abused by CNA #1 and was witnessed by CNA #2. CNA #1 and CNA #2 did not immediately report the abuse, until 3/17/25, which was ten (10) days after the first instance of abuse was witnessed. The facility's failure to immediately report the abuse placed Resident #1 and Resident #2 and other residents at risk for continued abuse by the abuser including the risk for serious harm, injury, impairment, or death. The situation was determined to Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 3/7/25 when CNA #1 was witnessed physically abusing Resident #1. The State Agency (SA) notified the facility's Administrator of the IJ and SQC on 4/3/25 at 5:00 PM. The facility provided an acceptable Removal Plan on 4/3/25 and the IJ was removed on 4/4/25. The SA validated the Removal Plan on 4/4/25 and determined the IJ was removed on 4/4/25, prior to exit. Therefore, the scope and severity for 42 CFR(s): 483.12(c)(1) Reporting of Alleged Violations (F609) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's policy, Abuse, Neglect, Exploitation & (and) Misappropriation revised 11/16/22, revealed, .Procedure .2. Training .Employee obligation .Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment .to a resident, is obligated to report such information, but no later than 2 hours after the allegation is made .to the Administrator and to other officials in accordance with State Law 5. Investigation The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation and exploitation .Review of Report: Report the results of all investigation to the Executive Director or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident . Resident #1 A record review of the admission Record revealed the facility admitted Resident #1 on 3/08/2013 with current diagnoses including Parkinson's Disease and Dementia. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated her cognition was moderately impaired. Resident #2 A record review of the admission Record revealed the facility admitted Resident #2 on 10/3/2019 with current diagnoses including Hypertension and Major Depressive Disorder. A record review of the Quarterly MDS with an ARD of 3/12/25 revealed Resident #2 had a BIMS score of 3 which indicated her cognition was severely impaired. Section GG revealed Resident #2 is dependent on staff for toileting hygiene. During an interview on 4//2/25 at 11:00 AM with CNA #3, she stated that on 03/07/25 at approximately 6:20 AM, she was working the overnight shift (11:00 PM - 7:00 AM) and Licensed Practical Nurse (LPN) #1 asked her to assist CNA #1 with providing care to Resident #1 because she was reportedly combative. As care began, Resident #1 swung at both CNAs. The resident grabbed CNA #1 by the hair and in response, CNA #1 grabbed the resident's nose and twisted it upwards, which caused the resident's nose to bleed. According to CNA #3, CNA #1 then stated, This is how you deal with crazy (expletive) like you. CNA #3 recalled telling CNA #1, You can't treat and talk to her like that, and stated she attempted to leave the room to locate the nurse but did not see her nearby. Not wanting to leave the resident alone with CNA #1, CNA #3 returned to the room and offered to finish providing care. She stated that CNA #1 appeared to ignore her and refused to leave the room. CNA #1 continued providing care, cleaned the blood from the resident's face using the resident's gown, finished dressing her, and transferred her to the chair before exiting the room. CNA #3 confirmed that she did not report the incident to the nurse, Director of Nursing (DON), or Administrator until 03/17/25, leaving all residents at risk for potential abuse. She stated she feared retaliation from other staff. During an interview with CNA #2 on 04/02/25 at 11:15 AM, she stated she was in Resident #2's room providing care to the roommate when she overheard CNA #1 say to Resident #2, If you (expletive) in the bed like you did yesterday, I'm going to beat your (expletive). CNA #2 stated she immediately told CNA #1 that she could not speak to a resident in that manner, to which CNA #1 replied, I bet it works. CNA #2 explained she did not report the incident at the time because she was afraid of retaliation from staff, stating that people had recently been losing their jobs and there were concerns about false allegations being made through the compliance hotline. In an interview with CNA #1 on 04/02/25 at 12:01 PM, she denied physically abusing Resident #1 and verbally abusing Resident #2. CNA #1 stated she believed the accusations were fabricated by another CNA because she was not part of the clique among staff at the facility. She further stated she had never worked with CNA #3 on the hall and that CNA #3's primary responsibility was providing showers. In an interview with the Administrator on 04/02/25 at 1:45 PM, he stated that on 03/17/25, he found two anonymous letters on his desk alleging abuse by CNA #1. The first letter described an incident in which CNA #1 physically abused Resident #1 during incontinent care by grabbing the resident's nose, causing it to bleed, and saying, It's how you deal with crazy (expletive) like you. The second letter alleged that CNA #1 verbally abused Resident #2 by stating, If you (expletive) out the bed like you did yesterday, I'm going to beat your (expletive), while CNA #1 was providing care. The Administrator stated CNA #1 was immediately suspended pending an investigation and was terminated on 03/18/25. Resident #3 The State Agency (SA) received a facility reported incident (CI: 28355) on 3/20/25 at 1:00 PM reporting an allegation of verbal abuse; it was reported that CNA #2 spoke very harshly to Resident #3. The Administrator called in the allegation of verbal abuse on the complaint hot line stating an anonymous call was made on the facility's compliance hot line. CNA #2 was suspended pending an investigation. As of 3/28/25 at 1:25 PM the Administrator has not submitted the final report. The SA attempted to converse with the Administrator on 3/27/25 several times and was not able to make contact. A record review of Resident #3's admission Record revealed the facility admitted the resident on 11/10/23 with the diagnoses of Parkinsons, Hypertension, and Alcohol Abuse. A record review of Resident #3's Quarterly MDS with an ARD of 3/4/25 revealed BIMS score of 15 which indicated the resident was cognitively intact. During an interview on 4/2/25 at 4:00 PM the Administrator stated he received a complaint from an anonymous person on the compliance hot line stating that CNA #2 was verbally abusing Resident #3. The Administrator said he started the investigation. The Administrator also confirmed he failed to send in the final investigation within five (5) days to the State Agency (SA). The Administrator explained the DON was supposed to send in the final investigation. The Administrator said the DON had been sick and was not in the building. He failed to send the final report into the State Agency. During an interview on 4/2/25 at 4:30 PM with the DON confirmed the facility received a complaint from the compliance hot line stating CNA #2 verbally abused Resident #3. This was from an anonymous person. The DON said they started investigating the complaint. The DON confirmed she was responsible for sending in the final report and got sick. She confirmed she forgot to remind the Administrator to send it in. The Facility presented the following Removal Plan on 4/4/25: On 4/2/25 Quality Assurance (QAPI) Committee met at 5:45 pm to review, develop, and implement the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause. The root cause was determined to be that employees were afraid of retaliation from other employees. Attendees were the Executive Director, (ED), Minimum Data Service (MDS) nurse, Medical Records (MRC), Regional Director of Clinical Services, (RDCS), Assistant Director of Nursing (ADON), Medical Director, Social Services (SSD) Staff Development/ Infection Preventionist nurse, Activities Director (AD), Human Resources (HR) Housekeeping, Dietary Manager, Therapy director, Unit Managers and the admission Coordinator. There were no changes made to the policy and procedure. The areas that were discussed were the re-education of staff members on the abuse and neglect policy with an emphasis on reporting requirements and that failure to do so is a crime. On 3/17/25 body audits were completed on Resident # 1 and Resident #2 by the Staff Development nurse and a licensed nurse. No signs of physical abuse was identified. On 3/17/25 interviews were conducted by SSD with alert and oriented residents on side 2. No residents voiced complaints of abuse. On 3/17/25 the physician and the Resident Representatives of Resident # 1 and Resident 2 were notified. On 3/17/25 education was started by the Staff Development Nurse. On 3/26/25 the Quality Assurance Performance Improvement Committee met to review the physical and verbal abuse. On 4/2/25 Social Services completed a psychosocial follow up with Resident # 1 and Resident #2. On 4/2/25 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse. No residents were identified. On 4/2/25 the ED was educated on the abuse policy by the RDCS and timely reporting of abuse within 2 hours to the state agency, attorney general and the abuse and neglect policy. On 4/2/25 the SSD and the Admissions Coordinator interviewed all alert and oriented residents (census) using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse. There were no residents that voiced any complaints of abuse. The Staff Development nurse started education with licensed nurses, CNA's and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements on 4/2/25 and 100 % has been completed on 4/3/25. All facility staff members were interviewed by the ED, HR, and ADON by phone on 4/2/25 to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements and that failure to do so is a crime. CNA # 2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime. New hires will be educated during orientation. Corrective Actions were completed on 4/3/25, and the Immediate Jeopardy was removed. Validation: The SA validated on 4/4/25, through interview and record review, that all corrective actions had been completed as of 4/3/25, and the IJ removed on 4/4/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to honor a resident's right to refuse treatment when Resident #1, who was a hospice patient and had a signed Do Not Resuscitate (DNR) Physician's Order, received cardiopulmonary resuscitation (CPR) by facility staff for one (1) of four (4) residents reviewed. Resident #1 Resident #1's medical record had conflicting information regarding the code status of the resident and caused Resident #1 to receive CPR by facility staff for 25 minutes, which was against his wishes and the Physician's Order. The situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE] when the facility received a signed DNR Physician's Order. This situation placed Resident #1 and other residents with DNR orders at risk for the likelihood of serious injury, serious harm, serious impairment or death. The State Agency (SA) notified the facility's Administrator of the IJ on [DATE] at 1:40 PM and provided the Administrator with the IJ templates. Based on the facility's implementation of corrective actions on [DATE], the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on [DATE], prior to the SA's entrance on [DATE]. Findings include: A review of the facility's policy, Advanced Directives, revised [DATE], revealed POLICY: .The center will honor all properly executed advance directives that have been provided by the resident and/or resident representatives. Process .5. Advanced Directives will be reviewed .Hospice admission . A record review of the facility's investigation Code Status Incident, revealed on [DATE], Resident #1 was found to be unresponsive. License Practical Nurse (LPN) #2 and LPN #3 verified in his hard chart (non-electronic medical chart) that Resident #1 was a Full Code (all resuscitation procedures would be provided) and his Advanced Directive sheet also indicated he was Full Code. At 5:45 AM, CPR was initiated. CPR was terminated at 6:10 AM when the Hospice nurse arrived at the facility and verified Resident #1 had a DNR status. On [DATE] at 6:30 AM, during an interview with LPN #3, she stated on [DATE] around 5:45 AM, Resident #1 was unresponsive, so she and LPN #2 reviewed the resident's chart. The hard chart did not indicate that he was DNR, but the electronic health record did. The Advanced Directive and the Physician's Order in the hard chart indicated he was Full Code. LPN #3 stated there was a discrepancy and since there was confusion, the nurses initiated CPR. The hospice nurse entered the facility after 6:00 AM and provided proof of the resident being DNR because there was a signed Advanced Directive in the hospice chart at the nurse's station. She reported that CPR was stopped at that time. On [DATE] at 9:28 AM, during an interview with LPN #1, she stated Resident #1 returned to the facility from the hospital on [DATE]. He had hospital discharge orders for DNR and Hospice services. She confirmed that she entered the DNR and Hospice orders into the electronic medical record but did not make any changes in the hard chart. She stated that since all orders are reviewed in the clinical meeting the next day, the necessary paperwork would have been reviewed by the Director of Nurses (DON) and the Social Worker at that time and they would make sure all the required documentation was on the resident's hard chart. On [DATE] at 9:42 AM, during an interview with the Social Services Director, she confirmed that she was unaware Resident #1's code status had changed on [DATE] when he returned from the hospital. She stated she was aware that he was on hospice services, but not all residents with hospice services have DNR orders. The Social Services Director stated she did not review the resident's new orders during the clinical meeting on [DATE], which was the day following the resident's return to the facility. On [DATE] at 10:05 AM, during an interview with the DON, she confirmed during the clinical meeting held on [DATE], the staff did not discuss new Physician's Orders for Resident #1, including the change to DNR status and the hospice admission. She stated the DNR order was correctly entered into the electronic health record, but a copy was not placed in the resident's hard chart. The DON stated she had made the mistake of not researching Resident #1's new Physician's Orders received upon the hospital discharge on [DATE] and following up with the Hospice provider. On [DATE] at 12:00 PM, during an interview with the hospice provider nurses, Registered Nurse (RN) #2 and RN #3, they confirmed that on [DATE] at approximately 7:00 PM, RN #3 entered the facility and gave LPN #1 the new orders from the hospice provider which indicated Resident #1 was DNR and the Advanced Directive signed by the family. She placed the documents in the resident's hospice binder at the nurse's station. On [DATE], RN #3 returned to the facility with the Advanced Directive signed by the Physician and placed it in the hospice binder. She stated this was the normal procedure for a resident when they are admitted to hospice services. A record review of the admission Record revealed the facility admitted Resident #1 on [DATE] and he had diagnoses including Dementia and Osteomyelitis. A record review of the Discharge Summary revealed Resident #1 was admitted to a local acute care hospital on [DATE] and was discharged from the hospital on [DATE]. Review of the Hospital Course revealed 1/28(2024) Discussed with family, POA (Power of Attorney). Patient is DNR, code status changed .1/31 (2024) .discussed with family and they wish hospice/comfort care . 02/01 (2024) .Plan to discharge to hospice today . The Goals of Care Treatment Preferences revealed, Code Status: DNR). A record review of the facility's Order Summary Report revealed Resident #1 had physician's orders, dated [DATE], for Do NOT Resuscitate and Hospice: Admit to (Proper Name of Hospice Service). A record review of the Mississippi Physician Orders for Sustaining Treatment (POST), revealed on [DATE], Resident #1's family member signed the form, indicating the facility should not attempt resuscitation (DNR) and medical interventions was Comfort Measures Only. The primary physician signed the form on [DATE]. Based on the facility's implementation of corrective actions on [DATE], the SA determined the IJ to be Past Non-Compliance (PNC), and the IJ was removed on [DATE], prior to the SA's entrance on [DATE]. Corrective Actions: Brief Summary of Events: 1. On [DATE] at 5:26 PM the Executive Director reported incident to State Agency via e mail. 2. On Friday [DATE] 100 % audit of Code Status was conducted by the Social Services Director (SSD) to ensure hard chart code status order, Advanced Directive sheet and code status order in PCC match. There were no other discrepancies noted. 3. On Friday, [DATE], the Social Services Director and Regional Director of Clinical Services initiated and completed on [DATE] notification of all Residents and /or Resident Representatives (RR) to verify and review wishes for an Advanced Directive to include Code Status. 4. On Friday, [DATE], the Director of Nursing (DON) verified the code status for 2 Residents currently on Hospice and reviewed the Hospice charts for any code status discrepancies. There were no discrepancies noted. The Director of Nursing (DON) combined Hospice charts with the facility hard chart. 5. On Friday [DATE] a 100% audit of all Residents physician orders was initiated and completed on [DATE] by the Regional Director of Clinical Services (RDCS), Director of Nursing (DON) and the Social Services Director (SSD). 6. On Saturday [DATE] review of Care Plans was initiated and completed on [DATE]. Care Plans were reviewed by the Director of Nursing (DON), Social Services Director (SSD) and Regional Director of Clinical Services (RDCS) to ensure Residents code status is appropriately care planned, code status in PCC and Resident paper chart reconcile and no discrepancies found between Hospice Chart and facility hard chart. No discrepancies were found. 7. On Friday [DATE] Quality Assurance Performance Improvement (QAPI) Committee met to review policies on Advance Directives SS 124, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and process for verifying code status on admit and readmit, determine Root Cause Analysis and begin immediate actions plan. There were no changes made to policies. There was a process implemented for verifying code status on admit and readmit to prevent future occurrences. The new process will include Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Attendees was Director of Nursing (DON), Executive Director (ED), Regional Director of Clinical Services (RDCS) , Social Services Director (SSD) , Minimum Data Set (MDS) Nurse , Business Office Manager (BOM) , Human Resources Director (HRD) ,Infection Control Preventionist Licensed Practical Nurse (ICP-LPN), Activities Director (AD) , Therapy Manager and Unit Manager - Registered Nurse (UM-RN). The Medical Director attended via telephone. Monitoring will include #8 and #9. 8. Quality Monitoring of code status and Advanced Directives began by the Social Services Director and continues weekly for 4 weeks then monthly for 2 months. Monitoring includes ensuring DNR order noted on hard chart and signed by physician, Comprehensive Care Plan reflects current code status, Code status on demographic sheet in Electronic Health Record (EHR) reconciles with code status noted on the Residents paper chart, Care Plan and Advanced Directive Form. 9. Regional Director of Clinical Services began monitoring morning clinical meeting twice weekly for 2 weeks, then weekly for 2 weeks then monthly for 2 months to ensure physician orders were being reviewed in clinical meeting to include code status physician orders. 10. On Friday [DATE] Regional Director of Clinical Services (RDCS) conducted education with the Director Nursing (DON), Executive Director (ED) and the Social Services Director (SSD) on Advance Directives SS 124, Care Plans N 1015, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and Process for verifying code status on admit and readmit. Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. 11. On Friday, [DATE], the Regional Director of Clinical Services (RDCS) conducted education with the Executive Director (ED), Director of Nursing (DON), and Social Services Director (SSD) on Comprehensive Care Plans and ensuring Care plans are comprehensive to include code status. The Comprehensive Care Plan will be implemented within 7 days after completing the comprehensive assessment. 12. On Friday [DATE] DON initiated education to all Licensed Nurses on Advance Directives SS 124, Abuse and Neglect N 1265, Care Plans 1015, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and process for verifying code status on admit and readmit. Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Education was completed on [DATE]. Education with new hires will be done in orientation. All corrective actions were completed as of [DATE] and the facility alleges the IJ removed on [DATE]. Validation: On [DATE], the SA validated through record review and interview the facility reported the incident to the SA via email on [DATE]. On [DATE], the SA validated through record review and interview that 100 % audit of Code Status was conducted by the Social Services Director (SSD) to ensure the hard chart code status order, Advanced Directive sheet, and code status order in PCC match. No other discrepancies were noted through record reviews and interviews. On [DATE], the SA validated through record reviews and interviews the Social Services Director and Regional Director of Clinical Services initiated and completed on [DATE] notification of all Residents and /or Resident Representatives (RR) to verify and review wishes for an Advanced Directive to include Code Status. On [DATE], the SA validated through record review and interviews the DON verified the code status for 2 Residents currently on Hospice and reviewed the Hospice charts for any code status discrepancies. There were no discrepancies noted. The Director of Nursing (DON) combined Hospice charts with the facility hard chart. On [DATE], the SA validated through record review and interviews 100% audit of all Residents physician orders was initiated and completed on [DATE] by the Regional Director of Clinical Services (RDCS), Director of Nursing (DON) and the Social Services Director (SSD). On [DATE], the SA validated through record review and interviews Care Plans was initiated and completed on [DATE]. Care Plans were reviewed by the Director of Nursing (DON), Social Services Director (SSD) and Regional Director of Clinical Services (RDCS) to ensure Residents code status is appropriately care planned, code status in PCC and Resident paper chart reconcile and no discrepancies found between Hospice Chart and facility hard chart. No discrepancies were found. On [DATE], the SA validated through record review and interviews Quality Assurance Performance Improvement (QAPI) Committee met to review policies on Advance Directives SS 124, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and process for verifying code status on admit and readmit, determine Root Cause Analysis and begin immediate actions plan. There were no changes made to policies. There was a process implemented for verifying code status on admit and readmit to prevent future occurrences. The new process will include Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Attendees was Director of Nursing (DON), Executive Director (ED), Regional Director of Clinical Services (RDCS) , Social Services Director (SSD) , Minimum Data Set (MDS) Nurse , Business Office Manager (BOM) , Human Resources Director (HRD) ,Infection Control Preventionist Licensed Practical Nurse (ICP-LPN), Activities Director (AD) , Therapy Manager and Unit Manager - Registered Nurse (UM-RN). The Medical Director attended via telephone. Monitoring will include #8 and #9. On [DATE], the SA validated through record review and interviews Quality Monitoring of code status and Advanced Directives began by the Social Services Director and continues weekly for 4 weeks then monthly for 2 months. Monitoring includes ensuring DNR order noted on hard chart and signed by physician, Comprehensive Care Plan reflects current code status, Code status on demographic sheet in Electronic Health Record (EHR) reconciles with code status noted on the Residents paper chart, Care Plan and Advanced Directive Form. On [DATE], the SA validated through record review and interviews the Regional Director of Clinical Services began monitoring morning clinical meeting twice weekly for 2 weeks, then weekly for 2 weeks then monthly for 2 months to ensure physician orders were being reviewed in clinical meeting to include code status physician orders. On [DATE], the SA validated through record review and interviews the Regional Director of Clinical Services (RDCS) conducted education with the Director Nursing (DON), Executive Director (ED) and the Social Services Director (SSD) on Advance Directives SS 124, Care Plans N 1015, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and Process for verifying code status on admit and readmit. Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. On [DATE], the SA validated through record review and interviews the Regional Director of Clinical Services (RDCS) conducted education with the Executive Director (ED), Director of Nursing (DON), and Social Services Director (SSD) on Comprehensive Care Plans and ensuring Care plans are comprehensive to include code status. The Comprehensive Care Plan will be implemented within 7 days after completing the comprehensive assessment. On [DATE], the SA validated through record review and interviews DON initiated education to all Licensed Nurses on Advance Directives SS 124, Abuse and Neglect N 1265, Care Plans 1015, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and process for verifying code status on admit and readmit. Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Education was completed on [DATE]. Education with new hires will be done in orientation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to develop comprehensive care plan interventions regarding Advanced Directives for one (1) of four (4) residents reviewed. Resident #1 The facility's failure to develop comprehensive care plan interventions caused Resident #1 to receive cardiopulmonary resuscitation (CPR) by facility staff which was against his wishes and the Physician's Order. Resident #1 received CPR for 25 minutes. The situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE]. The State Agency (SA) notified the facility's Administrator of the IJ on [DATE] at 1:40 PM and provided the Administrator with the IJ templates. This situation placed Resident #1 and other residents with DNR orders at risk for the likelihood of serious injury, serious harm, serious impairment or death. Based on the facility's implementation of corrective actions on [DATE], the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on [DATE], prior to the SA's entrance on [DATE]. Findings include: A review of the facility policy Plans of Care, revised on [DATE], revealed, An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements .Procedure .Develop a comprehensive plan of care for each resident .to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment .Develop and implement an individualized Person-Centered comprehensive plan of care .within seven (7) days after completion of the comprehensive assessment (MDS). A review of Resident #1's comprehensive care plan revealed Focus: [DATE] (Proper Name of Resident #1) has advanced directives r/t (related to) DNR. The date initiated was [DATE] which was the day after Resident #1 received CPR. Review of the medical record revealed there was no comprehensive care plan developed on [DATE] when the signed Advanced Directive was received from the hospice provider. A record review of the Baseline Care Plan and Summary revealed a baseline care plan for Advanced Directives which indicated Resident #1 as Full Code and had a handwritten date of [DATE]. A record review of the facility's investigation Code Status Incident, revealed on [DATE], Resident #1 was found to be unresponsive. License Practical Nurse (LPN) #2 and LPN #3 verified in his hard chart (non-electronic medical chart) that Resident #1 was a Full Code (all resuscitation procedures would be provided) and his Advanced Directive sheet also indicated he was Full Code. At 5:45 AM, CPR was initiated. CPR was terminated at 6:10 AM when the Hospice nurse arrived at the facility and verified Resident #1 had a DNR status. A record review of the Discharge Summary revealed Resident #1 was admitted to a local acute care hospital on [DATE] and was discharged from the hospital on [DATE]. Review of the Hospital Course revealed 1/28(2024) Discussed with family, POA (Power of Attorney). Patient is DNR, code status changed .1/31 (2024) .discussed with family and they wish hospice/comfort care . 02/01 (2024) .Plan to discharge to hospice today . The Goals of Care Treatment Preferences revealed, Code Status: DNR). A record review of the facility's Order Summary Report revealed Resident #1 had a Physician's Order, dated [DATE], for Do NOT Resuscitate. A record review of the Mississippi Physician Orders for Sustaining Treatment (POST), with an effective date of [DATE], revealed Resident #1's family member signed the form, indicating the facility should not attempt resuscitation (DNR) and medical interventions was Comfort Measures Only. The primary physician signed the form on [DATE]. During an interview on [DATE] at 9:42 AM, during an interview with the Director of Nurses (DON), she confirmed that on [DATE] during the clinical meeting, Resident #1's new orders were not reviewed and the change in his code status was addressed. The DON explained that a comprehensive care plan should have been developed within 14 days after [DATE] when Resident #1 was admitted to the facility. She stated the facility should have accurately completed a comprehensive care plan by [DATE]. The DON stated it was her expectation that the nursing staff develop the comprehensive care plan within the correct timeframe. She expressed that since the comprehensive care plan was not developed for Resident #1, he underwent CPR which was not his wishes. On [DATE] at 11:00 AM, during an interview with LPN #4/MDS (Minimum Data Set) Nurse, she confirmed that a comprehensive care plan for Resident #1 was not developed and explained that it should have been developed by [DATE], which was 14 days after the facility admitted him. On [DATE] at 11:20 AM, in an interview with Registered Nurse (RN) #1/MDS, she confirmed the facility did not develop a comprehensive care plan for Resident #1 and it should have been developed after the completion of the comprehensive MDS. Based on the facility's implementation of corrective actions on [DATE], the SA determined the IJ to be Past Non-Compliance (PNC), and the IJ was removed on [DATE], prior to the SA's entrance on [DATE]. Corrective Action Plan Brief Summary of Events: Facility failed to honor Residents wishes and implement an Advanced Directive for Resident to be a Do Not Resuscitate (DNR) which resulted in the Resident receiving Cardiopulmonary Resuscitation for 25 minutes. Facility Failed to develop comprehensive, care plan interventions regarding Advanced Directives for Resident #1, who had a signed Do Not resuscitate (DNR) Physicians Order. On [DATE] state agency representative notified Executive Director and the Director of Nursing of Immediate Jeopardy for F 578 and F 656 and presented template for Immediate Jeopardies. [DATE] Resident was transferred to hospital and was a Full Code at the time of Transfer with an Advanced Directive Consent Form in hard chart. While at the hospital was diagnosed with Respiratory failure secondary. On Thursday [DATE] Resident returns. Return orders included DNR orders. License Practical Nurse (LPN) did enter Do Not Resuscitate (DNR) in Electronic Health Record but did not communicate change in status to Social Services, change advanced directive on the hard chart or provide copy of DNR order in hard chart. Physician order reconciliation was not performed on [DATE] during the clinical nursing review and a signed DNR was in the hospice chart at the facility. On [DATE] the Hospice Nurse placed the Advance Directives with a signature on the Hospice Chart. The Mississippi Physician Order for Sustaining Treatment (POST) was not finalized with signature until [DATE]. Hospice nurse placed Mississippi POST to Hospice chart but did not communicate to anyone in facility the Mississippi POST for DNR had been placed on hospice chart. On Friday [DATE] Resident was unresponsive, and License Practical Nurse (LPN) #2 and LPN #3 verified code status in hard chart which was Full code and Advanced Directive Sheet indicating Full Code. Code Blue called at 0544 am. CPR was initiated at 0545 am. EMS and Hospice nurse arrived and according to nurses' notes took over and verified DNR Status. Cardiopulmonary Resuscitation (CPR) was terminated at 0610 am after Hospice Nurse arrived at facility and informed staff, she had placed a Mississippi POST for DNR on Residents Hospice Chart on [DATE], Family notified at 0620 am. Resident pronounced expired at 0625 am. Nurse Practitioner notified at 0750 am. On Friday [DATE] after incident DON found Mississippi Code Status POST in Hospice Binder that was signed and dated by family on [DATE]. Corrective Actions: 1. On [DATE] at 5:26 PM the Executive Director reported incident to State Agency via e mail. 2. On Friday [DATE] 100 % audit of Code Status was conducted by the Social Services Director (SSD) to ensure hard chart code status order, Advanced Directive sheet and code status order in PCC match. There were no other discrepancies noted. 3. On Friday, [DATE], the Social Services Director and Regional Director of Clinical Services initiated and completed on [DATE] notification of all Residents and /or Resident Representatives (RR) to verify and review wishes for an Advanced Directive to include Code Status. 4. On Friday, [DATE], the Director of Nursing (DON) verified the code status for 2 Residents currently on Hospice and reviewed the Hospice charts for any code status discrepancies. There were no discrepancies noted. The Director of Nursing (DON) combined Hospice charts with the facility hard chart. 5. On Friday [DATE] a 100% audit of all Residents physician orders was initiated and completed on [DATE] by the Regional Director of Clinical Services (RDCS), Director of Nursing (DON) and the Social Services Director (SSD). 6. On Saturday [DATE] review of Care Plans was initiated and completed on [DATE]. Care Plans were reviewed by the Director of Nursing (DON), Social Services Director (SSD) and Regional Director of Clinical Services (RDCS) to ensure Residents code status is appropriately care planned, code status in PCC and Resident paper chart reconcile and no discrepancies found between Hospice Chart and facility hard chart. No discrepancies were found. 7. On Friday [DATE] Quality Assurance Performance Improvement (QAPI) Committee met to review policies on Advance Directives SS 124, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and process for verifying code status on admit and readmit, determine Root Cause Analysis and begin immediate actions plan. There were no changes made to policies. There was a process implemented for verifying code status on admit and readmit to prevent future occurrences. The new process will include Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Attendees was Director of Nursing (DON), Executive Director (ED), Regional Director of Clinical Services (RDCS) , Social Services Director (SSD) , Minimum Data Set (MDS) Nurse , Business Office Manager (BOM) , Human Resources Director (HRD) ,Infection Control Preventionist Licensed Practical Nurse (ICP-LPN), Activities Director (AD) , Therapy Manager and Unit Manager - Registered Nurse (UM-RN). The Medical Director attended via telephone. Monitoring will include #8 and #9. 8. Quality Monitoring of code status and Advanced Directives began by the Social Services Director and continues weekly for 4 weeks then monthly for 2 months. Monitoring includes ensuring DNR order noted on hard chart and signed by physician, Comprehensive Care Plan reflects current code status, Code status on demographic sheet in Electronic Health Record (EHR) reconciles with code status noted on the Residents paper chart, Care Plan and Advanced Directive Form. 9. Regional Director of Clinical Services began monitoring morning clinical meeting twice weekly for 2 weeks, then weekly for 2 weeks then monthly for 2 months to ensure physician orders were being reviewed in clinical meeting to include code status physician orders. 10. On Friday [DATE] Regional Director of Clinical Services (RDCS) conducted education with the Director Nursing (DON), Executive Director (ED) and the Social Services Director (SSD) on Advance Directives SS 124, Care Plans N 1015, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and Process for verifying code status on admit and readmit. Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. 11. On Friday, [DATE], the Regional Director of Clinical Services (RDCS) conducted education with the Executive Director (ED), Director of Nursing (DON), and Social Services Director (SSD) on Comprehensive Care Plans and ensuring Care plans are comprehensive to include code status. The Comprehensive Care Plan will be implemented within 7 days after completing the comprehensive assessment. 12. On Friday [DATE] DON initiated education to all Licensed Nurses on Advance Directives SS 124, Abuse and Neglect N 1265, Care Plans 1015, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and process for verifying code status on admit and readmit. Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Education was completed on [DATE]. Education with new hires will be done in orientation. All corrective actions were completed as of [DATE] and the facility alleges the IJ removed on [DATE]. Validation: On [DATE], the SA validated through record review and interview the facility reported the incident to the SA via email on [DATE]. On [DATE], the SA validated through record review and interview that 100 % audit of Code Status was conducted by the Social Services Director (SSD) to ensure the hard chart code status order, Advanced Directive sheet, and code status order in PCC match. No other discrepancies were noted through record reviews and interviews. On [DATE], the SA validated through record reviews and interviews the Social Services Director and Regional Director of Clinical Services initiated and completed on [DATE] notification of all Residents and /or Resident Representatives (RR) to verify and review wishes for an Advanced Directive to include Code Status. On [DATE], the SA validated through record review and interviews the DON verified the code status for 2 Residents currently on Hospice and reviewed the Hospice charts for any code status discrepancies. There were no discrepancies noted. The Director of Nursing (DON) combined Hospice charts with the facility hard chart. On [DATE], the SA validated through record review and interviews 100% audit of all Residents physician orders was initiated and completed on [DATE] by the Regional Director of Clinical Services (RDCS), Director of Nursing (DON) and the Social Services Director (SSD). On [DATE], the SA validated through record review and interviews Care Plans was initiated and completed on [DATE]. Care Plans were reviewed by the Director of Nursing (DON), Social Services Director (SSD) and Regional Director of Clinical Services (RDCS) to ensure Residents code status is appropriately care planned, code status in PCC and Resident paper chart reconcile and no discrepancies found between Hospice Chart and facility hard chart. No discrepancies were found. On [DATE], the SA validated through record review and interviews Quality Assurance Performance Improvement (QAPI) Committee met to review policies on Advance Directives SS 124, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and process for verifying code status on admit and readmit, determine Root Cause Analysis and begin immediate actions plan. There were no changes made to policies. There was a process implemented for verifying code status on admit and readmit to prevent future occurrences. The new process will include Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Attendees was Director of Nursing (DON), Executive Director (ED), Regional Director of Clinical Services (RDCS) , Social Services Director (SSD) , Minimum Data Set (MDS) Nurse , Business Office Manager (BOM) , Human Resources Director (HRD) ,Infection Control Preventionist Licensed Practical Nurse (ICP-LPN), Activities Director (AD) , Therapy Manager and Unit Manager - Registered Nurse (UM-RN). The Medical Director attended via telephone. Monitoring will include #8 and #9. On [DATE], the SA validated through record review and interviews Quality Monitoring of code status and Advanced Directives began by the Social Services Director and continues weekly for 4 weeks then monthly for 2 months. Monitoring includes ensuring DNR order noted on hard chart and signed by physician, Comprehensive Care Plan reflects current code status, Code status on demographic sheet in Electronic Health Record (EHR) reconciles with code status noted on the Residents paper chart, Care Plan and Advanced Directive Form. On [DATE], the SA validated through record review and interviews the Regional Director of Clinical Services began monitoring morning clinical meeting twice weekly for 2 weeks, then weekly for 2 weeks then monthly for 2 months to ensure physician orders were being reviewed in clinical meeting to include code status physician orders. On [DATE], the SA validated through record review and interviews the Regional Director of Clinical Services (RDCS) conducted education with the Director Nursing (DON), Executive Director (ED) and the Social Services Director (SSD) on Advance Directives SS 124, Care Plans N 1015, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and Process for verifying code status on admit and readmit. Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. On [DATE], the SA validated through record review and interviews the Regional Director of Clinical Services (RDCS) conducted education with the Executive Director (ED), Director of Nursing (DON), and Social Services Director (SSD) on Comprehensive Care Plans and ensuring Care plans are comprehensive to include code status. The Comprehensive Care Plan will be implemented within 7 days after completing the comprehensive assessment. On [DATE], the SA validated through record review and interviews DON initiated education to all Licensed Nurses on Advance Directives SS 124, Abuse and Neglect N 1265, Care Plans 1015, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302, and process for verifying code status on admit and readmit. Physician orders from the last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status, the Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Education was completed on [DATE]. Education with new hires will be done in orientation.